Indian Journal of Urology Users online:1470  
Home Current Issue Ahead of print Editorial Board Archives Symposia Guidelines Subscriptions Login 
Print this page  Email this page Small font sizeDefault font sizeIncrease font size

  Table of Contents 
Year : 2019  |  Volume : 35  |  Issue : 5  |  Page : 1-49

Abstracts - USICON 2019

Date of Web Publication14-Jan-2019

Correspondence Address:
Login to access the Email id

Source of Support: None, Conflict of Interest: None

Rights and PermissionsRights and Permissions


How to cite this article:
. Abstracts - USICON 2019. Indian J Urol 2019;35, Suppl S1:1-49

How to cite this URL:
. Abstracts - USICON 2019. Indian J Urol [serial online] 2019 [cited 2019 Jun 27];35, Suppl S1:1-49. Available from:

   Brij Kishore Patna Prize Paper Session Top

   BKP 01: Urogynecological fistulae: A single centre experience of 40 patients Top

Leela Krishna Karri, Venkat Ramanan, Sriram Krishnamoorthy, Natarajan Kumeerasan, T. Chandru

Sri Ramachandra Medical College and Hospital, Chennai, Tamil Nadu, India

Introduction: Most of fistula are iatrogenic, may occur as a result of congenital anomalies, malignancy, inflammation and infection, radiation, therapy, surgical or external trauma, ischemia, parturition resulting in a great deal of incontinence, discomfort, and physical disability for the effected individual. Materials and Methods: This is observational study done in department of urology and renal transplantation for period of 5 years from January 2013 to January 2018. Inclusion Criteria: All the patients with confirmed urgynecologic fistulae either diagnosed at the study institute or referred from outside were included in this study. Exclusion Criteria: Patients with anatomical urinary incontinence from other causes. Results and Observations: (1) A total of 40 patients were studied, 31 patients were diagnosed with vesicovaginal fistula, 9 patients with ureterovaginal fistula, (2) Highest number of cases 31 were reported following abdominal hysterectomy, 9 cases following vaginal hysterectomy, (3) All cases of vvf presented with total incontinence with in 6 months to 2 years, whereas uvf presented with normal voiding associated with incontinence in time period of 5 months to 2 yrs (4) Size of fistulae varied from <1 cm to >4 cm, majority had 1-2 cm fistula (5) VVF 23 patients had supratrigonal 26, trigonal 5, (6) 26 patients had abdominal o'cornor repair, 4 patients had vaginal repair, 1 patient underwent laparoscopic vvf repair (7) 9 patients of UVF repair were managed with ureteral stenting in 6 patients, 3 patients required ureteric reimplantation (8) Post operative complications such as wound infection is seen in 6 patients, wound dehiscence in 1 patient, recurrence in 2 patients, bladder dysfunction in 4 patients. Conclusions: (1) Urogynecologic fistulae are devastating conditions that severely affect the quality of life of women (2) Thorough evaluation and planned surgical management are essential to correctly diagnose and treat this condition, successful outcome can be achieved with carefully planned and performed surgery (3) Best chance of successful repair is at first attempt, both abdominal and vaginal approaches for vvf can give excellent results in carefully selected cases (4) For ureterovaginal fistulae, ureteral stunting can be tried at first attempt and will be successful in a small fistful, (5) Unobstructed post operative urinary drainage is essential for successful healing of fistula (6) Regular follow up is essential to detect any complications and their successful outome.

   BKP 02: Implementation of enhanced recovery after surgery protocol in patients undergoing robot assisted radical cystectomy with intracorporeal ileal conduit urinary diversion for bladder cancer: An outcome analysis beyond the learning curve Top

S. Tamhankar Ashwin, Gagan Gautam

Max Institute of Cancer Care, New Delhi, India

Introduction: Robot assisted radical cystectomy (RARC) with intracorporeal ileal conduit urinary diversion (IIC) has a steep learning curve. Though the combination of enhanced recovery after surgery (ERAS) protocol and completion of learning curve for RARC+IIC has the best possible potential to decrease the overall morbidity, current evidence in this regard is quite limited. Methods: We conducted an outcome analysis of a prospectively maintained database of patients undergoing RARC+IIC with ERAS principles operated by single surgical team at a tertiary care centre, after excluding initial 30 patients amounting to the learning curve as per Pasadena consensus panel, after IEC approval. Results: 27 consecutive patients (excluding initial 30 out of total 57) with a median age of 69 years were evaluated. Median total console time and console time for diversion was 270 minutes and 80 respectively. Median estimated blood was 300 cc. Ryle's tube was removed immediately after the procedure and oral liquids were started on the first day in all. Median length of stay was 6 days (4-30). Overall and major (Grade 3) complication rates were 51.8% (14/27) and 11.1% (3/27) respectively, without any 90 day mortality at a median follow up of 11 months (1-27). Conclusions: ERAS protocol can be safely implemented in patients undergoing RARC+IIC. While the initial outcomes of this combined treatment strategy appear promising in terms of complication rates and perioperative parameters, greater insight is needed from multi-institutional data and prospective comparative studies to establish the true value of RARC/IIC and ERAS protocol in the treatment of bladder cancer.

   BKP 03: Exstrophy epispadias complex – Our experience Top

Arya Mukesh Chandra, Gupta Chirag, Kumar Mudit, Hariyawat Bheru Singh, Yogendra, Singh Abhiyutthan, Vasudeo Vivek

SP Medical College, Bikaner, Rajasthan, India

Objective: To present our 9 bladder exstrophy (1 adult) and 10 epispadias cases who underwent total reconstruction. Methods: During the time period of last 5 years nineteen patients with Bladder Exstrophy and Epispadias Complex were managed at our centre. Out of nine exstrophy case, 8 were newborn. In these 5 were male and 3 were females. Males and Females were treated in 3 and 2 stages respectively, however few patients did not turn up for subsequent stages after bladder closure. A 19 year old (reared as male) presented with urinary incontinence found to have classical female exstrophy. Bladder closure, bilateral ureteric reimplantation and bladder neck reconstruction done in stage one and bladder augmentation was done in second stage. Results: Follow-up ranged from 9 to 56 months. Three had wound infection. The adult case had vesicocutaneous fistula formation for which secondary closure with rectus abdominis flap is planned. 2 patients had vesicle calculi managed with suprapubic cystolithotomy. Urine tests, radiography and cystoscopy done in followup. All patients showed marked satisfaction and improved self esteem following surgery. Conclusion: Exstrophy epispadias complex is rare and requires high level of surgical skills and experience. Ultimate goal of urinary continence can be achieved by staged procedure with meticulous repair, and multidisciplinary approach in newborn. Bladder preservation is possible in adults with augmentation in the absence of histologic changes. Abdominal wall closure in adult may need flap.

   BKP 04: Intermittent catherisation confers immunity against urethral stricture. Fact or fallacy? Incidence of urethral stricture in indian sci patients being treated with clean intermittent catherisation Top

Vineet Narang, D. Suman, S. Gunawant, I. N. Verma, B. L. Choudhary

Indian Spinal Injury Centre, New Delhi, India

Introduction: Clean intermittent catherisation (CIC) is the gold standard for bladder evacuation in individuals with neurogenic bladder. Intermittent self dilatation has been used extensively after endoscopic treatment of urethral stricture to prevent its recurrence. It is a popular misconception that patients of Spinal cord injury (SCI) do not develop stricture urethra as they are employing CIC for emptying their bladder. We present our data showing a high incidence of stricture in Indian SCI patients using CIC. Methods: Patient database of SCI men who followed up in the OPD for urodynamic study was evaluated from a period of 2014 -2017. Only those patients who employed CIC to mange their bladder were included. Urethral stricture was defined as narrowing of urethral lumen in a patient with inability to introduce a 14 Fr catheter. Diagnosis was confirmed by retrograde urethrogram and flexible cystoscopy. Results: A total of 1200 SCI patients on CIC were included. Median age of the men was 41 years and mean duration of self catherisation was 6 years. 612 patients (51%) were identified to have stricture urethra. 50% (300) of these patients were not willing for any intervention and shifted to CIC with a smaller diameter catheter. About one fourth of these patients underwent an optical urethrotomy and remaining one fourth were treated by passive urethral dilatation. Conclusion: The occurrence of urethral stricture in Indian SCI men using CIC is almost 50%. This number is much higher than reported in world literature. Contrary to popular belief that regular catherisation will protect against stricture urethra, in-fact trauma by repeated catherisation may potentiate stricture formation. Adverse factors for stricture formation were CIC done by care giver, non sensate urethra (complete injury), poor socio economic status (catheter reuse, inadequate lubrication).

   BKP 05: Fluoroscopy free retrograde intra renal surgery – Is it feasible? Top

P. M. Siddalinga Swamy

Introduction: In recent years Retrograde intra renal surgery (RIRS) is one of the most preferred modality for renal stone less than 2 cm. Crucial steps requires fluoroscopy exposure leading to increased exposure to radiation to the patient, surgeon and staff in the operation theater. Increased exposure to radiation has adverse effects of ionizing radiation and increased risk of cancer. We describe our method of RIRS where in no c arm is used so that the risk of radiation exposure can be minimized. Aim and Objective: The aim is to know the outcome of RIRS without fluoroscopy with respect to stone free rate and complications. Materials and Methodology: A retrospective study was done at our hospital from Feb 2014 to May 2018. Inclusion Criteria: Solitary renal stones less than 2 cm were included in the study. Exclusion Criteria: Bilateral renal stones, upper ureteric stones, abnormal anatomy and pediatric patients were excluded from the study. All patients had ultrasound of abdomen and pelvis and computed tomography of kidney ureter and bladder (CT KUB) for diagnosis. Informed consent was obtained from all patients. Preoperative antibiotic was given as per hospital antibiogram.

   Chandigarh Best Video Session Top

   CBVP 01: Ambulatory supine percutaneous nephrolithotomy in flank-free oblique supine modified lithotomy position: Our point of technique Top

A. K. Sharma, Rahul Yadav, Vikas Sharma, Shajib Fareedi

Rajiv Gandhi Superspeciality Hospital, New Delhi, India

Introduction: We intend to describe standardised technique of Ambulatory Supine PCNL (Tubeless under spinal anaesthesia: SA with discharge within 24 hrs). Technique: Patient Position: After SA, patient is positioned in Flank free Oblique Supine Modified lithotomy (FOSML) Position. This position benefits one time painting and draping for simultaneous lower tract (for cystoscopy and ureteric catheterization) and upper tract (puncture and stone removal) access during surgery. Puncture and Dilatation: Puncture is done in desired calyx by triangulation technique under Fluoroscopic/ultrasound guidance. One step dilatation with 24 Fr Amplatz Dilator was done after putting guide rod. Stone fragmentation and extraction: Fragmentation is done with desired energy and most of the stone fragments drained under gravity. Confirmation of clearance done on fluoroscopy. Surgery done in sitting position with ergonomic advantages to surgeon. System Drainage: Post Procedure, ureteric and Foley catheter was left which is removed next day at the time of discharge (within 24 hrs) without the need of Nephrostomy or DJ stent. Conclusion: FOSML position helps in quick positioning after induction of anaesthesia. It also imparts all the advantages of other supine PCNL positions while overcoming their limitations like difficult superior calyceal access or spine superimposition. This position is easy, uncomplicated with various advantages over previously described positions for supine PCNL. In our vast experience, it has been found as most versatile position in terms of stone access (superior calyx, and simultaneous retrograde access to both systems), saving precious anaesthesia and OR time which finally resulted in quick recovery & early discharge.

   CBVP 02: Stepwise approach of testicular sperm extraction in non-obstructive azoospermia Top

Amit Tripathi, Rupin Shah

Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Introduction: Men with NOA, require sperm retrieval along with intra-cytoplasmic sperm injection (ICSI) for fathering children. Even though a variety of techniques have been described, there is confusion about which method of retrieval is best suited for a given patient, and most clinics tend to apply the same technique to all patients, which may not be in the best interest of a specific patient. In the same session, we start with needle aspiration biopsy (NAB), and then proceed to open single seminiferous tubule (SST) mapping followed by micro-TESE if sperms are not found in the preliminary steps. In this video we will illustrate each of these steps which has been performed in case of non obstructive azoospermia. Materials and Methods: Sixteen men with diagnosed NOA who were undergoing surgical sperm retrieval for ICSI were included in the study. We employed a stepwise approach of NAB followed by SST mapping and then micro-TESE on one testis followed by the other testis. Results: Following the staged approach sperms were retrieved by less invasive methods like NAB and SST in 43.75% of cases and additional 18.75% of sperm was retrieved by m-TESE. Conclusion: The ideal procedure is one that retrieves an adequate number of sperm with least trauma and discomfort to the patient. Thus by following the step wise approach one can optimize the sperm retrieval by minimising the invasiveness of the procedure in a single session.

   CBVP 03: Robotic renal transplantation in cases with complex vascular anatomy Top

T. A. Kishore, R. Vishnu, Himanshu Sharma, Sunil Bhat, M. K. Ramaprasad

ASTER Medcity, Cochin, Kerala, India

This video depicts the feasibility of Robotic assisted renal transplant in double vessels, right sided graft and atherosclerotic external iliac vessel. Methods: The video comprises of 5 different cases of renal transplantation 1. Depicts the technique of trousering in bench in equal sized renal arteries and the vessel is anastomosed to the external iliac. 2. Here the vessels are anastomosed in bench, end to side in unequal sized renal arteries and subsequent anastomosis to external iliac vessel. This also is a case of atherosclerotic external iliac vessel, where the plaques are stabilized and vascular anastomosis is being performed. 3. The vessels are anastomosed separately into the external iilac vessel in case of medium sized double vessel 4. Demonstrates the technique of robotic transplant where the second vessel is anastomosed to inferior epigastric artery 5. Right sided graft in a case of auto transplantation to external iliac vein. Results: All the patients had immediate graft function, and achieved nadir creatinine with in 72 hours. There were no post-operative complications. Conclusions: With increasing experience Robotic transplant can be performed in grafts with complex renal anatomy and atherosclerotic vessels.

   CBVP 04: Simultaneous bilateral laparoscopic adrenalectomy for pheochromocytoma in men syndrome Top

Rakesh Sharma, Ashwin Giridhar, T. S. Rao

Basavatarakam Indo-American Cancer Hospital, Hyderabad, Telangana, India

Introduction and Objective: Laparoscopic Adrenalectomy for MEN 2A patients has been the technique of choice for MEN 2A syndrome but there has been limited literature on the technique of simultaneous bilateral adrenalectomy in MEN 2A syndrome. Methods: A young lady presented with thyroid swelling and bilateral neck nodes, on further evaluation she was diagnosed to have Medullary carcinoma thyroid with malignant neck nodes. On whole body FDG PET imaging she was evaluated to have bilateral adrenal enlargement with raised plasma free metanephrines. In view of bilateral pheochromocytoma she was planned for a bilateral adrenalectomy followed by treatment for thyroid malignancy. Bilateral simultaneous laparoscopic adrenalectomy was planned. First Rt side was approached in the lateral decubitus position with standard ports and the camera port at the umbilicus. There was minimal blood loss and the operative time was 45 minutes, specimen was placed in endobag and placed securely in the intraperitoneum later the patient was positioned for the lt side lateral position and through standard ports the procedure was completed. There was minimal blood loss and the specimen retrieved through the camera port via an endobag. Total operative time including the positioning and re-positioning was 150 minutes. Results: Excellent postoperative recovery with minimal scar and blood loss Final HPE – pheochromocytoma. Conclusion: Simultaneous Bilateral Laparoscopic Adrenalectomy For Pheochromocytoma is a safe and effective procedure.

   CBVP 05: Robot assisted partial nephrectomy in unusual and challenging clinical scenarios: Our experience Top

Saurabh Patil, Ashwin Tamhankar, Surya Prakash Ojha, Puneet Ahluwalia, Gagan Gautam

Max Super Speciality Hospital, Saket, New Delhi, India

Introduction: Robot assisted partial nephrectomy (RAPN) is now gaining the popularity as a minimal invasive approach to manage small renal masses (SRMs). However, surgeons may face technical difficulties in certain situations. Horseshoe kidney, because of complex renal anatomy, and radio frequency ablation, due to dense intraoperative adhesions are such difficult scenarios. We share our experience of two such unusual and challenging scenarios managed by robotic approach. Methods: Our 1st case is a 55-year-old diabetic hypertensive female with a large upper polar mass extending upto renal sinus (RENAL score 9x), with a history of percutaneous radio frequency ablation. We had difficulty in upper pole mobilisation due to dense perirenal adhesions and in the localization of tumor resection margins due to its endophytic nature. 2nd case is a 34-year-old gentleman with 5x5 cm mass (RENAL score 9A) in lower pole of left moiety of a horseshoe kidney with two accessory renal arteries. We could clamp the accessory vessel supplying the tumor using intraoperative use of near Infra-Red fluorescence (NIRF). Results: Total console time was 263 and 297 minutes and warm ischemia time 50 minutes and 0, for 1st and 2nd case respectively. Both patients recovered well after surgery. Total length of hospital stay was 2 and 3 days. Both patient awaits their 1st follow up at 3 months. Conclusions: Robotic approach can be used safely and effectively even in unusual and difficult cases and so should be offered wherever feasible.

   CBVP 06: Saphenous vein sparing video endoscopic inguinal lymphadenectomy: Technical details with special emphasis to creation of plane of dissection Top

Sureka Sanjoy Kumar, Kumar Madhavan, Jena Rahul, Kapoor Rakesh, Pratap Uday

SGPGIMS, Lucknow, Uttar Pradesh, India

Introduction: Over last one decade, Video endoscopic inguinal lymphadenectomy (VEIL) has been popularised for surgical treatment of groin metastasis in penile cancer to duplicate the open template reducing morbidity and without compromising the oncological control. Creating a suitable initial space for carbon-dioxide insufflation is a crucial step for successful VEIL. There are debates in the literature regarding the plane of initial port placement at subscarpa's plane or below the camper's fascia. We present our experience with Saphenous vein sparing laparoscopic VEIL, a minimally invasive approach to avoid complications highlighting the important surgical steps with special emphasis on suitable plane of initial entry. Materials: Between October 2016 and January 2018, VEIL was performed for 8 groins in 5 patients including superficial veil in 4 groins. After suitable positioning of patients markings were done for femoral triangle and port placement. The video monitor was positioned at the contralateral side. An incision of 1-1.5 cm in the skin was made 2 cm below the apex of femoral triangle. A plane was developed deep to Scarpa's fascia with balloon insufflations by around 250 ml of air. Using thirty-degree telescope further dissection was done to develop the space. Two additional 10 mm ports were placed medially and laterally keeping the note of ergonomic proficiency. Transillumination and surface markings allow good orientation, maintenance of correct plane as well as adequate space for dissection. The dissection was carried out deep to the Scarpa's fascia. The main landmarks of dissection were medially the adductor longus muscle, laterally - the Sartorius muscle, superiorly - the external oblique aponeurosis and inguinal ligament, and the inferior margin were the apex of the femoral triangle. The saphenous vein was identified medially and preserved in all cases. The initial dissection was done on the floor to remove all the fibrofatty and lymphatic tissue with identification of SFJ, femoral artery and vein. Further dissection on the floor was done depending on the extent of proposed surgery. All the fatty and lymphatic tissue above the fascia covering the muscle was separated. Then the dissection was carried out at roof to remove all fibrofatty tissue till camper's fascia and superiorly exposing the inguinal ligament. The dissection was completed, and specimen consisted of all the fibrofatty tissue with deep and superficial inguinal lymph nodes. Results: Mean age of our study population was 53.5 yrs. Mean duration of surgery per groin was 75 minutes (60-110) with no intraoperative complication. Mean lymphnode yield was 11.5 (8-14) and mean hospital stay was 3.5 days. In first case the superficial horizontal group was missed on the right side since the inguinal ligament was not completely exposed. Four groins had one or more positive lymphnodes. Three patients had transient lymphedema, which resolved in mean follow of 10.5 months. One groin had lymphocele which was managed with aspiration. None had skin complications. There was no recurrence with mean follow up of 10.5 months. Conclusion: In our initial experience, Laparoscopic VEIL is a safe and feasible with satisfactory oncological outcome provided suitable initial space creation and step wise surgical nuances are followed. Considering very low morbidity and simplicity of procedure it is likely to replace the conventional open Ilio-ingional lymphnode dissection as standard of care.

   CKP Menon Best Paper Prize Session Top

   CKP 01: Predictors of progression free survival and overall survival in metastatic non clear cell RCC: Finding the devil in the dark Top

Y. Singh, S. K. Barua, S. J. Baruah, T. P. Rajeev, P. K. Bagchi, D. Sarma, M. Phukan

Department of Urology and Renal Transplantation, GMCH, Guwahati, Assam, India

Introduction and Objective: Due to the infrequency of non-clear cell RCC, there is currently a paucity of high-quality literature to help guide the effective treatment of these tumors. Recently, biomarkers such as platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), systemic immune inflammation index (SII) and CRP/Albumin ratio have demonstrated to be closely related to poor prognosis of patients with RCC. The objective of this study was to evaluate these biomarkers for determining the PFS and OS in patients with metastatic non clear cell cancer. Methods: We retrospectively reviewed 31 cases diagnosed with metastatic non clear cell RCC from January 2012 and December 2017. We assessed the prognostic value (overall survival and progression free survival) of pretreatment PLR, LMR, SII index and CRP/Albumin ratio based on multivariate analysis and Kaplan- Meier survival curve. Results: Median time of overall survival (OS) and progression free survival (PFS) were 62.15 weeks (95% C.I.-54.61 – 609.69) and 43.44 weeks (95% C.I. - 35.97-50.90), respectively. The median PFS (.001) and OS (p=.01) was shorter in patients with PLR > 171, LMR < 2.61. Moreover median PFS but not OS was significantly lower in SII index > 883 (p=.064) and CRP/Albumin > 0.11 (p=.229). Scan to surgery time (3.91 weeks, p=.001) was also significantly related to progression. Conclusions: Elevated pre-treatment inflammatory biomarkers such as PLR, LMR, SII index and CRP/Albumin ratio are significant determinants of shorter PFS and OS (PLR and LMR only) in patients with metastatic non clear cell RCC treated with cytoreductive nrphrectomy.

   CKP 02: Association of spontaneous expulsion with C-reactive protein and other clinico-demographic factors in patients with lower ureteric stone Top

Amit Jain, K. S. Sreerag, R. Manikandan, L. N. Dorairajan, Sidhartha Kalra, Vijay Kumar

JIPMER, Puducherry, India

Introduction: Aim of study is to find out definitive relation of C-reactive protein (CRP) and other factors with spontaneous stone passage in patients with distal ureteric calculus of 5-10 mm and to calculate risk of failure of medical expulsive therapy (MET) in particular patient with defined parameters. Materials and Methods: 185 patients of ureteric colic were included prospectively from August 2016 to May 2018. All patients started MET and followed for 4 weeks. Patients were divided into two subgroups. Subgroup A included successful spontaneous passage patients and subgroupB included failure. We compared age, gender, longitudinal and transverse diameter of stone, CRP, TLC, proximal and distal ureteric diameter and Hydroureteronephrosis (HUN). We performed univariate and multivariate analysis. To define individual risk, All patients divided according to number of significant factors and estimated success rate. Results: 122 (65.90%) patients included in subgroupA and 63 (34.10%) included in subgroupB. In univariate analysis CRP, longitudinal and transverse diameter of stone, HUN, proximal and distal ureteric diameters were significant. In multivariate analysis CRP (p=0.002), longitudinal diameter of stone (P<0.001) and HUN (p=0.005) were significantly associated with expulsion. Cut-off for CRP was 0.41 mg/dl and longitudinal diameter was 6.7 mm. Success rate in patients with no risk factor was 96.7% and with all three risk factors was 16.7%. Overall adjusted success rate after exclusion of patients with all three significant parameters was 85.40%. Conclusion: Patients with longitudinal diameter of stone>6.7 mm, HUN and CRP>0.41 mg/dl should be considered for early intervention. Success rate of MET can be increased to 86% after exclusion of patients with all three risk factors.

   CKP 03: Urinary aquaporin-1 concentrations in imaged renal masses: To evaluate its role as a biomarker for renal cell carcinoma Top

Abhilash Cheriyan, Arun Jose, L. Jeyaseelan, T. J. Nirmal, Santosh Kumar, Nitin Kekre

CMC, Vellore, Tamil Nadu, India

Introduction: Aquaporin-1 (AQP-1) has been under investigation as a promising potential urinary biomarker for renal cell carcinoma. There are reports suggesting high sensitivity and specificity of this marker. The aim of this study was to ascertain baseline urinary AQP-1 concentrations in healthy individuals and compare them with patients with imaged renal masses. Methods: Urinary AQP-1 concentrations were measured by an ELISA kit and normalized by measuring urine creatinine simultaneously. A freshly collected urine specimen was frozen at -80 degrees after addition of a protease inhibitor. A total of 72 subjects were planned for enrollment with equal number of cases and controls. However, the study was concluded after a planned interim analysis, with a total of 58 participants. An ROC curve was drawn to analyze the specificity and sensitivity of the test. Results: The mean AQP-1 concentration among the imaged renal masses was 9.42 ng/mg creatinine (1.0-50.0). Among healthy controls mean aquaporin concentration was 13.52 ng/mg creatinine (2.0-66.43). The sensitivity and specificity of the test was 67% and 63% respectively, and area under the curve was 63% at a cut of value of 7 ng/mg creatinine. The results of the interim analysis indicated that this test did not discriminate well between healthy individuals and patients with renal cell carcinoma nor did it discriminate between different T stages of the tumour. Hence, the study was terminated. Conclusions: In the Indian population, urinary AQP-1 is a not useful biomarker for renal cell carcinoma and the test has a poor sensitivity and specificity in diagnosing renal carcinoma.

   CKP 04: Is uroflow reproducible in healthy boys? Top

A. Kumar

Christian Medical College, Vellore, Tamil Nadu, India

Introduction: There are various nomograms of uroflowmetry in adults that have confirmed reproducibility. However in children the age at which uroflowmetry is reproducible has not been studied. Aim: To study the reproducibility of uroflowmetry in children aged 5-15 years and to establish the age at which uroflowmetry is representative. Materials and Methods: Of 291 boys screened, Uroflowmetry was done in 247 eligible boys. The flow was repeated at 2 weeks. A total of 227 children were included for analysis. 20 were excluded due to a voided volume less than 50 ml and/or an interrupted pattern of flow. The maximum flow rate (Q-max), average flow rate (Qmaxavg), voided volume (vv), time to maximum flow, flow time and voiding time was recorded. The reproducibility of all parameters was assessed using Inter-correlation coefficient (ICC) and correlation using Pearson's coefficient. Results: Q-max, Q-maxavg showed good to excellent concordance in boys of 5-15 years [ICC >0.6], implying the flows were reproducible. VV showed good to excellent concordance in boys of 8-15 years [ICC >0.6], but showed only moderate correlation in 5-7 years [ICC 0.4-0.6] probably due to the wide variation in the voided volumes. Q-max and Q-maxavg showed significant correlation, in all age groups, with voided volume, in first and second flow (Pearson's coefficient: 0.49 & 0.53 for Qmax1 and Qmax2; 0.48 & 0.51 Qmaxavg1 and Qmaxavg2 respectively), implying reproducibility of flow in this age group. Conclusion: Uroflowmetry is reproducible in children aged 5-15 years. Q-max and Q-maxavg are representative across all age groups studied.

   CKP 05: Study on immune response to intravesical bacillus calmetteguriene in non-muscle invasive bladder cancer Top

Mukesh Kumar Gupta, R. S. Mavuduru, G. S. Bora, S. K. Singh, R. Agarwal, A. K. Mandal

PGIMER, Chandigarh, India

Introduction: Intravesical BCG is the gold standard adjuvant treatment for non-muscle invasive bladder cancer (NMIBC). It is postulated that BCG response and adverse effects are cytokine mediated. The aim of the study was to know the urinary cytokine response pattern and to find association between their levels, and disease response /adverse effects. Methods: All patients with histologically proven NMIBC in intermediate or high risk category were included prospectively. Urinary levels of IL-2, IFN-γ and TNF-α were measured using ELISA kits at baseline, 6th week and at 3 month after intravesical BCG (120 mg, Danish1331 strain). Cystoscopy was done as per a standard follow-up protocol. Adverse effects were quantified using ICIQ-OAB questionnaire. Results: Forty-nine patients were included for the final analysis. Heterogeneity was observed in all urinary cytokine levels among the study cohort at different time frames. IL-2 showed a rise at 6 week and 3 month but was significant only at 6th week (Median Baseline: 6th week=8.12:9.64, p=0.043). TNF-α and IFN-γ showed an initial fall at 6th week and then rise at 3 month. Only TNF-α levels were significantly higher in BCG responders than in nonresponders at 6 weeks (responders vs nonresponders, 4.10 vs 0.0, p=.029). Higher IL-2 and IFN-γ levels were associated with greater adverse effects. Conclusion: We conclude that cytokine response to intravesical BCG is heterogeneous. TNF-α could be a marker of tumor response while high IL-2 and IFN-γ are associated with BCG adverse effects.

   CKP 06: Obstructive index – A novel predictor of failure of conservative management in antenatally detected pelviureteric junction obstruction using EC scan and ultrasonographic parameters: A single centre study Top

Rahul Jena, Priyank Yadav, S. Ashwin, Sanchit Rustagi, Ani Mani, M. S. Ansari

SGPGIMS, Lucknow, Uttar Pradesh, India

Objective: To analyze renal scan and ultrasonographic parameters to find obstructive index and its impact as a predictor of failure of conservative management in antenatally detected PUJO. Materials and Methods: Records of 180 cases of antenatal hydronephrosis (ANH), presenting to our centre from January 2011 to January 2017 were retrospectively analyzed. Patients with ipsilateral or contralateral kidney, bilateral PUJO, solitary kidneys, calculus disease and anatomic and neurogenic abnormalities were excluded from the analysis. Patients who underwent surgery at presentation were also excluded. The pelvic antero-posterior diameters of the affected [PAPD(A)] and normal kidneys [PAPD(N)] on the postnatal ultrasound scan at 6 weeks were noted. The T1/2 of the affected kidney [T1/2 (A)] and the normal kidneys [T1/2 (N)] on diuretic renal scan were also noted. Obstructive Index (OI) as defined by {PAPD(A) X T1/2 (A)} / {PAPD(N) X T1/2 (N)} was calculated for each patient. Results: The records of 135 renal units who had qualified for initial observation were analyzed. Of these, 30 renal units (22.2%) required pyeloplasty at a time ranging from 4 to 80 months and a median of 9 months. Mean OI in patients requiring pyeloplasty was 29.99 + 34.65 compared to 5.48 + 3.84 in patients who did not (p<0.005, Mann-Whitney). Using ROC analysis, area under curve for OI was 0.95. A value of 12.2 for OI could predict failure of conservative management with a sensitivity of 93.3% and a specificity of 92.4%. A value of 2.7 cm for PAPD (A) could predict need for surgery with a sensitivity of 70% and a specificity of 83.6%. Conclusion: PAPD at presentation is an established predictor for need of surgery in cases of ANH due to PUJO. Together with EC scan parameters and the calculation of OI, the need for surgery can be reliably predicted with high sensitivity and specificity.

CKP 07: A prospective randomized double blind, parallel group, single centre based study to evaluate the efficacy of tadalafil with dutasteride combination therapy versus tamsulocin with dutasteride therapy in patients with lower urinary tract symptoms secondary

Ankur Malpani, V. Suryaprakash, A. Singh, A. Ganpule, R. B. Sabnis, M. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Purpose: To evaluate the efficacy and safety of Tadalafil with Dutasteride combination therapy versus Tamsulocin with Dutasteride therapy in relieving LUTS secondary to BPH. Materials and Methods: Males over 45 years having LUTS secondary to BPH, IPSS >12 points, prostate volume > 30 ml (TRUS), PSA <4 ng/ml, and Qmax<18 ml/s with a minimum voided volume of 100 ml were enrolled to receive randomly Tadalafil with dutasteride (5/0.5 mg) or Tamsulocin with dutasteride (0.4/0.5 mg) orally once daily for 6 monthS. Details including IPSS score, IIEF-5 score, Uroflowmetry, TRUS were recorded at every visit (0, 1, 3, 6 months). Results: Of 242 screened, 55 of 67 patients in DUT/TAM group and 50 in DUT/TAD group completed this study. LS mean IPSS score change of -8.26,-11.26,-14.5 points of DUT/TAM group versus change of -5.92,-8.05, -13.59 points in DUT/TAM group seen (P>0.1). Least Square IIEF-5 score at end in DUT/TAM group (7.477ą2.112 point) was lower than 20.07ą2.90 in DUT/TAD group (p<0.001). Change in IIEF-5 score did not change QOL in the patients in either group (p=0.20). Mean Q-max in DUT/TAM group at 6 months was 3.23ą2.77 ml/sec versus 6.4ą3.5 ml/sec in another group (p<0.001). DUT/TAM group patients showed higher decrement in prostatic volume while Mean post void residue was higher in DUT/TAD group. Myalgia was main side effect in TAD/ DUT group unlike DUT/TAM group which showed higher number of sexual side effects. Conclusion: Dutasteride-Tadalafil is a novel combination for medical management of BPH which avoids the sexual side effects seen in standard Dutasteride-Tamsulocin combination keeping similar clinical efficacy.

   CKP 08: Role of biochemical and imaging parameters in predicting the outcome of prostate biopsy in patients of suspected carcinoma prostate Top

Harsh Jain, Hemant Goel, Umesh Sharma, Anurag Singla, Anuj Kumar, Rajeev Sood

PGIMER and Dr RML Hospital, New Delhi, India

Introduction: This study was done to evaluate the role of various biochemical and imaging parameters to predict the outcome of prostate biopsy, especially at intermediate prostate specific antigen (PSA) levels. Methodology: In this prospective study, 188 patients suspected of prostate cancer (PCa), with raised PSA between 4-20 ng/ml, or suspicious digital rectal examination (DRE) findings were included. Various parameters like age, family history, body mass index (BMI), International Prostate symptom score (IPSS), Vitamin D, testosterone levels, total PSA, percent free PSA (%fPSA), PSA density were evaluated. Prebiopsy magnetic resonance imaging (MRI) of prostate was done in all the patients and assigned MRI suspicion score (MRIss), a likert scale from 1 to 5 depending on the likelihood of malignancy. All the patients then underwent transrectal-ultrasound (TRUS) guided prostate biopsy. The association of these parameters with biopsy results was analysed by univariate and multivariate analysis. Results: DRE, tPSA, %fPSA, PSA density and MRIss were significantly associated with biopsy results. Age, IPSS, BMI, Vitamin D and testosterone levels had statistically insignificant association with biopsy results. tPSA, %fPSA and MRIss were insignificantly associated with Gleason score. On multivariate analysis, MRIss (95% CI Exp(B) 4.432-27.745) and %fPSA (95% CI Exp (B) 0.646-0.963) were found to be significantly associated with biopsy results (p value of <0.001, 0.02) with area under curve (AUC) of 0.866 (95% CI: 0.809-0.924) (p <0.001). Conclusion: %fPSA and MRIss were significantly associated with biopsy results. Further multicentric studies are required to validate our findings and to develop a nomogram to predict the outcome of prostate biopsy especially in Indian men.

   CKP 09: Human papilloma virus subtyping and telomerase activity in penile carcinoma in Indian patients: Prevalence, and correlation with clinico-pathological staging Top

P. Kumar, P. Singh, B. Nayak

AIIMS, New Delhi, India

Introduction: Carcinoma penis is an especially distressing disease. Etiology is multifactorial and clear association between HPV (Human Papilloma Virus) infection and penile cancer has been established. Objectives: We sought to provide novel data about prevalence of HPV in Penile cancer in Indian patients, correlating results with clinicopathological parameters and checked telomerase activity as signature of HPV activity. Methods: The study enrolled 30 patients with carcinoma penis as cases and 12 patients who underwent circumcision for phimosis as controls. Both groups underwent DNA isolation for HPV subtyping and Telomerase activity testing as signature of HPV activity. Results: In carcinoma penis patients, 20% patients were HPV16 positive and 23.33% patients were HPV18 positive. 33.33% patients were positive for either HPV16 or 18. In controls, 16.6% patients were HPV positive. Stagewise, 25% patients of Stage 0, 33% of Stage I, 39% of Stage II, 50% of Stage III and 17% of Stage IV were positive for HPV16 or 18. 20 patients had pathologically lymph node negative status (Stage 0, I and II), out of which, 7 patients (35%) were HPV positive. 10 patients had positive lymph nodes (Stage III and IV) and 3 patients (30%) were HPV positive. Telomerase activity was significantly increased in tissue of patients compared to control. Conclusion: This maiden study substantiates the prevalence of HPV16 & 18 infection in penile cancer patients which is independent of clincopathological staging. Higher telomerase activity in HPV positive subjects suggests HPV involvement in this disease.

   SS Bapat Prize Paper Session Top

   INT 01: Tissue engineered indigenous pericardial patch urethroplasty: A promising solution to a nagging problem Top

S. Dhanuka, T. K. Mandal, T. K. Majhi, S. Choudhury, M. Mondal

Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India

Introduction and Objective: Urethral stricture is a highly prevalent disease and has a continued rising incidence. The global burden of disease keeps rising as there are significant rates of recurrence with the existing management options with the need for additional repeat procedures. Moreover, the existing treatment options are associated with significant morbidity in the patient. Long segment urethral strictures are most commonly managed by augmentation urethroplasty. We explored the potential for the application of an acellular tissue engineered bovine pericardial patch in augmentation urethroplasty in a series of our patients suffering from urethral stricture disease. The decreased morbidity due to the avoidance of harvest of buccal mucosa, decreased operative time and satisfactory post operative results make it a promising option for augmentation urethroplasty. Methods: Nine patients with long segment anterior urethral strictures (involving penile and/or bulbar urethra and stricture length >4 cm) were included in the study after proper informed consent was obtained. Acellular tissue engineered indigenous bovine pericardial patch was used for urethroplasty using dorsal onlay technique. Results: A total of 9 patients underwent Tissue engineered indigenous pericardial patch urethroplasty for long segment urethral strictures, mostly catheter injury induced or associated with Balanitis xerotica obliterans (BXO). Median follow up was 8 months (range 2 – 12 months). Out of 9 patients, 8 (88.9%) were classified as success and 1 (11.1%) was classified as failure. Conclusion: Our study brings a product of tissue engineering, already being used in the cardiovascular surgery domain, into the urological surgery operating room with satisfactory results achieved using standard operating techniques of one stage urethroplasty.

   INT 02: Nephroscope assisted insertion and internal fixation of peritoneal dialysis catheter: A novel technique Top

Fusakele Ankit, Wadhera Vishal, Jain Prashant, Khandelwal Shradha

City Hospital and Research Centre, Jabalpur, Madhya Pradesh, India

Introduction: CAPD is a common modality of dialysis, indicated in patients with poor cardio-vascular status. Catheter tip migration is common. To overcome this, various laparoscopic techniques are described for internal fixation or peritonealisation of the tip. CKD patients with associated comorbidities are unfit for pneumoperitoneum and GA. Conventional technique of open mini-laparotomy, doesn't require GA, but there is no method to fix the tip under local anaesthesia. Technique: We are describing a novel technique wherein we use the nephroscope and amplatz sheath through peritoneal opening for peritoneoscopy. After a para-umblical incision under local anaesthesia and opening peritoneum, a Nephroscope (Richard wolf – Dresdan 22F) used to do peritoneoscopy under saline irrigation. An amplatz sheath (CooK-26F) probed on the nephroscope. With the help of a specially designed Fusakele's needle, dialysis catheter tip fixed to anterior abdominal wall. Amplatz sheath removed and peritoneal opening closed. Results: 11 patients (average age 49.1 year, 7 females, 4 males) have been operated under L. A., average follow up of 12.18 months (range 6-18 months). Average time per surgery 39.1 minute (+/-3.91). One patient (9%) developed infective peritonitis after 3 months, resolved after lavage and antibiotic course. No patient reported with catheter tip migration so far. One (9%) catheter removed after renal transplant surgery 6 months after catheter insertion. One patient (9%) died of CCF after 1 year of surgery. Conclusion: With the initial results of the above mentioned technique, it appears feasible, safe and simple without adding extra cost and time required for the surgery.

   INT 03: Effect of posterior augmentation of pubourethralis on early continence after robot assisted radical prostatectomy Top

Malik Abdul Rouf, Rajesh Taneja, Venkatesh Kumar, Mahender Sharma, Shrawan Kumar, Vaibhaw Sood, Azhar Ajaz, Vikas Bansal

Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India

Purpose: The idea of posterior augmentation of pubourethalis on early continence after RARP is based on the concept to restore normal anatomy of pubourethralis around the urethra which often gets distorted after RARP. Materials and Methods: In our study we have attempeted to study the effect of posterior augmentation of pubourethalis on early continence after RARP. Return of continence was assessed on day of catheter removal, day 1st, day 3, day 7, day 15, day 30, day 90 and day 180. Patients with post operative urinary incontinence were advised to use adult diapers. The number of diapers used per day was recorded till patient became dry. Continence was defined as no or one diaper use per day. Results: Continence was assessed after removal of Foleys catheter on 14 th day of surgery as per the protocol of study. Out of total 42 patients, 7 patients (16.6%) were continent on day zero of catheter removal (no pad in 4 patients and one pad per day in 3 patients). On day 3 of catheter removal, 9 patients (21.4%) were continent (no pad in 6 patients) and 23 patients (54.7%) at day 7 were continent (no pad in 10 patients). On day 15, 29 patients (69%) were continent (no pad in 16 patients), while 38 patients (90.4%) were continent at 1 month (no pad in 31 patients and 1 pad in 7 patients). At 3 and 6 months, 41 patients (97.6%) were pad free. One patient (2.3%) has been requiring 2 pads per day at 6 months follow up, and is termed incontinent as per the definition used in this study. He was on catheter preoperatively for incontinence even before the surgery. The median interval for the recovery of continence was 15 days. Complications: Out of 42 patients one patient had ureteric injury which was detected on post operative day 5, patient was managed with antegrade stenting. In another patient ureteric orifice was very close to urethro vesical anastamosis for which uretero neocystostomy was done and one patient had prolonged ileus which was managed conservatively. Conclusion: Although the early results seam to be encouraging but the sample size is small and needs further study with large sample size.

   INT 04: Construction and assessment of an innovative indigenious transurethral resection of the prostate simulator Top

Ashish Rawandale, Lokesh Patni, Jitendra Chaudhary, Parag Gulhane, Abinav Gade, Shakul Kaushik

Tejnaksh Healthcare's Institute of Urology, Dhule, Maharashtra, India

Introduction: Transurethral resection of the prostate (TURP) has a significant learning curve. Improper approach and techniques may have unwanted postoperative complications. We describe and validated our own, portable, sausage based TURP simulator. Methods: A short anatomical study of urethra, sphincter and prostate was conducted using CT sections and 10 endoscopic videos of TURPs. The simulator frame was designed, patented and constructed using silicon. The frame is designed to accept and allow resection of sausages or meat roles using any technique. Visual assessment by the mentor facilitates training. Evaluation using a 3 step test, GRS score and trainee feedback was analysed using SPSS. Results: 16 urology trainees, 3 experts participated in this single center study. Face and content validity evaluated by experts demonstrated satisfactory replication of the prostate and bladder anatomy. The simulator could differenciate novices from the experts. All subjects demonstrated statistically significant betterment in their GRS scores and total resection time. Parameters of trainees showed a shift, towards the control demonstrating the training capabilities. Subjective simulator assessment indicated high degree of satisfaction on effectiveness. Conclusions: Our portable TURP simulator is the first of its kind. It uses sausages as a substrate for resection using any resection technique. It allows evaluation and supervised, repetitive tailored learning in a controlled, low stress environment. It needs no preparation, has a low initial and no maintenance cost. Further studies would be aimed at further assessment of training and proficiency abilities.

   INT 05: Pedicled dartos wrap around technique for prevention of bulbar urethral entrapment in complex pelvic fracture urethral distraction defect repair Top

H. S. Bhatyal, Y. Garg, A. Arya, D. Mitra

BLK Superspeciality Hospital, New Delhi, India

Complex PFUDD is associated with long stricture, failed repair, urinoma and fistulae. The Cornerstone for repair is end to end anastomosis of distracted urethral ends through perineal or transpubic approach For a successful result all fibrous tissue occupying distraction defect has to be excised. This creates a large dead space along with raw surface on pubic bone on which bulbar urethra is going to rest. This large dead space becomes a potential area for a seroma, which can get infected or replaced by fibrous tissue which can entrap the delicate bulbar urethra thereby compromising its vascularity leading to ischemia and failure of urethroplasty. We have coined this terminology of bulbar urethral entrapment (BUE) syndrome to describe this. We also describe our technique to avoid BUE by interposing a pedicled dartos flap between the pubic bone and the bulbar urethra. Methods: 20 patients of complex PFUDD underwent perineal urethroplasty at our institution from 2013 to 2017. In first 5 cases drain was placed in the unobliterated dead space. In next 15 dartos flap was wrapped around the bulbar urethra filling the dead space. Results: 3 out of first 5 cases of had failure and required reoperation. 12 of the subsequent 15 patients are doing well. 3 have obstructive voiding and are being managed by OIU and periodic dilatation. Conclusions: BUE may be an unrecognized cause of failure of repair of complex PFUDD. Wrapping the bulbar urethra with a vascularised pedicle graft should become an important tenant in the repair of such cases.

   INT 06: Construction and assessment of an innovative indigenous All-Endo-Uro-Sim – A one stop solution for endourology training Top

Patni Lokesh

Institute of Urology, Dhule, Maharashtra, India

Introduction: Endourology is evolving at fast pace. Simulation based effective endourology training of the trainee at a low cost is the mandate of the day. Aims and Objectives: To provide a one stop solution for endourology training. Materials and Methods: The All-Endo-Uro-sim was designed and manufactured after a brief anatomical study of the human genitourinary system. It consists of a silicone model representing the penis, scrotum, bladder, ureters and pelvicalyceal system. This model was used for endourological procedures such as Cystolithotripsy, ureterolithotrity and flexible retrograde intrarenal surgery using routine endoscopes and accessories. Evaluation using a 3 step test, GRS score and trainee feedback was analyzed using Spearman rank order correlations and paired t test. Results: There was overall improvement in the pre and post test GRS scores of all the trainees. The procedure time, instrument handling and injuries to the organs showed a statistically significant betterment (Spearman rank order correlations) p<0.001. Face and content validity as evaluated by the experts was satisfactory. Subjective simulator assessment of the trainees indicated a high degree of satisfaction on effectiveness of the simulator. Conclusions: Our portable All-Endo-Uro-sim is a cost effective training model for endourologic training. It uses routine endoscopic instruments and accessories. It is portable and washable. It allows evaluation and supervised repetitive tailored learning in a controlled, low stress environment. The simulator has the potential to be used as a percutaneous trainer which would make it one of its kind; a complete solution for most endourological procedures.

   Vijayawada Best Poster Prize Session Top

   VPP 01: A randomised comparative study between laser with suction and shockpulse in management of renal calculi less than 2 centimeters in size Top

C. S. Deshmukh, S. B. Sudharsan, A. P. Ganpule, R. B. Sabnis, M. R. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Introduction and Objective: Energy source does play a vital role in the effective stone clearance in patients undergoing miniperc. Recent addition to the armamentarium of energy sources is the Olympus Shockpulse™. We intend to compare Laser with suction Vs Shockpulse as energy sources in miniperc to manage stones less than 2 cms in size. Methods: Sixty patients with stones less than 2 cm were randomised into two groups; Group 1 – Laser with suction and Group 2 – Shockpulse. Miniperc was performed using 20 – 22 Fr Amplatz sheath and an 18 Fr Storz nephroscope. Laser lithotripsy was performed using EMS laser with suction and Shockpulse lithotripsy was performed using Olympus Shockpulse device. Patient demographics, stone characteristics, intraoperative parameters, and postoperative outcomes were analysed. Results: The baseline patient demographics and stone characteristics were similar in both groups. In laser with suction group, the mean stone size was 21.4 ± 2.63 mm. The average operating time was 45.42 ± 14.79 minutes and average hospital stay was 1.47 days. Average tract size was 20 Fr and stone clearance rate was 100%. In Shockpulse group, the mean stone size was 23.2 ± 2.12 mm. The average operating time was 36.27 ± 11.41 and average hospital stay was 1.56 days. Average tract size was 20 Fr and stone clearance rate was 100%. Conclusion: Both the devices are very efficient. While the laser with suction expedites the process, Olympus Shockpulse is slightly superior with even better vision, faster stone clearance and shorter operative times.

   VPP 02: Will retroperitoneoscpy be superior for laparoscopic nephrectomy in patients with decreased pulmonary reserve? Results of a randomized study Top

Vishal Garg, V. Garg, H. Goel, N. Khattar, R. Sood, A. Gupta

PGIMER and Dr. RML Hospital, Delhi, India

Objective: Raised intrabdominal pressures during laparoscopy challenge the pulmonary reserves of a patient and hence bring a new dimension of concern during anaesthesia as compared to open procedures. Laparoscopic nephrectomy is the most common urological laparoscopic procedure performed and can be equally well performed both trans and retropperitoneoscopically. In this randomized study, we assessed the effect of route of laparoscopic nephrectomy on respiratory system. Materials and Methods: A prospective study was conducted in urology department, from 1st November 2016 to 15th May 2018 randomizing all patients admitted for nephrectomy for benign cause into retroperitoneal and transperitoneal group. Patients with creatinine >1.5, XGPN, GUTB, open surgery on the affected side and early conversion to open (within 1 hour of pneumoperitoneum) were excluded from the study. Intraoperative (duration of insufflation, IAP, urine output, urine flow rate) and PaCo2, EtCO2 were parameters were recorded at 1 hourly interval. Results: On univariate analysis, preoperative and demographic parameters were comparable in both the groups. IAP in transperitoneal group was significant with p value of 0.001. IAP correlation with EtCO2 and PaCO2 was calculated using Spearman correlation coefficient. In transperitoneal group, IAP is positively and significantly correlated to PaCo2 (rho-0.542, p value-0.014) but not in retroperitoneal group the correlation though positive but it is not significant. Conclusion: IAP in transperitoneal group is significantly more than in retroperitoneal group. Also PaCO2 increases significantly as IAP rises in transperitoneal group. Hence retroperitoneosvopy may be a safer procedure in patients with compromised pulmonary reserve.

   VPP 03: Percutaneous nephrolithotomy in patients with hemophilia: A tertiary center experience with its perioperative implications Top

Neeraja Tillu, Patwardhan Sujata, Patil Bhushan

Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Introduction: The existence of hemophilia in patients with a urological disease requires a complex course of action. To minimize the risk of hemorrhage, urologists need to manage both preoperative and postoperative periods in conjunction with the hematologist. Materials and Methods: We did a prospective analysis of preoperative and intraoperative measures, postoperative outcomes and safety of PCNL in 6 such patients from January 2015 to January 2018. Patients were operated after thorough preoperative counseling and after confirming the availability of replacement factors. Results: 4 patients were diagnosed cases of hemophilia and 1 patient was detected to have von Willebrand's disease postoperatively. Macroscopic hematuria was the most common presenting symptom and mean preoperative hemoglobin was 11.2 gm/dl. Stone size ranged from 11 mm to 4.2 cm. Substitution therapy was started an hour prior to surgery and was continued for up to 21 days. Mean dilatation of sheath was 22.6 Fr. Average blood loss was 350 ml, with 2 patients requiring blood transfusion. All patients were operated under general anesthesia and were given opioids for pain relief. The patients required intensive care monitoring along with the hematologists. 5 patients had complete clearance, done in a single stage procedure. 2 patients had clots which required bladder clot evacuation and angioembolisation respectively. All stones were calcium oxalate and there were no residual calculi on plain CT at 3 months of follow-up. Conclusion: Considering the morbidity associated with the condition, it is important to consider these patients for a comprehensive metabolic evaluation with serial imaging on follow up.

   VPP 04: Individualized management of obliterative urethral stricture in females – Five patients five management strategies Top

D. Bansal, R. Nayyar, P. Singh, S. Jain

All India Institute of Medical Sciences, New Delhi, India

Introduction and Objectives: Incidence of female urethral stricture ranges from 0.1-1%. Obliterative strictures require individualised treatment depending upon site, length and density of stricture besides associated fistulae, bladder capacity, introital tissue availability and continence. Goal is to achieve urethral patency with preservation/restoration of continence and sexual function. Methods: We describe a series of 5 females with completely obliterative urethral strictures over two years. Data was retrospectively collected on demographics, stricture characteristics, management and outcomes. Results: Mean age was 22.2 yrs. The etiology was road accident, stampede injury, railway accident, obstetric trauma and iatrogenic trauma in 1 patient each. All had pre-operative suprapubic catheter (SPC). Stricture site was bladder neck in 2, proximal urethra in 1 and mid-distal urethra in 2 patients. One patient had associated vesico-vaginal fistula and 3 had urethro-vaginal fistulae distal to stricture. The patient with obstetric trauma presented with obstructive uropathy. One patient each was managed with tubed buccal mucosal graft urethroplasty, tubed bladder mucosal graft urethroplasty and modified Tanagho bladder neck reconstruction. One patient underwent continent catheterizable pouch formation. Permanent SPC placement with VVF repair was done in one patient in view of very small capacity bladder and chronic kidney disease. At minimum follow-up of 6 months, all patients were continent. No patient required re-do procedure. Conclusion: Female obliterative urethral strictures have heterogenous causes and characteristics. Each patient requires a tailored surgical approach suiting needs, expectations and available options. Detailed anatomic and physiological assessment plays a key role beside vaginal surgical skills of operator.

   VPP 05: Future of endourology stone clinic -follow up online: A pilot study comparing virtual and real consultation (out patient) for stone patients follow up visit Top

Haresh Thummar, J. Vyas, T. Keya, N. Zinto, T. Nisha, P. Suthar

Sterling Hospital, Vadodara, Gujarat, India

Introduction: Healthcare professionals are among the last, service providers to not use Internet technology to communicate with the people they serve. As much as patients are able to communicate with their doctors, and physicians, medical professionals will also be able to transmit data between each other; overall helping the patients' well-being. Many a times, it's very difficult for patients to come from far places for stone clinic for consultation wasting a lot of time. With increased use of mobile phones, Internet and with increased skill of fast communication through handy available cell phone to almost everyone, its possible to use virtual consultation. Uncomplicated stone patients do not need detail clinical examination most of the time. Can we use these advantages in current era in providing health care at every corner of world without compromising quality of care? We could not find literature to address this issue. Aim of our study was to assess feasibility and accuracy of e-consultation in stone clinic and compare with standard consultation defining good practice and inform its implementation in relation to clinician-patient consultations via whatsapp and similar virtual media. Methods: We included 40 uncomplicated stone patients who underwent endourology surgery during Jan 2016 to June 2017 according our inclusion criteria. First we did e-consultation using whatsapp and other virtual media and assessed clinical history, biochemical profile and imaging with images and communicated through media and made a provisional diagnosis and decided management plan. Then we did real consultation as standard practice and decided management plan. We compared diagnosis and management plans in this both consultations virtual and real. We graded in five grades according to difference in diagnosis and management plan. We assessed 5-point likert scale also for virtual and real consultation feedback. Grade Description 1 Minor differences not affecting surgical plan 2 Difference that change in type of procedure 3 Difference that change decision for observation vs. surgery 4 Difference that leads to an additional procedure needed during surgery 5 Difference that result in potentially severe complication. Results: There was no significant difference in diagnosis or management plan in virtual Vs. real consultation. There was grade 1 change in 6 patients, grade 2 and 3 change in 2 & 1 patient. Five point likert scale score difference was not significantly different. Conclusion: Based on this pilot study, virtual consultation (e-consultation) for kidney stone patients is feasible and accurate in selected group of patients without compromising quality of care and may be a future of endourology clinic. However, further study with large number of patients are required to define its role in future.

   VPP 06: A warning for diabetes patients on metformin: Check your kidneys for calculi Top

Haresh Thummar, Shivang Dalwadi, A. Patel, T. Keya, V. Jigish, P. Shah, N. Thummar, F. Tyrone, M. Mehta

Sterling Hospital, Vadodara, Gujarat, India

Introduction: Metformin, a biguanide drug commonly used to treat type 2 diabetes all over the world. Diabetes patients are more prone to develop kidney stones other than non-diabetics. In the world, overall stone prevalence has doubled since the 2000–2002-time period (1). Metformin (dimethyl biguanide) is an antihyperglycemic agent used in type 2 diabetes. Beyond its action on glycaemic control, metformin exhibits other intrinsic effects that could play a role in prevention against diabetes complications. Some studies thus reported an improvement in the antioxidant status in patients treated with metformin. This might be in part related to its property to limit formation of advanced glycation end products (AGEs) and to decrease the overproduction of free radicals in diabetic subjects (2). Renal cellular exposure to oxalate (Ox) and/or CaOx crystals leads to the production of reactive oxygen species (ROS), development of oxidative stress followed by injury and inflammation. Renal injury and inflammation appear to play a significant role in stone formation (3). Hypothesis for this study indicates that metformin should decrease the number of renal calculi occurring in type 2 diabetes patient. We studied retrospective way to determine the results in 289 type 2 diabetics subjects. So undertaking retrospective study and asses various factors for the kidney stone such as duration of diabetes, history of stone, episodes, emergency room visits required during the time of kidney stone, surgery and any other complications. Materials and Methods: Retrospective analysation of patients on diabetes mellitus. This study includes the patients of time period from November 2015 to July 2017. Total 419 patients were included in this study. Sample inclusion criteria included patients exclusively on metformin (no other combination of drugs included with metformin) and insulin (no other hypoglycaemic adjuvant drug included), Type 2 DM. Whereas exclusion criteria included patients on combination of drugs, Active infection, pregnancy, pediatric age group, metabolic disorders. As we divided patients into two groups group A and group B. Group A patients are those who are taking metformin and Group B patients are those who are on insulin. Then we assessed duration of diabetes mellitus, medical management that either the patient was on metformin or on insulin, history of any kidney stones, episodes, emergency room visits due to kidney stones, surgery for removal of stone and any other complications. Each patient was labelled to have stone in past only by the reports and appropriate history. Results: Metformin Total number of Pts.- 168 Stone 35 (20.83%) Non-metformin Total number of Pts.- 101 Stone 9 (8.9%) Only insulin Pts.- 89, stone 4 (4.49%) Other than insulin Pts.- 12, stone 5 (41.6%) Total number of patients – 269 PRE-DM STONES NO. OF PATIENTS – 17 (8.54%) POST-DM STONES NO. OF PATIENTS-45 (16.70%) Pre-Metformin- 11 patients had stone (6.91%) (168 total no.) Post Metformin- 36 patients had stone (21.42%) (168 total) Discussion There are many studies showing Metformin increasing expression of reactive molecules leading to kidney injury and increases oxidative stress which in turn is the favourable factor for formation of most commonly calcium oxalate stones. but there were no conclusive data available on the humans for this hypothesis. Metformin increases the expression of SOD and TIM-1 in the kidney tissue suggesting increased predisposition to form kidney stones (4). The average age of patients having stone is =26 yrs and the predisposition is more in males than females, Ratio is 3:1. The avg. urine Ph of patients having stone 6.5, Avg. creatinine levels 0.98. total 419 samples were studied and as per the inclusion criteria 268 samples were included in this study and 151 samples were excluded. Patients those having stones, 11 (25%) required ER visit, 21 (51.25%) required surgery, 9 (20.45%) had complications like recurrent UTI. Conclusion: Metformin increases the incidence of kidney stones and stone related events in type 2 diabetics patients as compared to insulin group of patients. These group should have check up for kidney stones regularly. However, further studies are warranted in this regard to establish this association.

   VPP 07: Ureteric injury after celiac plexus block: A case report Top

Gaurav Sharma, C. Mallikarjuna, K. P. Reddy, D. R. Ragoori, M. T. Bendigeri, S. M. Ghouse, B. Enganti

Asian Institute of Nephrology and Urology, Hyderabad, Telangana, India

Introduction: Celiac plexus block is a pain management modality for chronic pancreatitis patients, and is associated with few complications. Though seven cases of ureteric injury after lumbar sympathetic block have been reported, ureteric injury following Celiac plexus block has never been reported in literature. We present a rare case report of ureteric injury after Celiac plexus block. Methods: An eighteen years old male, known case of chronic pancreatitis, underwent celiac plexus block for pain management. Two months later presented with persistent pain abdomen. On evaluation, CT showed right hydronephrosis with large well defined retroperitoneal collection. Right retrograde pyelography revealed extravasation of contrast from proximal ureter, for which right percutaneous nephrostomy was performed. Four weeks later nephrostogram showed right upper ureteric stricture approximately 4 cm starting from PUJ. Robotic assisted laparoscopic right uretero-calicostomy plus DJ stenting was done. DJ stent was removed after 2 months. Results: There were no perioperative and postoperative complications. IVP after DJ stent removal showed adequate drainage of contrast across right ureter. At six months follow up, patient is asymptomatic. Conclusion: Ureteric injury after celiac plexus block has not been reported in literature. We report a rare case of ureteric injury and retroperitoneal urinoma after celiac plexus block, successfully managed with initial drainage and subsequent repair.

   VPP 08: Prostatic urethral angle correlates with symptom scores and urinary flow rates in men with benign prostatic enlargement Top

M. Arora Amandeep, P. W. Pawar, A. S. Sawant, M. Maheshwari, S. R. Patil

Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India

Objective: To evaluate the impact of the prostatic urethral angle on the International Prostate Symptom Score (IPSS) and the maximum urinary flow rate (Qmax) in patients with benign prostatic enlargement (BPE). Methods: All patients presenting with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement were included. The IPSS was used to evaluate their LUTS. Prostatic volume (PV), prostatic urethral angle (PUA) and the intravesical prostatic protrusion (IPP) were determined by transrectal ultrasonography. Uroflowmetry was performed to measure the Qmax. The correlation between the ultrasound prostate parameters and Qmax and IPSS were determined using Pearson's correlation. Further Regression analysis was done to predict Qmax and IPSS using these variables. Results: Total 64 patients (mean age: 62.73 + 7.61 years) were studied. The PUA had a strong negative correlation with Qmax (r=-0.83, p<0.001) while IPP had a weak negative correlation with Qmax (r=-0.27, p=0.028). Also, PUA (r=0.44, p=0.0002) moderately correlated and IPP (r=0.29, p=0.02) weakly correlated with the IPSS. Linear regression showed that PUA could significantly predict Qmax (r=0.833, p<0.0005), IPSS (r=0.48, p=0.001) and voiding IPSS (r=0.54, p<0.001). The mean PUA in patients with moderate and severe IPSS was 49.4o and 52.2o while the mean PUA in patients with Qmax <10, 10-15 and >15 was 42.2o, 48.3o and 56.1o respectively. Also, a greater PUA significantly predicted (p=0.0009) failure of medical therapy and requirement of surgery. Conclusion: An increasing PUA is independently and significantly associated with worsening of the IPSS and decreasing Qmax in men with LUTS due to BPE. Patients with an increased PUA are more likely to fail medical management and require surgery.

   VPP 09: Novel techniques in DVIU using liquid buccal graft and stromovascular fraction – Improving outcomes Top

Pankaj Joshi, Ayman Atawa, Amar Rawal, Sanjay B. Kulkarni

Kulkarni Reconstructive Urology Centre, Pune, Maharashtra, India

Introduction: DVIU is still the commonest procedure performed for urethral strictures all over the globe. Santucci reviewed the results of DVIU. Success of third DVIU is 0%. CIC after DVIU does not offer cure. Urethroplasty offers stable long-term success rate. There has been a long thought to improve the results of VIU. We present our experience with VIU along with Liquid BMG and VIU with Stromovascular Fraction injection for short bulbar strictures. Materials and Methods: Ours is a tertiary referral center. We have performed 4358 Urethroplasties including 1190 pelvic fracture urethral distraction defects in last 2 decades. 6 patients were selected for Liquid BMG study and 3 for stromovascular Fraction injection after VIU. BMG was harvested and liquefied using mincing, centrifuging at 5000 rpm and then mixed with Glue, injected at site of VIU. In stromovascular fat, liposuction was done, 100 ml of fat was processed with collagenase enzyme, filtered and solution obtained was injected at site of DVIU. Results: 3/6 patients with Liquid BMG are doing well at median follow up of 27 months. These had recurrent strictures after VIU and proximal anastomotic narrowing.3/6 of them had failed posterior urethroplasty and did not do well on VIU as there is no spongiosa in posterior urethroplasty anastomotic site. 3/3 with stromovascular fat injection are doing well. Conclusion: Advances in VIU will be the future for endourology. Liquid BMG and stromovascular fraction injection after VIU are good techniques, easily reciprocated in any OT and may be the future in short bulbar strictures.

   VPP 10: Supravesical urinary diversion with ileal conduit for benign disease: A study assessing its indications, outcomes and its role today Top

Tillu Neeraja, Tamhankar Ashwin, Patwardhan Sujata, Patil Bhushan

Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India

Introduction: Ileal conduit urinary diversion for benign disease is the last resort for patients with severe LUTS who have not responded to less invasive forms of treatment. Literature covering this topic is sparse and historical. Materials and Methods: 17 patients undergoing ileal conduit urinary diversion for benign disease after all possible options/neglected disease were studied from a single institute from 2014 to 2017. Perioperative data was recorded and outcome measures included patients' operative course, hospital stay, 30-day and 180-day complications using Clavien Dindo grading scale. Results: The cohort included 12 females and 5 males. Mean age was 47.8 years Underlying conditions included: rectourethral fistula (1/12), radiation cystitis (4/12), genitourinary tuberculosis (4/12), neurogenic bladder (4/12), complex vesico-vaginal fistula (3/12) and exostrophy bladder (1/12). Patients of neurogenic bladder were significantly younger and had fewer comorbidities. The mean operating time was 3.5 hours (2.5 TO 6 hrs) and blood loss was 634 ml (350-900 ml). CKD patients underwent a short segment conduit (10 cm). Mean LOS was 10 days (6-19 days). On short-term followup, Clavien grade complications included- I (2/17), II (3/17), III (1/17), V (1/17). On long term followup - bladder spasms (6/17) urethral bleeding (1/17) and pyocystis (3/17). Conclusion: In attempting to “do no harm”, physicians might be reluctant to manage such patients with urinary diversion which could be their only chance at relief. However, it can be morbid and patients should be counseled regarding its risks and benefits and the need for long term follow-up.

   VPP 11: Diagnostic role of cognitive MRI-TRUS fusion-targeted prostate biopsy versus conventional TRUS biopsy of the prostate in patients with PSA less than 10 NG/DL Top

Laddha Abhishek, Bijalwan Priyank, Pooleri Ginil Kumar, Thomas Appu

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Introduction and Objective: The purpose of this study was to evaluate the prostate cancer yield rate of cognitive MRI-TRUS fusion-targeted prostate biopsy versus conventional TRUS Biopsy in patients with elevated PSA between 4 to 10 ng/dl. Methods: Our study is a retrospective review of consecutive patients undergoing MP-MRI of the prostate with a subsequent prostate biopsy from Jan 2017 to June 2018. A cohort of men undergoing conventional prostate biopsy was utilized for comparison. The cancer-detection rate, tumor location, Gleason score and PSA-related data were compared between both groups. Results: In the total 96 patients were included in this study. 42 patients underwent Cognitive MRI-TRUS fusion-targeted prostate biopsy and 52 patients underwent TRUS guided biopsy. There was no significant difference in demographics and PSA levels among the cohorts. Cancer rate detection rate were similar between the cognitive and TRUS guided groups (9.8 % % vs. 8.5 %). There was no significant difference in final Gleason scores or number of positive cores in both cohorts. Conclusion: Cognitive MRI-TRUS fusion-targeted prostate biopsy seems to have limited role in patients with PSA less than 10 with no previous history of negative biopsy.

   VPP 12: Pathological anatomy of spermatic veins in patients with varicocele- long term results from single institute Top

S. D. Sharma, R. K. Shimpi, B. Shah, P. Shah, P. Patel

Ruby Hall Clinic, Pune, Maharashtra, India

Objective: The pathogenesis mechanism through which varicocele causes testicular dysfunction and subsequent alteration in spermatogenesis, is not completely understood. This study intends to clarify the anatomical and histopathological features of varicocele veins. Methods: A prospective, observational study involved 62 Patients aged 18–35 years who underwent microsurgical varicocelectomy from May 2015 to April 2018. Testicular hemodynamic was evaluated by color Doppler study. Spermatic veins were obtained from varicocele patients during surgery. The venous anatomical details were evaluated by intraoperative venograms, testicular venous pressure studies, and histopathological findings. Postoperative results of semen analysis, testicular blood flow, and serum testosterone were compared with preoperative values. Results: The spermatic venography showed the precise anatomy of the pampiniform plexus and possible small venous communications with pelvic veins. The transverse sections of the vein show destruction of the intima, intimal endothelium which is with invaginated and thrown in folds. Degeneration of the muscle fibers of the media with the appearance of collagen bundles among them with apparent hypertrophy of muscularis. Conclusions: The hypertrophy of the muscularis explains the high venous pressure in the pampiniform plexus, which correlates with the grade of varicocele. Morphologic changes of the venous wall may lead to impaired venous return which promotes the development of varicocele and its pathogenesis effect on spermatogenesis.

   VPP 13: Nerve sparing laparoscopic radical cystoprostatectomy with extracorporeal ileal conduit: Technique, 30 and 90-day complications with early outcomes and sexual function in a series of 15 patients Top

Rahul Yadav, Adittya K. Sharma, Vikas Sharma, Shajib Faridi

Rajiv Gandhi Super Specialty Hospital, Delhi, India

Introduction: To describe technique & early outcomes of Nerve Sparing LRC with Extracorporeal IC in a series of 15 patients. Materials and Methods: 15 Patients between April 2017 to March 2018 were enrolled and underwent nerve sparing LRC with extracorporeal IC. Demographic, clinical characteristics, perioperative outcomes, complications, pathological and early oncological outcomes were recorded prospectively. Primary end points were 30 and 90-day complications as per modified Clavien-Dindo grading system. Secondary endpoints were pathological and early oncological outcomes and IIEF-5 scores as return of sexual function. Results: Mean Age and Charlson's comorbidity index were 59.14 years and 2.51 respectively. Post TURBT Histopathological ranges from Muscle invasive Low Grade transitional cell carcinoma (TCC) to High grade muscle invasive TCC. Clinical stage varies between T2bN0M0 to T4aN2M0 and same has been confirmed after LRC. In all patients, Enhanced recovery after surgery (EARS) protocols were used. Average Hospital stay was 4 to 5 days. 30-day complication rate was 33.3%, in which 4 patients had superficial wound infection (Clavien Grade 1) and 1 died at 6th Post-operative day due sudden uncontrolled Atrial Fibrillation (Clavien Grade 5). 90-day complication rates were same. IIEF-5 score showed mild to moderate Erectile Dysfunction and early oncological outcomes showed no clinical evidence of metastasis at 4 to 6 months follow-up. Conclusion: Nerve Sparing LRC is minimally invasive, safe, feasible, reproducible alternative to conventional open approach in well selected patients in experienced institutions. Early oncological and functional outcomes appear promising to be evaluated further with long term studies.

   VPP 14: Are we justified in performing robot assisted radical prostatectomy in men over 75 years of age? Analysis of surgical, oncological and functional outcomes Top

S. Tamhankar Ashwin, Patil Saurabh, Ojha Surya Prakash, Ahluwalia Puneet, Gautam Gagan

Max Institute of Cancer Care, New Delhi, India

Introduction: Management of prostate cancer in elderly age group is still debatable in terms of possibility of robot assisted radical prostatectomy (RARP). Methods: We conducted an outcome analysis of 31 patients aged >75 years undergoing RARP from a cohort of 450 total patients operated by single surgical team in last 7 years. Patients were explained all possible treatment options before subjecting for RARP, ensuring good performance status preoperatively. Results: Median age was 76 years with 74% patients having some comorbidity. Median preoperative serum PSA was 15.25 ng/ml (5.6-61). Nine patients were sexually active but with either mild to moderate erectile dysfunction. Median Gleason group grade was 3 with 38.7% patients having >T2 disease on imaging. Median console time and estimated blood loss were 156 minutes (110-300) and 100 cc respectively without any open conversion. Median length of stay and catheter removal day was 2 and 9 days. Median lymph node yield was 18 (6-38) with 70% patients having pathologically T3 disease and 45.2% having N+ disease. Overall margin positivity rate was 40% (16.6% multifocal). 90 day complication rate was 3.25% (Clavien grade 2- minor) without any major complication. Continence recovery was early (<3 months), average and delayed (>1 year) in 30%, 26.6% and 43.3% respectively. At a median follow up of 9 months (1-63), 54% patients did not develop biochemical recurrence till longest follow up with 33% patients requiring an adjuvant treatment. One patient developed metastasis at 44 months, with median overall survival and metastasis free survival being 9 months (1-63). Conclusion: RARP in patients > 75 years is safe with promising surgical, oncological and functional outcomes, which mandates careful patient selection and counselling.

   VPP 15: Incidence of male sexual dysfunction in northern India and reasons for non-evaluation in urology clinic Top

Laddha Abhishek

Pacific Medical College and Hospital, Udaipur, Rajasthan, India

Introduction and Objective: Male sexual dysfunction includes erectile dysfunction, ejaculation disorders, orgasmic dysfunctions, and disorders of sexual interest/desire. Although current epidemiologic research supports the high prevalence of erectile dysfunction worldwide, incidence data are limited. We wanted to study the incidence of male sexual dysfunction in Northern India and factors which are preventing patients from discussing sexual problems with doctors while in urology clinic. Methods: Any male more than 40 years of age presenting to the urology outpatient clinic from August 2015 to November 2017 as a patient or accompanying person were evaluated based on a set questionnaire. Any person with the previous history of sexual dysfunction in past or present were excluded from the study. Results: We evaluated 1429 patients in the urology outpatient clinic, out of which 1148 proformas were available for final analysis. 28% of Indian male between ages 40 to 67 reported sexual dysfunction. 67 % of people felt it is age-related and has no cure. 88% of patients wanted to discuss sexual problems with doctors. Inability to communicate due to shy nature or taboo (66 %) and lack of privacy (52 %) were other significant factor preventing patients from discussing sexual problems. Conclusions: With the strong association between sexual dysfunction and impaired quality of life, this problem warrants recognition as a significant public health concern. Most patient regard sexual dysfunction as a normal aging phenomenon with no cure. Patient education about available treatment options will lead to better utilization of health care in such patients.

   VPP 16: Creatinine velocity as a novel predictor of progression to end stage renal disease following transurethral valve fulguration in children with posterior urethral valves: A single institution 20-year experience Top

Rahul Jena, Priyank Yadav, S. Ashwin, Sanchit Rustagi, M. S. Ansari

SGPGIMS, Lucknow, Uttar Pradesh, India

Objective: To analyze the impact of creatinine velocity as a predictor of progression to end stage renal disease (ESRD) following transurethral valve fulguration (TUVF) in children with posterior urethral valves (PUV). Materials and Methods: Retrospective analysis of records of 583 patients who underwent TUVF between January 1992 and May 2013 at our institution was done. Out of these 472 patients with a minimum follow up of 5 years were included in the study. Nadir serum creatinine, following valve ablation and the creatinine velocity for the first five years following valve fulguration, defined as the rise in serum creatinine in mg/dl every 12 months was noted for each patient. The patients were divided into two groups: those who developed ESRD, denoted by start of renal replacement therapy (Group A) and those who did not (Group B). Results: A total of 87 patients (18.4%) developed ESRD at a mean age of 12.51 years (5 – 17). A total of 135 (28.6%) patients had a nadir creatinine > 1 mg/dl, of 77 were in Group A and 58 were in Group B. The mean nadir creatinine was 1.19 mg/dl in Group A and 0.74 mg/dl in Group B and the mean creatinine velocity was 0.52 mg/dl/year in Group A and 0.13 mg/dl/year in Group B (p<0.001, paired t-test). Using ROC analysis, AUC for nadir creatinine was 0.92 and 0.87 for creatinine velocity, in predicting progression to ESRD. Using a cut off value of 0.27 mg/dl/year for creatinine velocity, the sensitivity and specificity for predicting progression to ESRD was 81.6% and 78.2% respectively. The sensitivity and specificity in predicting progression to ESRD, using a nadir creatinine value of 0.99 mg/dl was 88.5% and 88% respectively. Conclusion: Along with nadir creatinine following valve fulguration, creatinine velocity is a useful predictor of progression to ESRD.

   VPP 17: Renal allograft compartment syndrome: an underappreciated cause of early graft dysfunction Top

Banthia Ravi, Surekha Sanjoy, Srivastava Aneesh, Singh Uday Pratap

SGPGIMS, Lucknow, Uttar Pradesh, India

Introduction: Renal allograft compartment syndrome is a rare cause of early graft dysfunction secondary to retroperitoneal hypertension/ graft compression due to paucity of space in the retroperitoneal compartment. Incidence of this complication which usually occurs in the immediate post transplant period is not well appreciated as there are only few literatures available on the same mostly in the form of case reports. Methods: All renal transplants between January 2012 and July 2017 (n= 656) at our center were reviewed. 8 cases of renal allograft compression syndrome were identified by sudden drop in urine in the immediate post operative period and Doppler showing normal main renal artery flow with poor flow in the segmental and lobar arteries. All cases were explored in the immediate post operative period with a mean time interval of 46 mintues (range – 20 to 120 minutes). All grafts were salvaged on reexploration with the common intraoperative finding of a soft and pale kidney becoming turgid and pink immediately on opening the abdominal wall. The sheaths were closed with multiple relaxing incisions all the while strictly monitoring the urine output. Conclusions: Surgeons must be aware of this complication which may cause rapid deterioration in graft survival and outcome. Strong clinical suspicion and low threshold for re exploration might be helpful to prevent the same and keeping the Foley's catheter inside the operative field for intraoperative urine output monitoring should be practised regularly.

   VPP 18: Management strategy of vascular access related major complications in hemodialysis patients Top

Yashpal, K. Madhavan, S. K. Sureka, S. Rathi, U. P. Singh, M. S. Ansari, A. Srivastava

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Introduction: We studied the clinical presentation and surgical management of the complications associated with surgically created AVF in patients on maintenance hemodialysis. Materials and Methods: This is a retrospective study on patients who underwent surgical intervention for complications related to AVF created at our centre and referred from other centres. Excluded cases were outflow venous stenosis, asymptomatic aneurismal dilatation and failure of maturation. Results: 210 complications seen in 3100 AVF created during period of 2001-2017 requiring surgical intervention. Preoperatively complications were evaluated with USG Doppler or angiography (CT /MR) in selected cases. Most Common complication was pseudoanerysm (PA) (n=128-68.2%), followed by Venous hypertension (n=40, 19.04%), complicated (skin ulcer/bleeding/infection) aneurismal dilatation (n=25), steal phenomenon (n=12, 10%), Pulmonary hypertension (n=3) and Cardiac failure (n=2). PA was Most common at anastomosis site followed by vein puncture site. Fistula could be salvaged only in 15%. Brachiocephalic (BCF) or Brachiobasilic fistula (BBF) complications required repair of artery with or without sephanous interposition graft when PA involved anastomotic site. Venous hypertension involving BCF were managed with ligation of outflow vein or angiographic balloon dilatation. Success of Angiographic management were 55 % with 80 % had recurrence of symptoms with median follow up of 11 months. Conclusion: Pseudoaneurysm is the commonest major complication of AVF and may require challenging vascular reconstruction if they involve the anastomotic site of elbow AVF. Angiographic balloon dilatation is a viable option for short segment outflow venous stenosis. Following major complication of AVF the overall salvage rate is low.

   Podium Session 1: Endourology Top

   POD 01-01: The spectrum of unplanned 30-day readmissions in patients undergoing endo-urological surgeries for upper urinary tract calculi Top

Ashish Sharma, Siddharth Pandey, Manoj Kumar, Satyanarayan Sankhwar, Apul Goel, Vishwajeet Singh, Bhupaeder Pal Singh

King George's Medical University, Lucknow, Uttar Pradesh, India

Introduction and Objective: Unplanned re-admissions not only add to healthcare costs but also are bothersome for the patients. To see the 30-day unplanned re-admission rates in patients underdoing endo-urological surgeries for upper urinary tract calculi we conducted this retrospective study at our institute. Materials and Methods: We retrospectively reviewed our prospectively maintained database from 1st January 2009 to 31st December 2017, for the patients who underwent endo-urological procedures for upper urinary tract calculi and were re-admitted within 30 days of discharge. Results: The re admission rate was 1.74% over the study period. The most common etiology for re-admission was sepsis followed by hematuria. The significant risk factors for re-admission in bivariate analysis included male gender, age >65 years, current smoking, COPD, DM, bleeding disorder, prior cardiac disease, and American society of anesthesiologists (ASA) class > 3. In multivariate risk adjusted logistic regression analysis ASA class > 3 was significant risk factor for re-admission. Conclusion: ASA class > 3 is the most important independent predictor of unplanned 30-day re-admissions.

   POD 01-02: Miniperc for stags – New standard of care Top

B. Bawri

Nemcare Hospitals, Guwahati, Assam, India

Introduction and Objective: Percutaneous nephrolithotomy (PCNL) has evolved into widely accepted and primary recommended management for staghorn calculi. Performing PCNL with a small size tract (12–20 F), named mini percutaneous nephrolithotomy (MPCNL), has acceptable low morbidity, with the advent of endourologic instruments, lithotripsy devices, and surgical techniques and may decrease the injury to the kidney and operative morbidity, compared to the standard PCNL with (26–30 F) tract. The purpose of this study was to evaluate the outcomes of MPCNL for patients with staghorn calculi. Methods: Between August 2017 and July 2018, 32 patients with staghorn calculi underwent MPCNL. Data analysis included procedure time, length of hospital stay, number of access tracts, transfusion rates, early and late complications, and stone-free status. Results: Mean patient age was 46.8 years (range 26-75 yrs). The average procedure time was 82 min (60-95 min). All cases needed multiple access tracts (range 2-5). Pneumatic lithotripsy was used in all cases. No patient required blood transfusion and all cases were tubeless with DJ stent placement. Average hospital stay was 2.4 days (2-4 days). There was no significant major complications with multiple tracts. Stone-free rates at the time discharge was 87.5% and 4 cases required ancillary procedures (extracorporeal shokwave lithotripsy) for complete clearance. Conclusions: MPCNL is a safe and effective procedure in the management of staghorn calculi, with outcomes similar to those reported for percutaneous management of smaller volume nonstaghorn stones.

   POD 01-03: Assessment and evaluation of preoperative stone scoring systems in predicting the outcomes in percutaneous nephrolithotomy – A single centre, prospective study Top

R. S. Batra, S. L. Paul, M. A. Rajput, S. Saikia, S. K. Singhania, P. M. Deka

Dispur Hospitals Pvt. Ltd., Guwahati, Assam, India

Introduction and Objectives: Many preoperative predictive systems for measuring the outcomes of percutaneous nephrolithotomy have been developed including the Guy's Stone Score, S.T.O.N.E. nephrolithometry score and the CROES nephrolithometric nomogram. We compared the Guy's Stone Score, S.T.O.N.E. nephrolithometry and the CROES nomogram for the ability to predict stone-free status after PCNL and its related complications. Methods: We prospectively studied the patients who underwent PCNL between June 2016 and December 2017 at our institute. We calculated the Guy's Stone Score, the S.T.O.N.E. nephrolithometry score and the CROES nephrolithometric nomogram score based on preoperative computerized tomography images and post operative results were compared. Results: We evaluated 113 patients in our study. The total post operative stone free rates were 72.56%. On comparing stone-free patients and patients with residual stones, the mean Guy's Stone Score was 2.04 vs 3.0, the mean S.T.O.N.E. score was 6.8 vs 9.0 and the mean CROES nomogram score was 249.48 vs 174.83 (p <0.001). The Guy's Stone Score, S.T.O.N.E. nephrolithometry score and CROES nomogram scores were significantly associated with stone-free status (p<0.001). None of the scoring system correlated with complication rates. Conclusions: All scoring systems equally predicted stone free status. S.T.O.N.E score was the easiest to apply clinically. No scoring system was predictive of complication rates. A unified scoring system should be adapted for standard reporting of stone free rates and complications across all the institutions.

   POD 01-04: Positive urine culture: Is it a hindrance for doing percutaneous nephrolithotomy? – A comparative study Top

Bala Bhaskar Reddy Challa, Kalyanaram Kone, T. Vasudevan, A. Mossadeq

MGMCRI, Puducherry, India

Background: Percutaneous Nephrolithotomy (PCNL) has become a widely accepted treatment for renal calculi more than 2 cm in size. Presence of bacteriuria was reported as one of the most important predictors for the development of post-operative complications. But in some patients even after giving culture specific antibiotics, urine culture continues to remainpositive. At that timethere is dilemma whether surgery can be done or not. This study was done to answer this question bycomparing the treatment outcome and infective complications between renal calculi patients with and without positive urine culture. This was a prospective study. Objective: To compare the incidence of complications as per Clavien-Dindo classification 1. Post-operative fever and need for antibiotics 2. Wound infection 3. Organ dysfunction 4. Sepsis 5. Hospital stay. Patients and Methods: All patients who underwent PCNL with positive urine culture in the Department of Urology from Jan 2017 till June 2018 were enrolled in this study. Patients with positive urine culture were treated with antibiotics for 5 days based upon the sensitivity and urine culture sensitivity was repeated. Patients were taken up for PCNL without waiting for the second culture report after completing 5 days of antibiotic course. Clinical parameters and laboratory parameters were assessed postoperatively. Patients with positive urine culture after treatment were included in group 1 and those with sterile culture were included in group 2. Inclusion and exclusion criteria: Inclusion criteria: (1) All patients who underwent PCNL for renal stones>2 cm. Exclusion criteria: (1) Patients with pre-operative fever and sepsis who underwent Diversion procedures were not included. (2) Patients with Bleeding diathesis and Diabetes. Statistical Analysis: The data was analysed using SPSS 19. The following statistical methods were used. 1. Comparison using t-test 2. Logistic Regression Analysis and ROC Curves 3. Cross tabulations with Chi-square test. Results: Totally 66 patients were included in the study. 27 patients were grouped into Group 1 (with positive urine culture) and 36 patients were grouped into Group 2 (with sterile culture). The procedure was stopped because of frank pus with placement of nephrostomy tube in 3 patients (2 patients in group 1 and 1 patient in group 2) 6 Patients (22.2%) in groups 1 and 5 patients (13.8%) in group 2 had postoperative fever (>99 F). There was no significant difference in bleeding, hospital stay and lab values- TC, DC, Urea and Creatinine (pre and post op) between the two groups. There were no Clavien-Dindo grade 3 or 4 complications in both the groups. Conclusion: Positive urine culture with antibiotic therapy does not make significant differencein outcome of PCNL

   POD 01-05: Does ureteroscopy for upper ureteric calculus need follow up? Top

Akhil Mane, Date Jaydeep, Shivde Subodh, Patwardhan Prakash, Nathani Akshay, Gopal Rathi

Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India

Ureteroscopy for Upper ureteric calculus is common procedure for upper ureteric calculus. Advances and miniaturization of ureteroscopes and their accessory instruments make modern ureteroscopy quite safe. However, complications of ureteroscopy still do occur and can result in severe ureteral injury and possible kidney loss. There exists no standard classification system to report complications of ureteroscopy. In our institute 115 patients underwent Laser ureteroscopy for upper ureteric calculus in last two years. Ureteroscope used- 6/7.5 F Richard Wolf. Laser used - Lumenis 100 Watt. Six patients developed ureteric stricture. Three patients were asymtomatic and three had mild pain abdomen. On evaluation moderate to severe hydroureteronephrosis was found on ultrasonography. All underwent CT IVU and DTPA renogram to localize site of ureteric stricture. Out of six patients who developed ureteric stricture, two patients underwent open ureterouretostomy, one patient underwent Laproscopic ureteroureterostomy, Nepherctomy done in 2 patients and one patient lost in follow up. All these complications developed within six months after ureteroscopy. Incidence of ureteric stricture in our study is 5.2%. In literature incidence of ureteric stricture post ureteroscopy is 7.8 % to 24 %. Factors responsible for ureteric stricture Post Ureteroscopy are mucosa oedema, mucosal injury by laser/ureteroscope/guide wire, longer duration of impacted stone, difficulty in negotiating Ureteroscope. According to this study, ureteral strictures will be formed within 6 months after patients have undergone ureterolithotripsy treatment. So close follow up is necessary in patients who underwent Laser ureeroscopy for upper ureteric calculus. Patients should undergo Ultrasonography after 3, 6 months after ureteroscopy.

   POD 01-06: Clinical outcomes of retrograde double j stenting of ureter in benign etiology under local anaesthesia – A prospective observational study Top

Amit Jain, Tepukiel Zaphu, R. Manikandan, L. N. Dorairajan, K. S. Sreerag, Sidhartha Kalra

JIPMER, Puducherry, India

Introduction: The aim of our study is To quantify the outcomes of retrograde double J (DJ) stenting of ureter for benign etiologies under local anaesthesia. To evaluate the causes of failure in retrograde double J stenting by rigid cystoscope. To analyze complications. Methods: 140 patients with indication for emergency urinary diversion were included prospectively. All patients were subjected to ultrasound and non-contrast CT (NCCT) scan of the kidney, ureter and bladder (KUB) region. DJ stenting was done under local anaesthesia (spongiosum block in male). According to success or failure of DJ Stenting, we divided patients into two groups. We compared different etiologies, demographic, biochemical and radiological parameters (Ureteral wall thickness, Ureteric diameter, Hydroureteronephrosis). Intraoperative parameters included patient's co-operation, pain on visual analogue scale (VAS), fluoroscopy time and duration of procedure. Results: Mean age of patients was 46 years with male to female raito of 3.2:1, Diabetes Mellitus (19%) was most common co-morbidity and calculus disease (78.5%) was most common etiology. DJ stenting was successfully done in 127 (90.7%) and failed in 13 (9.3%) patients. GUTB patients had 33% failure rate. Patient's co-operation (p=0.02) passing of contrast beyond obstruction (p<0.001) and low VAS (p=0.009) were only significant factors associated with success. Overall complication rate was 9%. 6 (4.2%) patients needed intensive care, among these 4 (75%) had positive preoperative urine culture. Conclusion: DJ stenting with rigid cystoscope under local anesthesia (spongiosal block in males) is safe and feasible with 90% success rate. Intraoperative patient's co-operation, VAS score and RGP findings are main determinant of success.

   Podium Session 2: Endourology Top

   POD 02-01: Ureteric stent removal by string: Patient satisfaction evaluation Top

Praveen Rao, Prathivi Shetty, Jag Chiran, Chandrasekharan Badrakumar

Blackpool Teaching Hospital Foundation Trust, Blackpool, UK

Ureteric stent (US) causes symptoms in 90% of patients. Removing temporary US as soon as its purpose is achieved gives the best relief of symptoms. Placing a stent with an extraction string eliminates the need for cystoscopy to remove stent. This technique was introduced in our hospital in 2015. We did a prospective study of US cohort with and without extraction string to compare patient satisfaction and complications. Methodology and Results: Between August 2015 and August 2017, 138 patients underwent ureteroscopy stone surgery and temporary US. 58 patients had string attached to the lower end of the stent to aid removal. 80 patients choose to have the stents removed by cystoscopy. Questionnaires were sent to all the patients. 50 patients replied to the questionnaire. 21 (42%) had stents with extraction string. The mean average stent dwell time (days) was 9 with extraction string compared to 38 without extraction string. There was no significant difference in stent symptoms with the patients in both groups (Fisher's exact test – two tailed - P value equals 0.1485). The Stent dwell time was significantly less in patients with the extraction string. 90% US removal by silk cohort preferred to have the same in the future. Conclusions: Stent removal by silk thread is a safe and viable option for adequately informed and well-motivated patients. This study therefore demonstrates that Stent removal by string is easy for patients to remove at home and there is shorter stent dwell time. There are also significant cost benefits to the hospital.

   POD 02-02: Evaluation of change of renal function in affected kidney in post percutaneous nephro lithotripsy patient with unilateral renal lithiasis using 99m TC DTPA scan Top

Samaddar Debasis, D. Sarkar, S. Gupta

IPGMER, Kolkata, West Bengal, India

Introduction and Objectives: PCNL (percutaneous nephro lithotripsy) is a standard operative technique in nephrolithiasis but it causes renal trauma and alteration of renal function. Earlier few studies have evaluated the effect of standard PCNL on long-term renal function, but studies showing functional changes in the early period is limited. The study was done to evaluate the post PCNL renal function alteration in early post operative period. Methods: The study was done between November 2016 to June 2018 on patients who underwent standard PCNL under GA with upto 24 Fr Amplatz dilatation and nephrostomy insertion without any post op complication, GFR was evaluated with DTPA Renogram at Preoperative period, POD-3 and POD-14. Results: Total 54 patients (Male-34, Female-20) were evaluated finally. Pre op Mean-GFR of affected kidney was 36.70 for male & 29.40 for female patients. At POD3 there were reduction of GFR in all patients, 1.78-22 % (p-.02) in male and 2.38-19.84% (p- <.00001) in female patients compared to pre op value. At POD-14 there were normalization of GFR towards pre op value in 19 male & 10 female patients but persistent low GFR were seen in 15 male (1.9-15.15%, p-0.79) & 10 female patients (0.93-15.53 %, p-0.28), but that were statistically insignificant. Conclusion: In early post op period there were statistically significant reduction of GFR in all patients, so it is advisable to avoid factors that can bear a negative influence on renal function during the early postoperative period such as nephrotoxic drugs, contrast agents, ESWL and Re-PCNL.

   POD 02-03: Mini-percutaneous nephrolithotomy vs retrograde intra-renal surgery – Edge? Top

P. S. Katti, B. A. Dar, P. K. Sharma, M. K. Chhabra

SN Medical College, Jodhpur, Rajasthan, India

Introduction and Objective: Mini-Percutaneous Nephrolithotomy (MINI-PCNL) and Retrograde Intra-Renal Surgery (RIRS) are 2 treatment modalities for renal stone disease. This study was undertaken to compare and assess the suitability among these two, with respect to our demographic settings, which is characterized by high stone burden, long waiting period and hence loss of working hours for economically challenged population. Methods: A randomized prospective study of patients presenting to our medical centre from September 2017 to April 2018, who were diagnosed with renal-calculi of size 1-2 cm and who underwent alternatively MINI-PCNL (N=20) and RIRS (N=20) were included in our study. Results: MINI-PCNL RIRS Stone-Free-Rate 95% 85% Hospital stay (mean-days) 2 3.5 Operative-time (mean-minutes) 62 83 Blood-transfusion required 5% Nil Procedures 1 2.5. Conclusion: In a limited-resources setup with high patient burden, keeping in mind the socio-economic status of our patients, MINI-PCNL fared better than RIRS, with reduced hospital stay, need for one operative sitting, avoidance of stent related symptoms which decrease quality of life/loss of working hours, lesser need for antibiotic coverage, avoidance of psychological trauma of being subjected to multiple operation-room visits, at the cost of slight increase in blood loss with potential need for transfusion, as the only factor MINI-PCNL asks for which can be covered up in view of plethora of benefits to patient and health care setup.

   POD 02-04: Comparison of safety and efficacy of standard PCNL and mini PCNL via supracoastal approach: Does size matter? Top

G. Girniwale, A. Srivastava, S. Singh, I. Dhayal

Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Introduction and Objectives: Complications like bleeding and pulmonary complications are a significant cause of morbidity and mortality in patients undergoing percutaneous nephrolithotomy surgery. Complications rate vary according to different types of approach. The purpose of this study is to compare complications mainly pulmonary and bleeding following standard and mini PCNL done via supracoastal approach in a matched cohort of patients. Methods: This is retrospective study of 252 consecutive patients who underwent PCNL surgery from January 2016 to December 2017. Out of these 181 patients which follow the criteria are selected for study and grouped into two group A and group B, group A includes 138 patients who underwent standard PCNL and group B includes 43 patients who underwent mini PCNL. Results: Overall eight (4.42%) patients had pulmonary complications following PCNL, Among these 6 patients belonged to group A, 2 had pneumothorax and 4 had pulmonary effusion. 2 patients belonged to group B, 1 had pneumothorax and 1 had pleural effusion. Other complications like bleeding and stone clearance rate were comparable in both groups of patients. Conclusions: Based on this study there is no significant statistical difference in pulmonary complications between standard and mini PCNL.

   POD 02-05: Dilema and challenges in management of bilateral emphysematous pyelonephritis Top

P. T. N. Mandrekar, P. R. Lawande, V. Gaude, N. B. Talwadker, M. R. Prabhudesai, H. M. Punjani

Goa Medical College, Goa, India

Aim: To study (1) Salvage rate of renal units in (B/L) EPN (2) Incidence of recurrent EPN after ancillary procedures. Emphysematous pyelonephritis (EPN) is an acute fulminant and potentially fatal necrotising infective process caused by gas forming organism. A Bilateral Emphysematous Pyelonephritis is a grade 4 EPN. Methods: Prospective study of 17 patients of (B/L) EPN at GMC over 10 years. Clinical presentation & assessment, co-morbid conditions, severity of sepsis and prognostic factors (altered sensorium, shock, acidosis, thrombocytopenia and need for dialysis) and incidence of recurrent EPN were analysed. All cases initially underwent DJ stenting/nephrostomy. Results: 17 patients (34 Renal units) 5 Renal units lost by nephrectomy, 18 renal units salvaged by regular stent exchange and maintaining stable serum creatinine. 10 renal units had obstructed system. 12 patients had uncontrolled DM of which 7 had recurrent episode of EPN after DJ removal with rise in serum creatinine only 1 patient is on maintainence dialysis, 10 patients had involvement of PCS on one side and/or renal parenchyma on other side, 6 had perinephric involvement Among four prognostic factors altered sensorium followed by shock had the highest Odd's ratio with maximum impact on the outcome of patients (logistic regression test). No.of deaths were 4. Conclusion: (1) (B/L) EPN is challenging and aim should be to salvage maximum number of units. (2) Patients with prognostic factors like altered sensorium ans shock found to have maximum impact on the need for nephrectomy and mortality (3) Regular stents exchange can salvage maximum number of kidney units.

   POD 02-06: Percutaneous nephrolithotomy in infants: Safety and outcomes with miniaturized equipment Top

Mohammed Taif Bendigeri, M. Chiruvella, K. P. C. Reddy, D. R. Ragoori, S. Ghouse, B. Enganti, P. K. Misra

Asian Institute of Nephrology and Urology, Hyderabad, Telangana, India

Introduction: We present our experience, safety and outcomes of percutaneous nephrolithotomy (PCNL) in infants with renal calculi. Materials and Methods: We analyzed 47 infants < 1 year (51 renal units) with renal calculi managed by PCNL from April 2013 to June 2018. Clinical presentation, stone burden, operative parameters, complications and outcomes were assessed. All procedures were performed with 12 Fr or 16 Fr percutaneous access. Stone clearance was assessed by ultrasonography and plain radiography. Results and Observations: A total of 47 infants were included in the present study (30 male and 17 females). Mean age of infants were 7.5 months (4-12 months) with the stone size of 13.5 mm (10-42 mm). 4 infants underwent bilateral PCNL. No infants required blood transfusion. 5 infants had fever in the postoperative period. Mean hospital stay was 2.5 days. Only 1 infant underwent PCNL for residual calculus after 1 month. 1 patient underwent staged procedure in view of large burden of stone with staghorn calculus. Conclusions: PCNL in infants is technically challenging, but with miniaturized instrumentation it can be performed safely and effectively with minimal morbidity and high stone free rates.

   Podium Session 3: Miscellaneous Top

   POD 03-01: The transobturator male system - ATOMS – Is this device the new golden standard in the treatment of low to moderate post-prostatectomy incontinence? Top

W. Bauer

Sisters of Mercy Hospital Vienna, Vienna, Austria

Introduction: We hypothesize that the ATOMS system is superior in the cure rate with lower complication rate in the low to moderate incontinent patients. Methods: From April 2009 till June 2018 we have treated 420 men with low to moderate urinary incontinence (1 to 4 pads, 50 to 350 ml/day) after radical prostatectomy with the ATOMS device and from 2015 till 2017 34 men with an artificial urinary sphincter (ZSI 375). All devices were implanted by a single surgeon and the follow up of the ATOMS device was up to 9 years and the follow up of the sphincter up to 3 years. Results: The revision or removal rate in the ATOMS population was 5% (n=21) in 9 years, the revision or removal rate in the Sphincter population was 97% in 3 years. There was 0% Erosion rate in the ATOMS cohort, 76% Erosion rate in the sphincter cohort. In the low to moderate incontinent patients (1 to 4 pads per day or 50 to 350 ml/24 h) the success rate with the ATOMS device was 80% (n=336) dryness rate (0 pads), 95% (n=399) overall success rate in 9 years (up to 1 pad/day) In the sphincter population the success rate was 80% (n=27, 0 pads) and 3% (n=1) overall success rate in 3 years (up to 1 pad/day). Conclusion: The ATOMS system was safe and showed a high success rate, the complications were low over a max follow up time of 9 years. The sphincter ZSI 375 was safe to implant but this device showed a high amount of erosions which are a severe complication in the treatment of stress urinary incontinence in men. So we were able to show that in low to moderate incontinent patients the ATOMS device is superior in comparison to the artificial urinary sphincter and should be considered as a gold standard in the treatment of post-prostatectomy incontinence.

   POD 03-02: Prospective evaluation of ejaculatory function in patients undergoing urethroplasty using a validated questionnaire Top

Siddharth Pandey, Apul Goel, Satyanarayan Sankhwar, Vishwajeet Singh, Bhupender Singh, Rahul Sinha, Manoj Kumar

King George's Medical University, Lucknow, Uttar Pradesh, India

Introduction and Objective: Ejaculatory dysfunction and urethral stricture disease run hand in hand. Sexual morbidity is significant in determining overall satisfaction after urethral reconstructive surgery. We present the final data of our prospective study that had an objective to evaluate the effects of urethroplasty on ejaculatory function using a validated questionnaire. Materials and Methods: The study included all adult male patients who underwent urethroplasty from November 2016 to June 2018 at our institute. They were asked to fill the male sexual health questionnaire - ejaculatory function domain (MSHQ-EjD) with 7 questions and IIEF-5 pre-operatively, at 6 months post surgery and at 1 year. Along with that we also used a visual analog scale to assess pain during ejaculation. Results: Out of the seven domains of MSHQ-EjD, painful ejaculation was present consistently in the study population. There was statistically significant improvement in MSHQ-EjD after the surgery both at 6 and 12 months after surgery. The ejaculatory function post surgery was statistically same as it was before the patient had symptoms of his urethral stricture disease. There was statistically significant improvement in visual analogue scale for ejaculatory pain after surgery. The IIEF-5 score was overall decreased after urethroplasty. Conclusion: Ejaculatory function is an important aspect of post urethroplasty success and satisfaction. The ejaculatory function of patients is restored to pre-disease levels in patients after successful urethroplasty. The most striking improvement is in ejaculatory pain.

   POD 03-03: Evaluation of proliferating cell nuclear antigen expression in development of renal cell carcinoma in indian patients Top

Pramanik Sandip, Pal Dilip Kumar, Panda Chinmay Kumar

IPGMER, Kolkata, West Bengal, India

Introduction: Renal cell carcinoma (RCC) accounts for approximately 2% of all cancers. Proliferating cell nuclear antigen (PCNA) is a DNA clamp that acts as a processivity factor for DNA polymerase δ in eukaryotic cells and is essential for replication. Methods: Patients of Renal Cell Carcinoma (RCC) who have been operated at our department were taken for the study. Total number of patients taken for our study was 32. Renal cancer patients who received radiotherapy, chemotherapy etc. before operation and benign tumours of the kidney in histopathological examination were excluded from the study. Histopathological examination of the Renal Mass and Immunohistochemistry (IHC) of samples from renal mass as well as of samples from normal renal tissue for detection of expression of PCNA were done. Results: In normal tissues 4.5% of cells showed PCNA expression in nucleus and proliferating cells were found to be mainly tubular epithelium. Significantly increased proliferation was evident in Clear Cell RCC samples (48%) and other subtypes (57%–66%) throughout the lesions compared to the normal. Interestingly, significant increased proliferation was seen in Stage T1 (40%) followed by gradual increase in Stage T2 (52%) and Stage T3 (69%), indicating its clinical importance with progression of the tumour.

Conclusion: Our data showed that expression profile of PCNA has got clinical importance in development of RCC irrespective of different sub-types. This might have implication in diagnosis and probably prognosis of the disease.

   POD 03-04: Outcomes of Chennai enhanced recovery protocol after major urological surgery Top

N. Ragavan, Kunal Dholakia, V. C. Karthik, Priyank Shah, Malarvizhi Ramesh, Jegadish Baskaran, C. Pradeep

Gleneagles Global Hospital, Chennai, Tamil Nadu, India

Introduction: Enhanced recovery after surgery (ERAS) protocol has traditionally been followed in colorectal surgery. Convincing evidence to advocate the use of these protocols in major urological surgery however is currently lacking except radical cystectomy. But urology domain includes several other major surgeries which have potential to be benefited by ERAS protocol. This project aimed to study a specially designed ERAS methodology in patients undergoing major urological non-cystectomy surgery. Materials and Methods: This study was conducted in prospective fashion on patients undergoing major urological procedure like Nephrectomy, Prostatectomy etc via any access [Open or Minimal Invasive (Laparoscopy or Robotic)]. The multidisciplinary team was formed, led by Surgeon to implement multimodal rehabilitation regime (non-opioid analgesia, enforced mobilisation, early feeding and early discharge). The study was carried out from August 2016 – August 2017. The perioperative outcomes were compared in open vs minimal invasive groups using non-parametric tests. Results: A total 70 patients underwent major urological non-cystectomy surgery during the said duration [Open (n=11), Minimal Invasive (n=59)]. There was no significant difference in Pain Score (p =0.114), Ambulation (p=0.298), Bowel Activity (p=0.0716) and Resumption to Oral Diet (p=0.091) in both the groups. The mean length of stay in both group was similar (p= 0.187) and also no difference in complications (p=0.78) and readmission rates (p=0.74). Conclusion: Our specially designed ERAS pathway suggests that with optimised pain relief, enforced mobilisation and early oral nutrition results early recovery and early discharge with very less complication rates irrespective of technique used for surgery. This ERAS pathway not only cut costs but also there is minimal interruption of physiology with the best rehabilitation of patients.

   POD 03-05: Heparinised alkaline lidocaine: Intravesical therapy for interstitial cystitis Top

Anwar Ali

SMS Medical College, Jaipur, Rajasthan, India

Objectives: To test the efficacy of a new intravesical therapeutic solution in relieving urgency/frequency and pain in interstitial cystitis (IC). Methods: 30 patients of Interstitial Cystitis not responding to oral medications (Pentosan polysulfate and Amitryptiline) were randomized into 2 groups of 15 each with group 1 receiving a cocktail solution of 40,000 Units heparin in 20 ml distilled water, 8 mL of 1% lidocaine (80 mg) and 4 mL of 8.4% sodium bicarbonate administered intravesically and group 2 receiving Normal Saline. The response to treatment was evaluated within 20 minutes of instillation in all patients and after 24 to 48 hours. Significant symptom relief was defined as 50% or greater symptom improvement. Results: After one instillation, 7 (46.67 %) of 15 patients in group 1 (1% lidocaine) and 1 (6.67%) of 15 in group 2 (Normal Saline) reported significant immediate symptom relief. The difference in the response rates was statistically significant (P <0.01). Conclusions: Intravesical treatment with combined heparin and alkalinized lidocaine immediately reduced the pain and urgency of IC in most patients. Symptom relief lasted beyond the duration of the local anesthetic activity of lidocaine, suggesting the solution suppresses neurologic upregulation.

   Podium Session 4: Reconstructive Urology Top

   POD 04-01: Dorsal plus ventral buccal graft urethroplasty using dorsal approach – A modified technique Top

Arya Ankur, Bhatyal Hardev, Garg Yogesh

BLK Superspeciality Hospital, New Delhi, India

Introduction and Objective: Oral mucosa is considered the gold standard substitute for graft urethroplasty and its placement as dorsal or ventral urethrotomy approach has become contentious issue. Palminteri (2008) described dorsal plus ventral graft (DVG) by using ventral approach for tight bulbar urethra strictures. Our objective is to present a modified technique of managing these strictures by dorsal approach for DVG to overcome the problem of less working space and graft buckling. Methods: From January 2014 to December 2017, a total of 24 patients underwent urethroplasty for tight urethral strictures by using this technique. Mean age was 40 years (19-60 years). Out of 24 cases, 14 were infective and 10 were of unknown etiology. Retrograde urethrogram and urethroscopy was done preoperatively. Ability to perform urethroscopy with 6 Fr ureteroscope was our criteria to choose patient for combined DVG approach. Strictured urethra was opened up dorsally for graft placement Ventral inlay graft- first buccal graft is placed ventrally over spongiosa after excising scar tissue Dorsal onlay graft- 2nd buccal graft is placed dorsally over cavernosa and suturing it to the urethral margin over silicon catheter followed by SPC placement. Results: Average stricture length was 4 cm (2-6 cm). Of these 24 cases 20 (83.3%) were successful and 4 (16.7%) were treatment failures with re-stricture which was managed by OIU. Conclusions: DVG placement using our technique (ventral inlay + dorsal inlay) is reliable procedure for single stage reconstruction of tight bulbar urethral strictures and this technique provides wide working space, less buckling of ventral graft, decrease incidence of bleeding intraoperatively.

   POD 04-02: Risk factors for recurrence after buccal mucosal graft urethroplasty: A study in tertiary care hospital in Kolkata Top

Sudipta Kumar Singh, Aashu Anshuman, Bahal Bandhan, Gupta Prashant, P. K. Sharma, S. N. Mandal

Calcutta National Medical College and Hospital, Kolkata, West Bengal, India

Background: The aim of this study is to determine risk factors for stricture recurrence and complications in patients having buccal mucosal graft (BMG) urethroplasty for anterior urethral stricture. Methods: We conducted a retrospective review of a prospectively gathered database of 56 patients undergoing various forms of BMG urethroplasty between 2015 and 2017. Risk factors studied were: patient profile, aetiology, stricture length, location, previous urethral surgeries, and patient compliance with CISC in postoperative period. Results: The mean age of patients - 42.8 years. Average follow-up - 11 months. The total re-stricture rate- 19.6 % (11 patients). Postoperative complications were reported in 12.5 % (7 patients). The most frequent complications recorded were urinary fistula (2 patients), graft contracture (2 patients) and graft failure (3 patients). Complications were more common in strictures of length more than 8 cm (8 patients). Another factor for recurrence was presence of previous BXO changes (6 patients). Stricture with more proximal location (bulbar urethra) had more chances of recurrence. Previous h/o of urethral surgeries predisposed these patients to recurrence. Patients not doing CISC properly in follow-up had greater recurrence. Co morbidities like diabetes; heart disease did not affect recurrence. Conclusion: BMG urethroplasty represents a reliable therapeutic option for patient with urethral strictures with a good success rate. Complications and recurrence are more common in patients with long strictures, more proximally located, those with BXO changes, previous h/o of urethral surgeries. Another group of patients in whom recurrence occurred were those not doing CISC properly.

   POD 04-03: Role of MRI in post traumatic posterior urethral distraction defects in comparison to RGU/MCUG Top

M. Prakash, R. Shivakumar, C. S. Manohar, R. Keshavamurthy

Institute of Nephro Urology, Bengaluru, Karnataka, India

Introduction and Objectives: Pelvic fracture urethral injuries were assessed using RGU and MCUG. MR urethrogram is indicated to look for stricture and urethral distraction defects. We aimed compare MRU with RGU/MCUG with the surgical findings of PFUI's. Methods: RGU, MCUG and MRU was done on 20 male patients presenting between 2016 and 2018 with PFUI and evaluated prospectively. Preoperative Surgical planning was done on findings based on conventional RGU and MCUG and MRU. Delayed stricture repair managed by stricture excision and anastomosis. RGU/MCUG and MRU findings were compared intraoperatively with the length of urethral defect and lateral displacement. Results: 50% patients were between 21-30 years of age. There was a difference of 0.3-1.1 cm in the urethral gap measurement between RGU and MCUG compared to MRU intraoperatively. RGU and MCUG did not provide accurate determination of the urethral defect length and extent of fibrosis of the corpora spongiosa or prostatic displacement. Stricture length assessment and prostatic displacement was better demonstrated on MRU. Based on preoperative findings of MRU, 4 patients underwent inferior pubectomy as a part of urethroplasty. Correlation between surgical measurements of strictures showed a stronger linear relationship with MRU than between RGU, MCUG. Conclusion: RGU/MCUG cannot accurately determine the defect length, fibrosis, prostatic displacement because of poor prostatic urethral filling. MRU is more accurate in assessing obliterative urethral strictures, extensive scar tissue as compared to RGU/MCUG and helps in planning surgical approach. MRI could easily predict the need for pubectomy in preoperative evaluation.

   POD 04-04: Use of Yang-Monti modification of ileal ureter replacement for long segment ureteric strictures: Our experience Top

Krishnan Anup, Thomas Appu, Sundar Praveen, K. V. Sanjeevan

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Introduction: Ileal replacement of ureter has been an accepted form of treatment for long segment ureteric strictures. The Yang-Monti modification of simple ileal ureter replacement allows for the creation of a long tube from short bowel segment after its reconfiguration. In this study, we evaluate its safety, surgical outcome and impact on renal function based on our experience in our centre. Materials and Methods: We had 4 patients with long segment ureteric stritcures who underwent ileal ureter replacement using the Yang-Monti principle. 3 patients had long segment strictures as sequelue to Genitourinary TB. 1 patient had ureteric stricture following URS with Laser for a right PUJ calculus. Patients were kept on close follow up after the surgery. Results: No intra-operative or postoperative mortality or significant complications occurred. Patency of the interposed segment was assessed with Antegrade Nephrostogram through Per Cutaneous Nephrostomy (PCN) at 3 weeks, post-operatively. One of the Tuberculous patient had a leak near the cysto– ileal anastamotic junction and PCN was retained for 2 weeks more. Leak eventually settled and PCN and DJ stent were removed. Other patient had good flow of contrast and PCN and DJ stent were removed. All patients had preserved/improved renal function without any evidence of urinary obstruction. Longest followed patient of 7 years showed no strictures. Conclusions: The Yang-Monti modification for ureteric substitution is a safe technique with an excellent outcome. A short segment of ileum can be used to replace a large ureteric stricture/defect and offers a durable preservation of renal function without urinary obstruction.

   POD 04-05: Intraoperative endoscopic assessment in pelvic fracture urethral distraction defect repair: A case series Top

Yaser Ahmad, Muzayen, Manzoor, Rouf Khawaja, Arif Hamid, Saleem Wani

SKIMS, Srinagar, Jammu and Kashmir, India

Introduction: Posterior urethral strictures are difficult cases to treat. Anastomotic open urethroplasty is major treatment option, and various manipulations to the procedure have been recommended. Perfect Surgical technique has big role to play as treatment of recurrence is considered difficult. Objective: Assess role of two dimensional diagnostic imaging (RGU/MCU) and endoscopic assessment in management of PFUDD. Materials and Methods: 23 perineal urethroplasties combined with intra operative antegrade and retrograde cystoscopy were performed in 23 male patients between 2014 and 2018. Pre-and peri-operative records were evaluated, with a particular focus on RGU/MCU, and cystoscopy findings. Results: The mean stricture length was 2.6 cm. In 7 cases the preoperative RGU had under diagnosed the length which affected our treatment plan. In one case fistula opening was identified during endoscopy, it was missed by RGU and in other patient initially hay groove dilator was used as tract guide but it created a false tract which was rectified on table with aid of cystoscopy. In 18 cases with normal bladder necks, the anastomosis was created under the guidance of antegrade and retrograde cystoscopy. In 5 cases, stiff guide wires were used in addition to endoscopic light for correct anastomosis. The overall success rate was 90 %. Conclusion: Antegrade and retrograde cystoscopy are an easy-to-perform adjunctive modalities in perineal urethroplasty. It provides benefits of supplementary endoscopic findings and feasibility of certain manoeuvres that facilitate debridement and anastomosis formation. It also overcomes limitations of RGU/MCU, previous manoeuvres of tract identification and thus decreasing percentage of complications.

   POD 04-06: Technical issues in upper polar heminephrectomy in duplex kidney: Our experience with 15 cases Top

Panda Sumit Kumar, S. Choudhuri, R. K. Panda, S. Swain, S. Panda, G. P. Singh

SCB Medical College, Cuttack, Odisha, India

Introduction and Objectives: Upper polar heminephrectomy is a complex procedure with none the less complications either done laparascopically or open, but some modification of procedures may prevent complications. We present our experience with 15 cases of duplex anomalies with poorly functioning upper pole emphasizing on techniques we practice. Methods: Between 2015 to 2018 at our institute around 15 patients with duplex system anomalies with flank pain, recurrent UTI or with incontinence underwent open or laparoscopic heminephrectomy after evaluation. We approached superiorly from upper moiety instead of dissecting directly over the ureter. Argon plasma coagulation knife or hydrojet was used for aiding the plane of dissection. Surgical complications, operative time, blood loss and late complications were registered. Follow up DTPA scan was done in all patients at 3 months of surgery. Results: Mean operative time for laparoscopic surgery was less than open surgery. No major intraoperative or post operative complications observed except one case of urinary leak who was managed with selective angioembolisation. Mean hospital stay and comorbidities for laparoscopic surgery was less. Follow up DTPA scan showed normal function of the lower moiety and the opposite kidney. After 48 months of follow up there were no similar symptoms or UTIs. Conclusion: Whether open or laparoscopic upper polar heminephrectomy in duplex with poorly functioning upper moiety, starting dissection around the upper pole instead of directly over the ureter and identifying vessels carefully can save the patient from disastrous complications like urine leak, hemorrhage and atrophy of the remaining moiety.

   Podium Session 5: URO Oncology Top

   POD 05-01: Gata3 expression pattern in patients with non-muscle invasive urothelial carcinoma of the bladder Top

B. Jagadish Kaushik, Sriram Krishnamoorthy, Sandhya Sundaram, Natarajan Kumaresan

Department of Urology, Sri Ramachandra Medical College Hospital, Chennai, Tamil Nadu, India

Introduction: GATA3, a major transcription factor, plays a pivotal role in differentiation of breast epithelia, urothelium and varied subsets of T-Lymphocytes. GATA3 expression is considered to be a potential marker in urothelial cancer, urethral and parathyroid malignancies. The aim of this study is to determine the significance of GATA3 in non muscle invasive bladder cancers (NMIBC), to correlate its expression to the grade and stage of tumour and also to assess its association with recurrent lesions in patients with NMIBC. Materials and Methods: A prospective study on 40 consecutive patients was conducted from December 2016 – December 2017. All patients with non-muscle invasive bladder cancer were included. Patients with muscle-invasiveness and urethral and prostate involvement and metastasis were excluded from the study. Results: Of the 40 patients studied, 29 of them were of high grade and 17 had recurrent tumours. Of the 11 patients with low grade lesion, none of them were GATA negative, suggesting that GATA3 positivity strongly correlates with lower grade lesions. Of the 17 patients with recurrent tumours, 11 (65%) were GATA3 negative. On the other hand, none of those patients who had no recurrence were GATA 3 negative, suggesting that GATA3 under-expression strongly correlates with aggressiveness of the tumour. Conclusions: GATA 3 appears to be directly correlating with biological behaviour of the cancer. Loss of GATA3 is associated with higher grade and higher recurrence rate of the tumour. This marker might help the clinicians to prognosticate the long term behaviour of urothelial malignancies.

   POD 05-02: Significance of mini chromosome maintenance complex 10 overexpression in non-muscle invasive bladder tumor Top

S. Das, R. K. Dey, R. K. Das, S. Basu

R. G. Kar Medical College, Kolkata, West Bengal, India

Introduction and Objectives: Urinary Bladder cancer is the 9th most common cancer worldwide and 13th most common cause of death. The molecular pathogenesis of urothelial carcinoma has not been fully elucidated. Li-Win et al. identified Minichromosome maintenance complex component 2 (MCM2) and MCM10 as the two most significantly up regulated gene in urothelial cancer among MCM gene family. Managing patients with T1 disease poses problem because of high recurrence and progression. Our objective is to predict those T1 patients who are at risk of recurrence and progression. Methods: Total 20 patients with NMIBC were taken. MCM10 Immunohistochemistry was done. Results were interpreted as Positive or Negative. Patients were followed up for minimum period of 12 months. We compared MCM10 positivity in Ta and T1 disease; recurrence and progression in MCM10 positive and negative cases. Pearson's X2 test was used to analyze data. Results: 35.71% (n=5) of T1 patients were IHC positive, whereas none of Ta patients had positive result. 35% of patients with T1 disease had recurrence; among them 80% patients were MCM10 positive, whereas only 11% IHC negativeT1 patients had recurrence. (P = 0.0230) 21.42% of T1 patients progressed to higher stage. MCM10 positive patients had 60% progression rate, compared to nil in negative group. (P = 0.0275). Conclusion: MCM10 can be a vital immunohistochemistry in patients with NMIBC to predict recurrence and progression of disease. Scope of aggressive management of MCM10 positive NMIBC patients should be reviewed to give a better disease specific survival.

   POD 05-03: Significant impact of Apo lipoprotein A1 genetic polymorphic sequence variation and its relative expression in patients with bladder cancer Top

Javaid Magray, Iqbal Muzzain, Dar Manzoor, Khawaja A. B. Rouf, Hamid Arif, M. S. Wani, Pandith Arshad

SKIMS, Srinagar, Jammu and Kashmir, India

Introduction: Apo-A1, a constitutive anti-inflammatory factor, is a potential biomarker due its variable concentration in blood in different types of cancers. We evaluated the association of the APOA1 -75 G/A and +83 C/T genotypes with predisposition to bladder cancer. APOA1 protein expression was analyzed in urine samples to find out relationship between differentially expressed urinary proteins and variation in APOA1 -75 G/A and +83 C/T genotypes. Methods: Confirmed 90 bladder tumor samples and 100 healthy controls were included in this case–control study. Genotyping of the APOA1 was performed by PCR-RFLP and expression of Apo A1 protein in the urine of patients with bladder cancer was done by ELISA. Results: Patients with bladder ca were associated with APOA1 -75 AA genotype (nearly 4 fold risk) and APOA1 -75 A allele (p<0.05). APOA1 +83 CT heterozygotes showed inverse relation with bladder tumors (p<0.05). Higher expression of urinary APOA 1 protein (≥20 ng) of bladder ca patients was observed in APOA 1-75 AA genotype. Pattern of urinary APOA 1 concentration in low-grade tumors were 52.5% i.e high (≥20 ng) as against 15.4% in higher grades. 84.6% high-grade cases had APOA 1 concentration <20 ng/ml versus 47.6% low-grade cases (O.R= 6.08 and p=0.01). Conclusion: APOA1 protein expression can serve as a diagnostic marker for more malignant bladder tumors and its sequence variation APOA 1-75AA can act as a marker for risk assessment of the disease. Since this a first study from the world, our results need to be further investigated in large series of samples to authenticate the status of this gene.

   POD 05-04: Oncosurgical status and continence in radical perineal prostatectomy: Outcome in 25 cases Top

T. Chaure Mayur, H. Goel, N. Khattar, K. Singh, R. Sood

Dr. RMLH and PGIMER, New Delhi, India

Introduction: Radical retropubic prostatectomy (RRP) is the standard surgical procedure for localized prostate cancer in appropriate patients. In recent years, radical perineal prostatectomy (RPP) has regained interest due to various unique advantages. Objective: To evaluate post surgical margin status, serum prostate specific antigen (PSA) and continence in RPP patients. Materials and Methods: We analyzed post surgical margin status, serum PSA and continence data from 25 patients with localized prostate cancer undergone RPP between 2015-2017. Continence was assessed on the day of catheter removal, at the end of 1st, 3rd, 6th month and 1 year. Results: 4 (16%) patients had positive surgical margins, 1 (4%) positive bladder margin, 1 (4%) positive urethral margin and 2 (8%) with extraprostatic extension. At 1 and 6 month, same 7 (28%) had persistent detectable serum PSA (>0.01 ng/ml). On removal of catheter, 5 (20%), 13 (52%) and 7 (28%) had grade 1, 2 and 3 incontinence respectively. At 1 month, 10 (40%), 7 (28%) and 1 (4%) had grade 1, 2 and 3 incontinence respectively. At 3 month, 7 (28%), 1 (4%) and 1 (4%) patients had grade 1, 2 and 3 incontinence respectively. At 6 months, 1 (4%) had grade 1 and other 1 (4%) had grade 3 incontinence. At 1 year, 1 (4.34%) had grade 3 incontinence, rest 22 (95.65%) were continent, while 2 patients lost followup. Conclusion: This study outlines the post surgical margin status, serum PSA and urinary continence. Most patients gained urinary continence within 6 months. RPP is an excellent alternative to robotic and laparoscopic prostatectomy resulting in good oncosurgical outcome and early functional recovery.

   POD 05-05: Liquid based cytology and immunocytochemical detection of minichromosome maintenance protein-2 as potential marker in bladder cancer Top

Kunal Kapoor, Dilip Kumar Pal, Chhanda Datta

IPGME and R, Kolkata, West Bengal, India

Introduction: Urinary cytology and biomarkers have been investigated for diagnosis and follow up of bladder cancer, but none has achieved desirable acceptability. In search of improved method of detection of urinary malignant cells and biomarkers, LBC (liquid-based preparation of cytopathology slide) and MCM2 (cell cycle regulatory protein) were investigated. Early results are promising. So, we conducted study to investigate the status of LBC and MCM2. Objective: To know the impact of LBC in comparison to conventional cytology and correlation of detected urinary MCM 2 protein with biopsy, obtained by TURBT/TUR biopsy. Methods: 100 cases (known admitted patients of bladder SOL) and 100 control patients (not having urothelial malignancy) were recruited. 2 freshly voided 50 ml urine were collected and examined for conventional urinary cytology, LBC and immunocytochemical analysis of MCM2 protein. Biopsy reports were also recorded. Results: LBC detection of malignant cells were more in bladder cancer as compared to conventional cytology (32 vs 23; p value <0.05) and were better in background of haematuria during evaluation (20 vs 12 out of 42 patients; p value< 0.05). Both are significantly positive in High grade bladder SOL (28 vs 21 out of 38 high grade bladder cancer). Cut off value 50+ MCM2 positive cells/hpf showed 89 % positivity (Vs 3% control) while 200 cut off value showed 81 % positivity without any false positive. Conclusion: LBC offers better detection of malignant cells specially in background of haematuria. MCM2 has promising role in detection of bladder cancer.

   POD 05-06: Role of preoperative neutrophil lymphocyte ratio as a marker in predicting lamina propria invasion recurrence and progression in non muscle invasive bladder cancer Top

G. R. Manjunath, C. S. Manohar, R. P. Sanjay, R. Keshavmurthy, C. S. Ratkal

Institute of Nephrourology, Bengaluru, Karnataka, India

Introduction and Objectives: Recently published data have revealed that an elevated NLR is an independent predictor of disease progression and recurrence in patients with NMIBC. The aim of the current study was to evaluate whether preoperatively measurement of NLR can predict lamina propria invasion, recurrence and progression in patients with NMIBC. Materials and Methods: The medical records of 223 consecutive patients who underwent TURBT and were diagnosed with non-muscle-invasive bladder cancer from 2007 to 2012 were analyzed. the patients were divided into two groups according to the pathological stage (Group 1: Ta, Group 2: T1). NLR was calculated by dividing the absolute neutrophil count (N) by the absolute lymphocyte count (L). Results: The mean NLR was 2.0 +/- 0.58 in Group A (Ta) vs 2.9 +/- 0.68 in Group B (T1) (p <.0001). NLR of > 2 was associated with 132 (90.4%) cases of T1 & 21 (27.3%) cases of Ta & NLR of <2 was associated with 56 (72.7%) cases of Ta & 14 (9.6%) cases of T1 (p<0.001). NLR >3 was associated with 95 (70.9%) cases of recurrence vs 45 (50.6%) cases of recurrence in NLR of <3 (p=0.002). A NLR >3 associated with 42 (31.3%) cases of progression vs 14 (15.7%) in NLR <3 (P<0.001). Conclusion: Pretreatment measurement of NLR can predict the lamina propria invasion (NLR>2) recurrence and progression (NLR>3) in patients with NMIBC. Prospective studies are now required to further validate the role of NLR as a risk factor in NMIBC.

   Podium Session 6: URO Oncology Top

   POD 06-01: A comparative study of monthly maintenance protocol vs south west oncology group maintenance protocol of intravesical bacillus calmette gue'rin in non muscle invasive bladder cancer Top

Naveen Kumar Gupta, D. Sarkar, D. K. Pal

IPGMER, Kolkata, West Bengal, India

Introduction and Objectives: Urinary bladder cancer is the most common malignancy of the urinary tract. Following trans-urethral resection of bladder tumor, intravesical immunotherapy with Bacillus Calmette-Gue'rin (BCG) is considered the most effective treatment to prevent recurrence and progression for patients with intermediate and high-risk non muscle invasive bladder cancer (NMIBC). The present study aims to at comparing the tolerability and efficacy in preventing recurrence and progression. Keeping the induction therapy same, the present study aims to compare the maintenance schedule of monthly instillation of single dose of intravesical BCG for 12 months with the South West Oncology Group (SWOG) protocol over one year with a minimum of one year follow up. Methods: The study was conducted at Department of Urology on intermediate and high risk NMIBC patients following resection. Patients were randomized into two groups following 6 weekly 80 mg intravesical BCG induction. One group received maintenance with SWOG protocol and other group received one monthly dose of 80 mg BCG for 12 months. Results: 78 patients were randomized into 2 groups with mean follow up of 19.5 months (12-26 months). There were no statistically significant differences in demographics or tumor characteristics in both groups. There was no statistically significant difference in outcome in terms of recurrence (3/40 vs 2/38 p=0.68), progression (1/40 vs 0/38 p>0.05) or adverse reactions (6 vs 5 p>0.05). Conclusion: The shorter less intense monthly maintenance protocol may improve patient compliance without hampering outcomes and may provide a suitable alternative to the SWOG maintenance protocol.

   POD 06-02: Significance of serum total testosterone to total prostate specific antigen ratio in prostate cancer diagnosis: A study in north-eastern India Top

Nabajeet Das, Sasanka Kumar Barua, S. J. Baruah, T. P. Rajeev, P. K. Bagchi

Department of Urology and Renal Transplantaion, Gauhati Medical College and Hospital, Guwahati, Assam, India

Introduction: The lifetime risk of prostate cancer (PCa) is around one-in-seven and is the most common malignancy in men. Few recent pieces of research have investigated serum testosterone/PSA (T/PSA) as a biomarker, which can be used alternatively to free PSA. Aim and Objective: We investigated whether total serum testosterone and testosterone/total prostate-specific antigen ratio (T/PSA) might be used PCa biomarkers. Materials and Methods: We prospectively studied 71 patients with benign prostatic hyperplasia (BPH) and 73 patients of PCa treated during January 2016 – December 2017. Serum total testosterone, total PSA and T/PSA ratio of BPH and PCa patients were analysed. Results and Observations: Compared with the BPH group, the PCa group had higher PSA (25.02 vs. 3.88) and lower T/PSA (1.67 vs. 5.89) (all p < 0.001). Patients with PCa and PSA ≤20 ng/ml had higher testosterone (17.16 vs. 15.06; p =.0232) and higher T/PSA ratio (2.74 vs. 0.44; p < 0.001) than those with PSA >20 ng/ml. Patients with PCa and Gleason score ≤7 had higher testosterone (18.03 vs. 13.94; p < 0.001) and T/PSA (2.68 vs. 0.44; p < 0.001) than those with Gleason score >7. In patients with PSA ≤20 ng/ml, T/PSA was higher in those with BPH than in those with PCa (5.89 vs. 2.74; p <.001). ROC curve analysis yielded an AUC of 0.873; for the optimal cut-off of 3.89, with sensitivity of 91.8% and specificity of 52.1%. Conclusion: T/PSA ratio may have a role in improving the accuracy of in differentiating PCa from BPH in patients with PSA <20 ng/ml.

Keywords: Benign prostatic hyperplasia, prostate cancer, serum total testosterone to total PSA ratio

   POD 06-03: A prospective study on association of prognostic inflammatory markers with renal cell carcinoma characteristics Top

Rayeez Rasheed, M. Manikandan, A. T. Rajeevan, K. V. Shanmugha Das, K. M. Dineshan, A. V. Venugopal, Felix Cardoza

Government Medical College, Kozhikode, Kerala, India

Introduction and Objective: There is increasing evidence of systemic inflammation in cancer development and progression and renal cell carcinoma (RCC) is no exception. Tumor-associated inflammation is commonly considered the seventh hallmark of cancer and is characterized by inflammatory cell infiltration. Our objective was to find out the correlation of prognostic inflammatory markers i.e. C Reactive Protein (CRP), Neutrophil-Lymphocyte ratio (NLR) and Serum Lactate Dehydrogenase (LDH) with RCC characteristics like histology, tumor size, presence of necrosis and calcification. Patients and Methods: A prospective study was conducted on patients with localized RCC. 46 patients who fulfilled our inclusion criteria underwent preoperative assessment of CRP, LDH and NLR ratio, apart from routine investigations. Patients were subjected to either partial or radical nephrectomy. Histopathological report was followed up after surgery. Statistical analysis was done to find out if there is any significant correlation. Results: Of the 46 RCC patients majority (76.1%) were clear cell carcinoma cases followed by papillary carcinoma (19.6%). Clear cell carcinoma was significantly associated with elevated CRP (Pvalue = 0.024) while none of the other varieties were associated with elevated CRP. All tumor parameters were associated with elevated LDH and NLR. Conclusions: There is correlation between inflammatory markers and RCC. Whether these markers play any role in incitation of RCC has to studied.

   POD 06-04: Non transitional cell carcinomas of bladder – A single center experience Top

K. Ravi Chandran, Priyank Bijalwan, Ginil Kumar Pooleri, Appu Thomas

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Bladder tumours are known for many histological variants. The aim is to evaluate incidence, clinical presentation, histopathology, treatment and prognosis of rare variants of bladder cancer. A retrospective review of institutional database was done to identify all bladder tumours between January 2012 and December 2017. Patients underwent cystoscopy with biopsy /TURBT and histopathology was evaluated. Patients were treated according to standard treatment protocols. Patients were evaluated for incidence, clinical presentation, pathological stage, treatment and median survival. 640 patients were identified to have bladder tumour. 39 (6%) patients had rare variant of bladder tumour with adenocarcinoma 17 (2.8%), squamous cell carcinoma 7 (1.1%), sarcomatoid variant 4 (0.7%), poorly differentiated carcinoma 4 (0.7 %), carcinosarcoma 3 (0.6%) and one of nested variant (0.1%). The most common presentation was hematuria 29 (76%) and irritative LUTS 13 (33%). 30 (78%) of patients had muscle invasive disease on presentation. Majority of patients underwent radical cystectomy 34 (88%). The patients had median survival adenocarcinoma 17 months, squamous cell carcinoma 36 months, sarcomatoid variant 15 months, poorly differentiated carcinoma 30 months and carcinosarcoma 34 months. The rare bladder tumors clinically have presentation similar to transitional cell carcinoma. They present at an advanced stage with majority being muscle invasive at presentation. These variants have poor median survival with adenocarcinoma and sarcomatoid variant having median survival less than 18 months. These rare variants of bladder cancer are aggressive tumours which present late and have poor survival. They should be diagnosed early and managed aggressively.

   POD 06-05: Biochemical failure after radical prostatectomy in high risk carcinoma prostate and its co-relation to the number of risk factors Top

Priyank Bijalwan, Ginil Kumar, Appu Thomas

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Introduction: We analyzed the biochemical recurrence free survival of patients with high-risk prostate cancer (HRCaP) as per D'Amico classification undergoing radical prostatectomy at our center. We aimed to determine whether the number and type of risk factors (cT2c-T3b, PSA >20 ng/ml, Gleason score (GS) > 7) are associated with biochemical recurrence in HRCaP patients undergoing radical prostatectomy (RP) in Indian population. Methods: Between 2006 and 2017, 192 patients underwent radical prostatectomy (open, laparoscopic and robotic) at our center, of which 109 had D'Amico high-risk disease. Preoperative, post-operative and pathological outcome data were analyzed for patients with HR disease as per D'Amico classification. Subgroups were formed to determine whether an increasing number of risk factors (1, 2 or 3) were associated with poorer oncological results and early biochemical recurrence (BCR). The Kaplan-Meier method with Log Rank test was used to test the difference in biochemical recurrence free survival between the groups. Univariate and multivariate analysis was done to find significant variable against BCR. Results: According to the D'Amico criteria, 109 patients had high risk, 63 patients had intermediate risk and 19 patients had low risk disease. These 109 patients with high-risk disease were analyzed in our study (50 robotic, 33 open, 26 laparoscopic). 59 patients (54.1%) had one high risk factor (1HR), 44 (40 %) had two high risk factors (2HR) and 6 (5.5%) had three high risk factors (3HR). The mean follow up for our patient population was 21.5±19 months (median 18 months, range 0-108). Overall the 2-year and 5-year biochemical recurrence free survival (BRFS) was 45% and 35% respectively (mean BRFS 46±6 months). 2 year BRFS was 63%, 23% and 22% respectively for 1HR, 2HR and 3HR (log rank p < 0.0001). The prognostic sub-stratification based on three risk factors was significantly predictive for adverse pathologic features and oncologic outcomes. Conclusion: Sub-stratification based on three well-defined criteria leads to a better identification of the most aggressive cancers and prediction of need for additional treatment modalities. Localized HRCaP includes a heterogeneous population of patients with variable oncological outcomes.

   POD 06-06: Long-term outcomes of nephrectomy and inferior vena cava thrombectomy in patients with advanced renal cell carcinoma Top

G. K. Shreedhar, B. Priyank, P. Ginil, T. Appu

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Introduction: To evaluate the long term outcomes of nephrectomy and inferior venacava thrombectomy in patients with advanced renal cell carcinoma in a single tertiary care centre. Materials and Methods: We retrospectively collected data of 30 patients who underwent Nephrectomy and venacava thrombectomy from Jan 2005 to Dec 2017. All the patients underwent surgery through abdominal approach (n=27) and throacoabdominal approach (n=3). The outcomes of surgery such as cancer specific survival, Progression free survival and 90 day post operative complications were studied. The prognostic factors are also analysed. Results: The median age group was 57 years. At presentation majority (59.4%) of the patients have Level II (n=18) thrombus. 9 patients (30%) had mets at time of presentation. The patients with Level IV thrombus (n=3) underwent IVC exploration with Cardiopulmonary Bypass and deep hypothermic cardiac arrest. Involvement of IVC was seen in 5 patient and graft was used to reconstruct the IVC. Post OP mortality was 6% (n=2). 6% (n=2) had significant post op morbidity (Clavien Dindo >2). The medain follow up was 24 months. Cancer specific survival at 5 years was 39%. The 5 year CSS of patients with metastasis was 6% and insub group without metastasis was 59%. On Multivariate analysis grade of the tumour, presence of metastasis and lymphnode were the independent prognostic factors. Level of tumour has no statistical influence on the survival. Results: Surgery remains the main modality of the treatment in RCC with IVC thrombus. This offers a resonable long term survival in patients without metastasis. Again the metastasis and grade of the disease deterines the prognosis rather than the level of the thrombus.

   Podium Session 7: Transplantation Top

   POD 07-01: Challenges in transplantation of small pediatric cadaver kidneys – IKDRC experience Top

Venkata Chaitanya Singamsetti, S. J. Rizvi, P. R. Modi

IKDRC - ITS, Ahmedabad, Gujarat, India

Introduction: Pediatric kidney transplant into adult recipient is a well recognised procedure to expand donor pool. Transplantation of pediatric kidneys have become an acceptable option. Pediatric deceased organ donation can help in increasing the organ pool in countries with high organ demand like India. Materials and Methods: A retrospective analysis of prospectively collected data from 1998 to 2018 was performed. Patients were divided into 4 groups. Group 1 is enbloc transplant of pediatric donor less than 5 yrs (n=4), group 2 is single kidney pediatric cadaver donors of less than 5 yrs (n=2), group 3 is 6 – 12 yrs (n=10) and group 4 is 12 – 18 yrs age group (n=24). These recepients were on regular follow up from 1998 till date. Results: Recepients were followed up regularly. Mean creatinine is 1.1 mg/dl, 0.55 mg/dl, 0.82 mg/dl and 1.25 mg/dl respectively in all the four groups. Patient survival and graft survival were 75% and 75%, 100% and 100%, 70% and 90%, 79.2% and 96% respectively in all the 4 groups. Conclusion: Pediatric cadavers are excellent resourses which increase donor pool and have to be harvested whenever available. Enbloc transplantation can be preferred if the donor age is less than 5 yrs of age. Pediatric kidneys can adapt their growth and function to adult recipients and provide them with excellent function. In order to alleviate the burden on the waiting list, pediatric kidneys should be transplanted more often when available.

   POD 07-02: Vesicoureteral reflux in transplant recipients and role of deflux Top

Ujwal Kumar, S. J. Rizwi, Raghuveer, Ravi Jain, P. R. Modi

IKDRC, Ahmedabad, Gujarat, India

Introduction and Objectives: Vesicoureteral reflux (VUR) due to non-anatomic ureterovesical anastomosis is not uncommon in kidney transplant patients after surgery. Currently the gold standard treatment of patients with high-grade VUR and resulting recurrent urinary tract infections is open surgery to revise the ureterovesical anastomosis. Very few studies address Deflux injection in transplanted kidneys. The objective of this study is to determine efficacy and feasibility of Deflux injection for vesicoureteral reflux in kidney transplant patients. Methods: Out of 577 transplantations done from January 2016 to December 2017, five patients (0.87%) were identified to have symptomatic vesicoureteral reflux. Four patients received one Deflux injection into the transplant ureterovesical junction and one patient needed injection twice. Baseline patient characteristics and treatment characteristics were recorded. Outcomes were assessed with regular patient follow-ups. Results: All the 5 patients were found to have improvement in symptoms including resolution of recurrent urinary tract infections and improvement in renal function and none needed open intervention. Conclusion: Endoscopic treatment with subureteral injection of the bulking agent Deflux to manage VUR in cases of recurrent pyelonephritis of kidney grafts is a non-invasive treatment option with a good success rate and safety profile and can avoid open surgeries in many.

   POD 07-03: Transposed brachiobasilic AV fistula: Outcome analysis Top

R. Kumar, R. Manikandan, L. N. Dorairajan, K. S. Sreerag, S. Kalra, V. Khelge

Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Introduction and Objective: According to the NKF-K/DOQI (National Kidney Foundation Kidney Disease Outcomes Quality Initiative) Clinical Practice Guidelines, transposed brachiobasilic arteriovenous fistula (TBBAVF) is the third AV fistula recommended for cases who are unable to undergo dialysis by using radiocephalic or brachiocephalic AV fistula, because of either unsuitable anatomy or access failure. The primary objective of this study is to determine the outcomes of brachiobasilic AV fistula transposition performed as a two stage procedure. Methods: The study involves evaluation of data of 25 patients in whom brachiobasilic AV fistula transposition was performed as a two staged procedure at our centre during the study period from June 2014 to January 2018. In all the patients, TBBAVF was performed as secondary or tertiary vascular access site after failed access at previous sites. Results: The operative time was 180-240 minutes (mean: 218 minutes). Three (12%) patients developed post operative limb edema and were managed conservatively. Three (12%) patients had bleeding at the wound site which required re-exploration. Post operative thrombosis of draining vein occurred in 6 patients (24%), out of which 4 (66%) were successfully treated by thrombectomy. The patency rate was 91.6 % at a median follow up of 3 months. Conclusion: The two-step technique of fashioning brachiobasilic arteriovenous fistula is associated with good patency rate and related complications can be treated conservatively without loss of the fistula.

   Podium Session 8: Pediatric Urology Top

   POD 08-01: Sacral trans-cutaneous electric nerve stimulation vs oxybutynin for children with overactive bladder Top

Utsav Shah, Ramesh Babu Srinivasan, Sekar Hariharasudhan, K. Natarajan

Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India

Introduction: Sacral transcutaneous electric nerve stimulation is an alternative technique to antimuscarinic agents for treating children with overactive bladder. Aim: To compare the effectiveness of sacral Trans-cutaneous Electric Nerve Stimulation (TENS) vs oxybutynin in treatment of overactive bladder in children. Materials and Methods: 40 children (M:F 17:23) with a mean age of 6.2 years were divided into two groups. Group 1 received parasacral TENS –surface electrodes in the S2/S3 region with a symmetric biphasic current of 10 Hz frequency and pulse width of 400 μs for 20 minutes – on alternate days for a total of 10 sessions. Group 2 received oxybutynin 2 mg/kg /dose given daily for 20 days. Success was assessed by 1) the rate of complete symptom resolution, 2) a visual analog scale of 0 to 10, 3) the dysfunctional voiding scoring system (DVSS). Results: Twenty patients were randomized to groups 1 and 2, respectively. A significantly higher number of drop outs (p=0.001) was noted 9/20 (45%) in group 1 (due to non compliance with multiple visits to hospital) compared to 1/20 (5%) patient in group 2. Among those who completed the treatment, symptoms completely resolved in 6/11 patients in group 1 (54%) vs 10/19 (52%) in group 2 with no significant difference (p=1). Visual analog score improved in 8/11 (73%) in group 1 vs 15/19 (79%) in group 2 with no significant difference between the groups (p=1). DVSS improved in 9/11 (81%) in group 1 vs 16/19 (84%) in group 2 with no significant difference between the groups (p=1). Group 1 showed no side effects while significantly higher side effects (p=0.001) like dry mouth, hyperthermia and constipation were encountered by 9/19 (47%) in group 2. Conclusions: Parasacral TENS is as effective as oral oxybutynin with lower side effects. However it has poor compliance due to multiple hospital visits involved. Message: Considering the equal efficacy with no side effects of oxybutinin therapy, TENS is a considerable and a feasible option in compliant patients.

   POD 08-02: Extended ulaanbaatar procedure for proximal penile hypospadias with moderate to severe chordee Top

U. S. Chatterjee

Park Medical Research and Welfare Society, Kolkata, West Bengal, India

Introduction and Objective: Ulaanbaatar urethroplasty is two stage procedure. Partial urethroplasty is done following chordee correction at glans & distal portion during first stage and rest is done at second stage. In our modified, extended procedure, full length of urethra is constructed following orthoplasty and urination is kept diverted from neo-urethra by perineal urethrostomy would be closed after 6 months. Methods: We performed urethroplasty with inlay buccal mucosa along with tunica vaginalis as onlay in 28 patients; aged 1 to 24 years (mean 8.5 years). All neo-urethras were kept on regular calibration for 6 months. Urethrostomy closure was done either with local, regional or general anaesthesia, needs 15- 20 minutes as a day care procedure, following maturation of neo-urethra in adequate calibre, usually after 6-10 months. Follow up period ranged from 4 years to 6 months. Results: Urethral fistula and diverticulum did not develop in any patient. However, in one patient had partial wound disruption and two had stenosis, needed reoperation prior to urethrostomy closure. In all patients the glans with vertical meatus looked normal. Conclusions: At the outset, longer neo-urethra exerts greater resistance to urine flow causes distress both in patients & parents and, so the difficulties of calibration. So the matured urethras, made after regular calibration with diverted urination, obviate that predicament. Similarly disruptions and strictures are managed comfortably with re-operations as urination is diverted. In this procedure, we avoided repeat degloving unlike traditional two-stage procedure. Actually, it's not a two stage procedure, rather less than that.

   POD 08-03: Comparison between open and robot assisted kidney transplant in paediatric population - preliminary experience Top

Sarita Syal, R. Maheshwari, S. Chaturvedi, M. Kumar, P. Desai, Y. Qadri, Kumar Anant

Max Superspeciality Hospital, New Delhi, India

Introduction: Robotic Assisted Kidney Transplant (RAKT) is being increasingly utilized in adult patients. Its application in paediatric population is still controversial. Equipment size, learning curve and small working space are major issues. Herein, we are sharing our initial experience of three children who underwent RAKT in our institute and compared their outcome to open kidney transplant in paediatric patients. Materials and Methods: Three children (M:1, F:2) aged between 7-16 years underwent RAKT and 14 (M:8, F:6) aged between 11 -17 years underwent OKT between April 2016 to March 2018. Grafts were procured from adult donors using laparoscopy. Kidney was introduced inside peritoneum through Pfannenstiel incision in one child and GelportŽ in two. Anastomosis was performed with common iliac vessels (end to side) in all the three cases of RAKT while in open cases depending upon the age of children, anastomosis was done with common, internal or external iliac vessels. Modifed Lich-Gregoir ureteroneocystotomy was performed over DJ stent. Results: Patient demography, operative characteristics and mean operative time, warm ischaemia time, duration of hospital stay and functional outcomes at one week, one month and three months was comparable between the two groups. Operative time was longer in OKT, but was not statistically significant. Diuresis was immediate. Mean estimated blood loss (EBL), need for analgesia, length of scar and incidence of wound infection significantly favoured RAKT. Conclusion: Well performed RAKT is technically feasible and safe in children with similar functional outcomes. More number of cases of RAKT are required to established better comparative results.

   POD 08-04: A long-term international collaborative model for bladder exstrophy-epispadias: Can it sustain and deliver? Top

Jaishri Ramji, R. Joshi, A. Shukla, P. Reddy, J. L. Salle, D. Canning

Civil Hospital, Ahmedabad, Gujarat, India

Introduction and Objective: In a complex congenital anomaly like Bladder exstrophy-epispadias, achieving the ultimate goals of adequate bladder capacity, continence and good cosmetic outcome pose a tremendous challenge to the surgeon. The benefits of a collaborative approach with surgeons from different centers combining their expertise for complex surgeries are well known. We review the outcomes of an international collaboration initiated for the management of exstrophy-epispadias. Methods: A long-term collaboration to treat exstrophy- epispadias was created at our institute in 2009. From 2009 to 2018, 124 children operated upon for exstrophy-epispadias were prospectively enrolled in a data registry with institutional review board approval. A strict protocol of follow-up evaluation was maintained. Comprehensive assessment included annual and biannual bladder capacity measurements, incidence of UTI, upper-tract changes, continence (dry-interval) and surgical complications. Results: 124 children with exstrophy (103) and epispadias (21) underwent combined-primary-repair-of-exstrophy with anterior pubic osteotomies and epispadias repair respectively. The follow-up patient retention rate was 95% (n=119). Only 2 exstrophy patients (4%) suffered a bladder dehiscence and underwent redo-repair. Twenty-three (19%) patients experienced complications. The International Consultation on Incontinence Modular Questionnaire administered to a subset of patients (47) in 2016 showed six having complete functional continence (2 exstrophy, 4 epispadias); while 24% of exstrophy and 73% of epispadias patients reported dry intervals >90 minutes. Conclusions: This collaborative focused on exstrophy-epispadias is sustainable and delivers optimal outcomes; it also affords the opportunity to accelerate the learning curve in treating this rare anomaly. We have shown a significant patient retention rate which is critical as upper tract changes can occur years after the initial repair.

   Podium Session 9: Uro Oncology and Transplantation Top

   POD 09-01: Robotic partial nephrectomy for renal hilar tumors: Revised technique – A single institutional analysis using Da Vinci Xi® System Top

Saurabh Joshi, R. Kaushal, R. Maheshwari, S. Chaturvedi, K. Banerjee, A. Kumar

Max Super Speciality Hospital, Saket, New Delhi, India

Introduction: Management of hilar tumours are a surgical challenge as they are in close proximity to hilar vessels and pelvicalyceal system (PCS) and lack a hilar parenchymal margin for renorrhaphy. We believe that robotic assistance using da vinci Xi® system with revised technique using selective arterial clamping (clamping of segmental artery), early de-clamping might facilitate a minimally invasive approach to partial nephrectomy for renal hilar tumours in selected cases. Methods: And surgical technique From October 2015 to April 2018, We evaluated 15 patients with renal hilar tumours who underwent robotic partial nephrectomy. The selective arterial clamping (clamping of segmental artery) without clamping of main renal artery was done in six cases after doing meticulous hilar dissection. Early unclamping was done after completion of inner renorrhaphy. Results: A total of 15 patients (mean age 58 years, range 30−76 years) underwent successful robotic partial nephrectomy for renal hilar tumours. Selective arterial clamping was done in 6 cases. Mean warm ischemia time was 22.33 + 10.8 minutes. Mean operating time was 210 minutes (180−260 min). Mean estimated blood loss was 230 ml (80-800 ml) Mean tumour size was 4.1 cm (3.1-6.8 cm). Mean hospital stay was 3.0 days. Conclusions: RPN using da Vinci Xi® robotic system with revised technique is feasible for selected patients with renal hilar tumours. Robotic assistance may facilitate the technical challenges of a minimally invasive application, with revised technique using selective arterial clamping, early de-clamping might reduce warm ischemia time for renal hilar tumours in selected cases.

   POD 09-02: Skeletal related events in renal cell carcinoma: Prediction with A.C.H.E score for risk stratification Top

Y. Singh, T. P. Rajeev, S. J. Baruah, S. K. Barua, P. K. Bagchi, D. Sarma, M. Phukan

Department of Urology and Renal Transplantation, GMCH, Guwahati, Assam, India

Introduction and Objective: Skeletal metastasis are catastrophic in patients with renal cell carcinoma and lead to skeletal related events such as nerve entrapment, hypercalcemia and even pathological fractures which may require surgical intervention. In this analysis, we aim to correlate blood parameters and bone metastases secondary to renal cell cancer and to identify determinants for bone metastasis in newly diagnosed patients and those who have already received treatment. Methods: The clinical data of 42 patients with RCC and bone metastasis were reviewed from January 2010 to December 2017. The correlation between erythrocyte sedimentation rate (ESR), alkaline phosphotase (ALP), CRP, calcium, hemoglobin (Hb), CEA and bone metastases was analyzed. Risk factors were identified by multivariate logistic regression analysis. The cutoff value of the independent correlation factors were calculated by receiver operating characteristic curve. Results: ESR, ALP, CRP and Hb were significantly associated (p=.003) and correlated (p=.02) with bone metastasis. Multivariate logistic regression analysis indicated that ESR, ALP, CRP, Hb were independent risk factors correlated with bone metastasis (p < 0.01). ROC curves demonstrated these factors had comparable accuracy at predicting bone metastasis (AUC= 0.945, 0.845, 0.733, 0.765, respectively). Conclusion: We propose that an A.C.H.E score aka ALP, CRP, Hb, ESR was a potential risk factors for bone metastasis in patients with RCC. For new RCC patients, if the values of ALP > 128 U/L, CRP ≥ 74 mg/L, Hb < 11.5 g/L, ESR ≥ 55 mm/hr were detected, intensive monitoring and bone scanning are warranted for them.

   POD 09-03: Pediatric renal transplant: Institute of kidney diseases research center and transplant sciences experience Top

Mishra Amit, P. R. Modi, S. J. Rizvi, B. C. Pal, S. Kumar, V. Kothari

Institute of Kidney Diseases Research Center and Transplant Sciences, Ahmedabad, Gujarat, India

Introduction: Major diagnostic groups leading to Chronic Kidney Diseases in pediatric population includes obstructive uropathy, congenital anomalies and inherited disorders, focal segmental glomerulosclerosis and reflux nephropathy. Materials and Methods: A single-center retrospective cohort study was conducted to evaluate our experience with pediatric renal transplantation. The medical records of 150 patients upto the age of 18 years who underwent a renal transplantation procedure between the years 2012 and 2017 was reviewed. These data included information about demographic characteristics of patients, graft function and survival. Results: Out of total, 111 patients underwent open transplant, 34 robotic and remaining 5 underwent laparoscopic renal transplant procedure. 118 patients underwent living related donor kidney transplant and 32 patients received kidneys from cadaveric donors. About 80 % were males. The mean age was 13.7 years. Mothers were donor in 77% of the cases, followed by fathers and other family members. The mean pre transplant serum creatinine was 5.6 and post transplant mean serum creatinine value at 1 year was 1.49 and the latest mean serum creatinine is 1.30. The overall graft survival and patient survival was 91 % and 96% respectively. Conclusion: Advances in surgical techniques, preoperative and post operative care, as well as immunosuppressive therapy have contributed to increased patient and graft survival for this population thus leading to better growth and development, good quality of life and also added cost advantage over chronic dialysis.

   POD 09-04: Prospective non-randomized comparison between open and robot assisted kidney transplantation Top

A. Kumar, R. Maheshwari, S. Chaturvedi, S. Y. Qadri

Max Super Specialty Hospital, New Delhi, India

Introduction: Open Kidney transplant (OKT) has been a well-established procedure for ESRD. Robotic Kidney Transplantation (RKT) has been a recent development, but is yet to gain popularity. Herein, we compare our first 48 RKT with OKT done between April 2016 and March 2018. Materials and Methods: Data of 48 robotic kidney transplant procedures was prospectively collected and compared with randomly selected 48 cases of OKT done during the same period. All graft kidneys were harvested laparoscopically. Kidney was wrapped in an ice slush jacket and inserted into the abdominal cavity of the recipient through a midline umbilical (21 patients) or Pfannensteil approach (27 patients). A Gelport® was used to seal the midline incision. The comparison was done using Levens's test for equality of variances and student's t-test for equality of means. Results: The two groups were comparable in terms of age, sex, duration on hemodialysis and warm ischemia time. Recipients in RKT group were having higher body mass index. There was statistically significant less requirement of perioperative analgesic dose in RKT group. Re-warm ischemia time was longer in RKT group, which was statistically significant. There was slow fall in creatinine levels in RKT group (statistically significant). If we exclude 5 patients with medical complications, the difference is not statistically significant at days 7 and at 3 months. Conclusions: RKT confers advantage of decreased wound morbidity with similar functional outcomes as compared to OKT in short term. It looks promising; however, long term follow-up of large number of patients in needed.

   POD 09-05: Comparison of outcomes between low and high nephrometry score renal tumors managed by robot assisted partial nephrectomy: Our experience Top

R. Maheshwari, R. Kaushal, S. Chaturvedi, S. Joshi, Y. Qadri, A. Kumar

Max Super Specialty Hospital, New Delhi, India

Introduction: Nephron preservation is important while managing renal tumors, especially in patients with co-morbidities. Herein, we reviewed our prospectively maintained data to compare the outcomes between low and high Renal Nephrometry score renal masses in patients who were managed with Robot assisted partial nephrectomy (RAPN). Materials and Methods: From October 2015 to January 2018, around 51 RAPN were done in our center using da Vinci Xi surgical robotic platform. by single surgeon. The patients were evaluated in detail and renal nephrometric scoring was done in all cases. Briefly, the robot was docked, hilum dissected and control taken. Artery was clamped after surface marking of tumor using intraoperative USG. Venous control was taken selectively. Renorrhaphy was done in two layers with V-lok suture. Bolsters and topical hemostatics were used selectively. Pre-operative variables including patient age, BMI, pre op Hemoglobin (Hb%) and creatinine, tumor characteristics, post op Hb%, creatinine, HPE and all complications were recorded prospectively and analyzed. Results: 51 patients (30 males, 21 females) with mean age of 56.7 (28 – 77) years were operated. Mean BMI was 26 + 3.8 kg/m2. 26 patients had low and 25 had moderate to high nephrometry score. In patients with higher nephrometry score, the warm ischemia time (minutes) was slightly longer (21.38 + 7.9 vs 24.78 + 7.58) and injury to PCS was slightly higher (7% vs 20 %). All other variables were comparable. Conclusion: In the hands of an experienced surgeon, even most complex renal masses can be managed by RAPN, with comparable oncological clearance and functional outcomes.

   Podium Session 10: Andrology Top

   POD 10-01: Premature ejaculation: A comparative study of on demand dapoxetine and daily dosing paroxetine in terms of efficacy and side effect profile Top

Barun Kumar, Dilip Kumar Pal

IPGMER and SSKM Hospital, Kolkata, West Bengal, India

Background: Premature ejaculation is the most common male sexual disorder causing psychological distress for both partners and diminished quality of life. Selective serotonin reuptake inhibitors are now the cornerstone of drug therapy in premature ejaculation. Dapoxetine and paroxetine have not been studied comparatively in past. Methods: In our study, patients with premature ejaculation with intravaginal ejaculation latency time (IELT) of less than 60 seconds were included. Patients with known history of substance abuse were excluded. Patient and their partner were taught to measure IELT with a stopwatch. Thirty patients were given on demand 30 mg dapoxetine and another thirty patients were given 20 mg daily dose of paroxetine. They were called up after four weeks and increase in IELT and side effects were recorded. Results: After 4 weeks, mean increase in IELT in the dapoxetine group was 57.06 seconds while in paroxetine group was 64.5 seconds. The mean increase in IELT was more in daily dose paroxetine was more and it was statistically significant. Side effect profile was similar in both groups with daily dosing group experiencing slightly more side effects. Nausea headache and diarrhea were the most common side effects. Anejaculation and loss of libido were rare but serious side effects. Conclusions: Both dapoxetine and paroxetine are effective drugs for premature ejaculation and they have been shown to increase IELT in daily or on-demand dosing. It was shown that daily dosing paroxetine was more effective than on-demand dosing of dapoxetine but with slightly more side effects. Both drugs have good tolerability.

   POD 10-02: Does varicocelectomy improve testosterone to estradiol ratio in infertile men Top

U. A. Hemnath, W. Harry Santhaseelan, T. Antan Uresh Kumar, R. Balasubramaniam, G. Chengalvarayan, K. Saravanan

Madras Medical College, Chennai, Tamil Nadu, India

Introduction: Varicocele is the most common attributable cause of male infertility. Microscopic subinguinal varicocelectomy is preferred surgical approach. Testosterone levels and Testosterone to Estradiol ratio is found to be lower in varicocele patients with male infertility. Objective: To measure the testosterone levels and testosterone to estradiol ratio in varicocele patients with male infertility preoperatively and 6 months postoperatively and compare the values with normal controls. Methods: In this prospective clinical study, 50 men were assigned to 2 equal groups. The varicocele-treated varicocelectomy group included patients with varicocele who underwent loupe-assisted subinguinal varicocelectomy for infertility and the control group included fertile men without varicocele. Semen analysis, serum testosterone, estradiol, calculation of testosterone to estradiol ratio (T:E ratio), and scrotal Doppler ultrasound were assessed at baseline and 6 months later. Results: Total testosterone levels and T:E ratio were within the normal range in both groups. Men with varicocele had significantly lower levels of total testosterone and T:E ratio than men without varicocele (P<.001 for each). Average baseline testosterone levels were 4.6 ng/ml and 7.8 ng/ml and T:E ratio were 18.6 and 28.7 in varicocele patients and control group respectively. Testosterone level and T:E ratio were significantly higher in the negative control group at baseline assessment (P<.001). These parameters improved significantly 6 months after varicocelectomy (testosterone level is 6.2 ng/ml and T:E ratio is 24.4), whereas, they remained unchanged in the control group. Conclusion: Varicocelectomy is associated with improved hormone profile in varicocele patients with male infertility.

   POD 10-03: Folate deficiency: Risk factor in erectile dysfunction? Top

Saurabh Mittal, Suryakant Choubey, Zaffar Karam Sayed

St. Johns Medical College and Hospital, Bengaluru, Karnataka, India

Introduction: Erectile dysfunction (ED) has an overall prevalence of 52% among 40–70 years old men. ED is due to disruptions in neural, vascular, and hormonal signaling. Endothelial dysfunction is related to uncoupling of the endothelial nitric oxide (NO) synthase thereby reducing the NO levels. Folic acid (FA) potentially reverses the uncoupling of NO synthase. The aim of this study was to find the correlation of FA deficiency and ED. Materials and Methods: Patients between age 35 to 65 affected by ED assessed by the International Index of Erectile Function-5 (IIEF-5) on treatment with tadalafil 10 mg were evaluated. Patients improved on tadalafil were taken as control (n=40) and those who did not as case (n-42). After informed consent, fasting serum FA was measured. Statistical analyses were performed using SPSS 13. Results: The mean IIEF scores before and after treatment with tadalafil were 9.65 and 11.80 in group A (case) and 9.70 and 17.37 in group B (control) respectively. The difference of mean IIEF score after treatment with tadalafil between the two groups was significant (P=0.002). The serum FA concentrations were lower in patients of group A (7.61 ng/ml), than in Group B (21.23 ng/ml) P < 0.05. The serum FA levels were positively correlated with IIEF-5 scores (r = 0.589, P < 0.01). Conclusion: Serum FA was deficient in patients refractory to treatment with PDE5 inhibitors. FA supplementation may prove advantageous to men with sexual dysfunction. However, additional experimental and clinical studies are needed to determine appropriate doses of FA.

   POD 10-04: Association between lower urinary tract symptoms, erectile dysfunction and metabolic syndrome Top

J. Mohammed Farooq, P. R. Saravanan, Ezhil Sundar, K. Subramanian, Sivabalan

Institute of Urology, Madras Medical College, Chennai, Tamil Nadu, India

Introduction: Many large epidemiological studies provide overwhelming evidence of a link between erectile dysfunction (ED) and lower urinary tract symptoms (LUTS). Clinical evidence suggests that several common pathophysiological mechanisms are involved in the development of ED, LUTS & Metabolic syndrome (MetS). Objective: To determine the association between ED and MetS in patients presenting with LUTS due to BPE. Methods: 100 patients admitted to our urology dept. with BPE-related LUTS were included in the study period Jan-April 2018. LUTS &ED were classified as mild, moderate and severe according to IPSS & IIEF-5 respectively and NCEPAT Panel III criteria was used to diagnose MetS. Student T test and chi-squared tests were performed to calculate the continuous and categorical variables respectively using SPSS software & “P” value < 0.05 was considered as statistically significant. Results: Mean age of the patients was 63.8 years. 36% of the patients with MetS, 72% of the patients with ED and 39.2% of the patients with severe LUTS were determined. A statistically significant relationship was not observed between the mean IPSS scores and the severity of LUTS with Mets. Mean IIEF-5 scores of patients with MetS were significantly lower than those without MetS. Severity of ED in patients with MetS was significantly higher than those without MetS. The percentage of ED in patients with severe LUTS was found to be statistically higher than those with mild and moderate LUTS. Also a negative correlation was appreciated between IPSS and IIEF-5 scores. Conclusion: In patients with LUTS due to BPE, when the severity of symptoms increases, frequency of MetS & ED follows suit.

   POD 10-05: Comparision of testicular volume between fertile and infertile population Top

Manish Pandey, V. Shrivastava, V. Pattidar, Dias Sabby, S. Trivedi, U. S. Dwivedi

IMS BHU, Varanasi, Uttar Pradesh, India

Introduction: Testicular volume has long been associated with testicular function. Racial variations in testicular volume do exist. Neither the critical minimum testicular volume that guarantees adequate function, nor the optimal testicular volume that indicates peak testicular function are also known. we have compared testicular size among fertile and infertile people attending our urology opd. Methods: About 1301 subjects were clinically examined over a period of two years attending department of urology. 413 patients were fertile with at least one child without any supportive treatment attending urology opd with ailment other than infertility and 888 patients were infertile as per WHO definition. Testicular volumes of all subjects were measured by using prader's orchidometer. Results: Were evaluated by t test and p value < 0.05 was considered significant. Results Mean testicular volume for fertile and infertile patients was 17.08 ml and 16.45 ml respectively. Contrary to previous studies there was no significant difference between testicular size among fertile and infertile patients. Subjects with as low as 12 ml were fertile and even patients with testicular volume of 20 ml were infertile. If patients with UDT, orchidopexy, abnormal karyotype etc are excluded then results are more difficult to associate testicular size and fertility. Conclusion: Testicular volume doesnot correlate well with infertility. Critical mean testicular volume for adequate fertility is still not established. Large population studies are required to correlate testicular size and fertility.

   POD 10-06: To study the impact of surgical viagra in enhancing sexual function and sex hormones in obese males Top

Harish K. Sinha, Y. P. Singh Rana, Aditya Pradhan

BLK Super Speciality Hospital, New Delhi, India

Introduction: Obesity has been associated with decreases in testosterone and sex hormone binding globulin for men and increase in testosterone and estrogen for women. Several studies have shown improvement in sex hormone levels in both men and women following weight loss. Aim: To evaluate the changes in sexual function in males following bariatric surgery for obesity. Materials and Methods: This was a prospective study conducted over the last 2 years. The inclusion criteria included patients more than 18 years age, BMI more than 30 with undergoing bariatric surgery. Patients with previous diagnosis and treatment of hypogonadism, pituitary disease, Chronic Kidney Disease, Chronic Liver Disease, history of testosterone replacement therapy were excluded. A total of 32 patients were included in our study. Apart from anthropometric data and standard bariatric surgery investigations, Serum testosterone level and the SHIM score were recorded for each patient preoperatively and post operatively. Results: The mean age was 37.5 years. 40.6 % patient were diabetics, 46.8 % were hypertensives, 59.3% had Sleep Apnoea 71.8 % patients underwent Laparoscopic Sleeve Gastrectomy while the rest underwent Laparoscopic Rouz enY Gastric Bypass. The preoperative SHIM score and testosterone levels were 9 and 2.5 ng/ml respectively. At 6 months the SHIM score and testosterone level were 16 and 4.5 ng/ml respectively which further improved at 12 months to 21 and 6.2 ng/ml respectively. Conclusion: This study demonstrated a marked improvement in sexual function shown by the increase in SHIM scores and serum testosterone following bariatric surgery for obesity in males.

   Moderated Video Session 1: Uro Oncology General, Pediatric and Reconstructive Urology Top

   MV 01-01: Technique of laparoscopic nephroureterectomy in multiple lower ureteral TCC avoiding tumour spillage Top

K. Senthil, M. Ramalingam, K. Sivasankaran

Urology Clinic, Coimbatore, Tamil Nadu, India

Introduction and Objective: The major concern in laparoscopic nephroureterectomy for multiple ureteric TCC is the spill of tumour tissue around the hiatus. Here we illustrate the spill free technique and inclusion of bladder cuff. Methods: A 53 year old female presented with hematuria associated with clots for two weeks duration. On evaluation Contrast CT Abdomen showed multiple right lower ureteric tumours. Cystoscopy revealed no bladder tumour. During laparoscopy in our spill free technique, we mobilised the distal ureter upto hiatus and further dissected the detrusor muscle upto the mucosa around the ureteric orifice. Then ureter was ligated at the level of the ureteric orifice. Before dividing the ureter, stay was secured in the bladder mucosa one cm distal to the orifice. Bladder was closed in two layers. Results: Patient made an uneventful recovery. Drain was removed on post operative day 4 and discharged on next day with catheter in situ. Bladder cuff margin was free of tumour in histopathology. Conclusions: Our technique to prevent spill in nephroureterectomy is novel and easy to adopt.

   MV 01-02: Asopas single stage repair for proximal hypospadias – Step by step video Top

H. R. Pathak, V. V. Agarwal

Department of Urology, BYL Nair Hospital, Mumbai, Maharashtra, India

Hypospadias is one of the oldest disease known to mankind, despite this the treatment protocol is not standardized. Its repair is one of the most challenging problems for operating surgeons due to its high complication rate. The reported incidence of complications range from 6% to 30% depending upon severity of hypospadias. One of the major dispute is between single stage vs. two stage repair. A single-stage repair is used by many surgeons and achieves a high success rate, being safe, effective, less morbid with comparable success as staged repair and better cosmetic outcomes. Asopa performed a single stage repair by using transverse inner preputial onlay flap based on superficial dorsal vessels for repair of proximal hypospadias. After degloving of the penis, the inner preputial flap was wrapped around the shaft of penis and anastomosed to the urethal plate on both sides. Healing is better as the transferred skin carries its own blood supply. The advantage of Asopa's repair over other repairs like Duckett, Snodgrass is that there is less incidence of fistula formation. Here we describe a step by step approach of Asopas single step repair for proximal hypospadias.

   MV 01-03: Laparoscopic assisted radical cystectomy and anterior exenteration with ileal conduit urinary diversion for locally advanced bladder cancer Top

Adittya K. Sharma, Rahul Yadav, Vikas Sharma, Shajib Fareedi

Rajiv Gandhi Super Speciality Hospital, New Delhi, India

Introduction: Laparoscopic surgery is proven beyond doubt, in terms of lower morbidity and mortality compared to open surgery with equivalent oncological outcome. But locally advanced CA bladder is traditionally managed by open surgery. We intend to define technique of Laparoscopic assisted Radical Cystectomy and anterior Exenteration with Ileal conduit Urinary diversion for locally advanced Bladder cancer. Patients and Methods: 56 year old lady presented with history of hematuria and flank pain for past 3 months. On primary evaluation with CECT KUB metastatic workup, Cystoscopy & URBT she had clinically T3a N1 Mo TCC bladder with Right side obstructive Uropathy. She underwent Laparoscopic assisted RC and anterior exenteration with Ileal conduit urinary diversion by 4 laparoscopic ports and 12 cm long midline incision. She had hard lymph nodes encasing iliac vessels hence lymph node dissection was completed through open incision after laparoscopic RC and anterior exenteration. Patient had uneventful postoperative recovery and was discharged on 5th postoperative day. Histopathological examination showed T4a N1 M0 TCC bladder hence patient was referred for adjuvant chemotherapy. Conclusion: Laparoscopic assisted Radical cystectomy and anterior exenteration is feasible with excellent post operative outcome and should be tried as first option whenever feasible.

   MV 01-04: Absent urethra, MRKH in an operated case of cloacal malformation: A management challenge Top

H. S. Bhatyal, Y. Garg, A. Arya

BLK Superspeciality Hospital, New Delhi, India

A 17 year old female presented with complaints of amennorhoea and continuous urine leakage ever since she underwent surgery shortly after birth for a common urinary and fecal channel. On evaluation patient was found to be devoid of all the female genital organs (Ovaries, uterus, cervix and vagina). She had a normal looking anal opening with a widely patulous bladder neck with continuous urine leakage. There was scar tissue in between the bladder neck and anus. Patient was offered urethral reconstruction and creation of neo vagina but she refused the latter. She underwent creation of neo urethra from locally available tissue which was wrapped around with a gracilis flap harvested from right thigh. Following catheter removal patient is continent with just 1-2 pad/day.

   MV 01-05: Laparoscopic partial nephrectomy for completely endophytic tumour Top

Anil Kumar Gulia

VPS Rockland Hospital, Qutab Institutional Area, Delhi, India

Objective: To demonstrate technique of laparoscopic partial nephrectomy (LPN) for completely endophytic tumour in a difficult location. Materials and Methods: A 72 year old diabetic lady with incidentally detected right renal endophytic tumour. Tumour was 3x2.5 cm sized, completely endophytic, located posteriorly and abutting renal sinus. Transperitoneal laparoscopic right partial nephrectomy done with clamping of both renal artery as well as vein. Results: Tumour size was 3x2.5 cm, warm ischemia time 35 minutes and estimated blood loss 150 ml. There was no complication and patient discharged on postoperative day 3. Histopathology report showed clear renal cell carcinoma with negative margins. At 8 months of follow up, patient is doing well with no recurrence and preserved renal function. Conclusion: In experienced hands, laparoscopic partial nephrectomy for challenging endophytic tumours can be done safely with good outcome.

   MV 01-06: Laparoscopic-assisted radical nephroureterectomy with bladder cuff excision and lymphadenectomy Top

Ashwin Giridhar

   Moderated Video Sesion 2: Uro Oncology Robotic Top

   MV 02-01: Robot assisted radical nephrectomy + hysterectomy and specimen retrieval per vaginum (Natural Orifice Specimen Extraction) Top

Sushrut Ashok Bhukte, Jagdeesh N. Kulkarni, Nitesh Maurya, Vrunda Karanjgaonkar

Asian Cancer Institute, Somaiya Ayurvihar, Sion East, Mumbai, Maharashtra, India

We here in demonstrate robot assisted radical nephrectomy with hysterectomy in same sitting followed by specimen retrieval per vaginum (NOSE- Natural Orifice Specimen Extraction) A 36 year old female P2L2, presented with long standing dysmenorrhoea. Abdominal sonography detected incidental large left renal mass with a large fundal fibroid. CT scan revealed 8 cm*8 cm mass arising from mid and lower zone of the left kidney without vascular invasion and lymphadenopathy with a large fundal fibroid. Rest of the adnexe were normal. She underwent Robot assisted left radical nephrectomy first in lateral docking position. After bagging the nephrectomy specimen, robot was dedocked. Later patient was put in lithotomy position and with central docking hysterectomy was completed. Both the specimens were retrieved through the vaginally without compromising the oncologcal principles. Patient had a smooth post-op recovery and discharged on postoperative day 2. Histopathology revealed RCC Furhman grade 4 while hysterectomy specimen showed fibrodenoma with adenomyosis. No adjuvant therapy was instituted and at 3 months patient is doing well. We conclude that two organ excision and extraction of specimen through vagina (NOSE) using two arms is possible in selected cases with excellent outcome in terms of early return to work with minimal morbidity. Further limited use of instruments augments reduction in treatment cost.

   MV 02-02: Laparoscopic (robot-assisted) saphenous vein sparing VEIL video demonstration and single centre experience Top

A. Pednekar, T. B. Yuvaraja, S. Waigankar, R. Srivathsan

Kokilabhen Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India

Introduction and Objectives: Open inguinal lymphadenectomy is a gold standard treatment for patients with invasive penile SCC who are at risk of regional and distant metastases. Despite the use of thick skin flaps based on the blood supply superficial to Scarpa's fascia, perioperative complications of cellulitis, flap necrosis, and leg edema can affect as many as two thirds of patients We report the study of robotic-assisted saphenous vein sparing inguinal lymph node dissections in high risk patients or palpable lymph nodes. Materials and Methods: We reviewed our patient series from 2012 till 2017 which included carcinoma penis and carcinoma of distal urethra and analysed the data set. Our technique of R-VEIL is shown in the video. A 2-cm mid-thigh incision was made to develop a plane just deep to Camper's (fatty) fascia. Once a sufficient working space was created to place 3 robotic ports and 1 assistant port, subcutaneous gas was instilled, and the robotic device was docked and used to perform the dissection. The surgical approach replicated the principles of open techniques such that the contents of the femoral canal were dissected to include both superficial and deep lymph nodes in the dissection template. Results: A total of 18 patients underwent R-VEIL in this period of 5 years. Mean age was 59.2 years. Eight patients underwent bilateral veil while rest underwent unilateral. R-PLND was performed in five of eighteen. Total console time reduced from 230 minutes to 90 minutes with experience. The mean EBL was 67 ml. the average lymphnode yield was around 15 nodes. Lymphocele was the commonest complication, which were managed conservatively. Conclusion: Early results suggest that this approach is feasible, safe, and affords an appropriate oncological dissection in selected patients. Saphenous vein sparing technique ensures a lower complications rate reducing lymphorrhea, skin necrosis.

   MV 02-03: Robotic partial nephrectomy in a case of multifocal tumor Top

A. Pednekar, T. B. Yuvaraja, S. Waigankar, R. Srivathsan

Kokilabhen Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India

Introduction and Objective: Partial nephrectomy is the gold standard in the management of T1 Renal tumor. However in the case of multiple renal tumors the decision to do multiple partial nephrectomies depends on the eGFR a. Methods: A 60 year old gentleman was incidentally detected to have multiple renal masses in the right kidney in a routine health checkup. CECT showed multiple renal masses – largest being 4 cm – lateral cortex upper pole 1. 3 cm lateral – mid right kidney 1. 7 cm medial anterior – mid right kidney 1.6 cm corticomedullary lesion posterior lower pole 2 cm cyst in right mid kidney. Results: Partial nephrectomies were succesfully completed with a warm ischemia time of 27 minutes. Postoperative period was uneventful. He was discharged with a creatinine value of 1. 1. The video depicts the technique of the same. Conclusions: Robotic partial nephrectomy for 3 or more tumors in a single kidney is safe and feasible in selected patients. More importantly, these data demonstrate exceptional renal function preservation despite the highly challenging nature of this type of surgery.

   MV 02-04: Laparoscopic (robot-assisted) retroperitoneal lymph node dissection in non-seminomatous germ cell tumors: Video demonstration and single centre experience Top

Naresh D. Badlani, T. B. Yuvaraja, Waigankar Santosh, R. Srivathsan

Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India

Introduction and Objectives: Laparoscopic RPLND (L-RPLND) in non-seminomatous germ cell tumors (NSGCTs) have several limitations. The robotic approach is being attempted to overcome these limitations. We aim to evaluate the surgical technique and outcomes of the robot-assisted retroperitoneal lymph node dissection (R-RPLND) for NSGCTs at our institution. Materials and Methods: 11 patients (2012-2017) underwent R-RPLND for NSGCT [Clinical Stage (CS) I-IIA and Post-chemotherapy residual masses]. Retrospective data on patient demographics, preoperative tumor characteristics, perioperative outcomes [open conversion rate, lymph node (LN) yield, rate of positive LNs, operative time, estimated blood loss (EBL), length of stay (LOS)] & tumor recurrence rates were recorded. Steps of R-RPLND include caecal mobilization upto ligament of treitz, full bilateral template dissection redocking & excision of the ipsilateral spermatic cord remnant. Results: The mean operative time was 190 mins, EBL was 103mL, and LOS was 2.4 days. Teratoma was the commonest pathology with mean LN yield of 22. At a mean follow-up of 15 (6–24) months, there were no recurrences. There were no intraoperative complications, 2 early postoperative complications (18%), no late complications. One patient (9%) with positive nodes received adjuvant chemotherapy. The 2-yr recurrence-free survival rate was 97% (95% CI: 82-100%). Conclusions: Robotic surgery is a safe and feasible method for resecting masses especially in areas difficult to reach via open or maneuver laparoscopically. Robotic approach with its 3D - Imaging system improves maneuverability & precision of the dissection in the retroperitoneum and cul-de-sac.

   MV 02-05: Use of near infrared fluorescence and intraoperative ultrasound in robot assisted partial nephrectomy Top

Priyank Bijalwan, Ginil Kumar Pooleri, Abhishek Laddha

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Partial Nephrectomy Introduction and Objective: With more complex kidney tumors treated by nephron-sparing surgery (NSS), complete tumor resection becomes challenging. Intraoperative imaging during Robot Assisted NSS may improve the establishment of negative surgical margins. Herein, we present an edited video of 4 cases in which we utilized intraoperative ultrasound and near infrared fluorescence (NIRF) for robot assisted excision of complex renal masses alongwith our experience in Robot Assisted Partial Nephrectomy. Materials and Methods: Using intra operative ultrasound (X12C4 drop-in transducer, BK ultrasound) the tumour margins were marked on all sides, before proceeding with enucleation. Following hilar dissection and clamping of renal artery, 5 ml Indocyanine Green (1 mg/ml) was intravenously injected and near infra red light was activated. Depending on the fluorescence of the tumour bearing area selective/ total clamping of renal vessels was done. Results: RENAL score Blood loss Warm ischemia Case I 10H 200 ml Main vessel clamped depending on fluorescence 30 mins Case II 11P 200 ml Intraoperative USG identification of intrahilar tumour 30 mins Case III 8A 250 ml Selective arterial clamping 20 mins Case IV 8P 200 ml Main vessel clamped depending on fluorescence 24 mins. Conclusion: Intra operative ultrasound aids in tumour localization and delineation enabling margin identification, especially in completely endophytic tumours. NIRF additionally guides selective renal ischemia in real time and helps in selective renal clamping.

   MV 02-06: Avoiding tumor transgression while doing partial nephrectomy: Cognition vs. calculation Top

Prafull Mishra, Anil Mandhani, Laxmikant Sharma, Vadher Rakesh Kumar, Ankur Agarwala

Medanta Medicity, Gurgaon, Haryana, India

Aim: Tumor transgression while doing partial nephrectomy in large and complex tumor is not an infrequent occurrence. This video describes use of simple measurements to avoid tumor violation during partial nephrectomy. Methods: Morphometric measurement of a tumor was done in axial cuts on contrast enhanced CT scan of renal tumor with RENAL equal to or more than 10. Two key points were measured, one is the distance from renal cortex; site of an incision, to the innermost part of the tumor and second the distance from the pelvicalyceal system. Correspondent distances were compared with the scissors tip to see for the depth of incision. This method was applied in 5 consecutive cases and margin status was documented on visual impression and on histopathology. Results: From June 2017 to May 18, With a mean Renal score of 12, and average warm ischaemia time of 16 min, there was no tumour transgression in all 5 cases with negative surgical margin Compared to the control arm of 5 cases in which this methodology was not applied had 1 case of tumour transgression and 1 case underwent Radical nephrectomy. Conclusion: Our Study concluded that using this simple measurement technique, tumour transgression can be avoided efficiently in simple and precise manner.

   Moderated Poster Session 1: Endourology - Upper Tract - Kidney, Ureter Top

   MP 01-01: Evaluation of the impact on efficacy of direct Visual Internal urethrotomy by intralisional injection of tri-mixture (triamcinolone, mitomycin C and hyaluronidase) Top

Shashi Kant Tewary, R. K. Das, Basu Supriya, Dey Ranjan, Das Surujit, Priytosh Dey

R. G. Kar Medical College, Kolkata, West Bengal, India

Introduction: Urethral stricture is the common entity in young and middle-aged male patients. Various modalities of treatment are available with different outcomes. Direct Visual Internal urethrotomy (DVIU) is one of the currently favored modality for short segment bulbar urethral stricture. However, the long-term efficacy of DVIU is not satisfactory. So, in order to increase the long-term efficacy of DVIU, local injection of steroid, mitomycin-c and hyaluronidase was tried and results were evaluated. Materials and Methods: Patients attended urology OPD of with anterior urethral stricture during March 2017 to May 2018 with short segment anterior urethral stricture were studied. Those patients who were enlisted for DVIU intervention were included in study. All included patients were randomly divided into two groups- Group 1 patients included only internal urethrotomy. Group 2 patients were those with a single dose of tri-mixture injection intra-lesionally at the site of urethrotomy using endoscopic needle immediately after internal urethrotomy. Results: “Treatment Success” was defined as either Q max of at least 12 ml/sec, no visible stricture on RGU at 3 months and the decrease in PVRUV. A total of 55 patients were included in the study. 22 patients were taken up for DVIU only and 28 were included for DVIU and intra-lisional injection of trimixtrure. 5 patients lost to follow up. Conclusion: Effect of tri-mixtutre intralisional injection at the site of DVIU has shown to increase the total efficacy of the procedure in a stastically significant.

   MP 01-02: A dilemma of treatment: Kyphoscoliasis with renal calculi Top

Shashikant V. Asabe

Dr. DY Patil Medical College, Pune, Maharashtra, India

History: A 50 yr old male presented to us with complaints of left flank pain, burning micturition, dysuria, hematuria occasionally since 1 year. Patient has severe kyphoscoliosis with severe pectus carinatum. Imaging: USG - Left kidney shows (18x16 mm) calculus and (6.8 mm) calculus at midcalyx, (10x11 mm) calculus at upper pole. CXR shows severe rib crowding and scoliosis. CT KUB: Large Staghorn calculus of size 45x25x17 mm in left kidney. Left kidney shows caliectasis at mid region and upper pole shows severe parenchymal thinning. Procedure: USG guided puncture of the system taken. Proceeded with supine PCNL with back support. Complete clearance obtained. Discussion: The risk of urolithiasis is significantly increased in patients with spinal deformity due to abnormal renal anatomy, recurrent urinary tract infection, restricted mobility and urinary stasis. Due to spine deformity it is very difficult for other modalities of treatment. So the management of nephrolithiasis by PCNL is the standard treatment of choice.

   MP 01-03: An unusual association – TCC with staghorn calculi Top

Shabbir Husain

Global Hospital and Urology Research Center, Jabalpur, Madhya Pradesh, India

Introduction: Commonly staghorn calculi are associated with squamous cell carcinomas. Low grade Transitional cell carcinoma with staghorn calculi is rare. Case Summary: 50 yrs male presented with occasional Left flank pain since few years. No positive history of hematuria before. No significant LUTS. No significant history of tobacco ingestion. Labs – Hb – 13 gm%, creatinine- 1.2 mg/dl, urine R/M - NAD USG – S/o multiple stones located in all calyces and pelvis X ray- showing left large staghorn calculi CECT – showing left staghorn calculi with contrast in PCS and Ureter. PCNL surgery was done, three punctures were taken. After breaking and evacuating stones from upper calyceal puncture, a papilliform growth could be visualized. That growth was biopsied using peanut forcep. HPR came as Low grade transitional cell carcinoma. Discussion: Though occurrence of Malignancy along with stone is rare phenenomena. Mainly the staghorn calculi are associated with squamous cell carcinomas but here we have encountered a case of TCC of low grade which a very rare occurrence. Although the rate of malignant tumor present in staghorn stone is rare, a few cancers still can be seen during operations that can not be found before the surgery. Conclusion: Though malignancy are rare with staghorn calculi but they should be kept in mind while dealing with long standing calculi. There are some pointers like filling defects or renal margin abnormalities on CECT which can guide us preoperatively in picking up such lesions.

   MP 01-04: Is prone position for PCNL safe? A prospective study of cardio-respiratory changes Top

J. K. Chiran, K. Subramonian

Queen Elizabeth Hospital, Birmingham, UK

Prone aneshthesia poses challenges for the anesthetist due to splinting of diaphragm, difficult airway control and awkward intra venous access. In this study we present the changes in cardio-respiratory parameters before and after prone postioning for PCNL in patients from a wide range of age, Body Mass Index (BMI) and Bodysurface area (BSA). Methods: Prospective study of 42 patients we collected cardio-respiratory parameters pre and post in undergoing PCNL. Parameters collected were Age, BMI, BSA, Heart Rate, Non Invasive Blood pressure (NIBP). Respiratory parameters collected were: Sp02, Respiratory Rate, Ppeak (cmH20). PEEPtot (cmH20), Tvexp (ml), I:E Ratio, O2 - ET / FI and Co2 - ET / FI. Data were paired by the time before and after prone positioning - 10 mins and + 10, +60 and +90 mins. The data were evaluated using Paired sample T Test. Results: Demographic characters of Patients included a age range 21-83 years, BMI 19-41 & BSA 1.4-3 metres. Statistically significant change was seen in Heart Rate at 60 minutes, Peak ventilatory pressure at 10 mins and Tidal Volume at 60 & 90 Minutes post prone positioning. Conclusions: No physiologically significant differences seen in a majority of the cardio-respiratory parameters. There is a reduction of Tidal Volume, however the gas exchange has remained stable. Hence we conclude that prone position for PCNL is a safe from a cardio-respiratory perspective.

   MP 01-05: Our experience of olympus shock pulse for large burden renal stone disease Top

Shailendra Gupta, Gopal Tak, S. B. Sudarshan, Abhishek Singh, Arvind Ganpule, R. B. Sabnis, M. R. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Aim: To summarize the data and initial experience regarding use of Olympus shock pulse for large burden renal stones. Materials and Methods: It is an observational study, Study period was December 2016 to May 2018, Number of patients Observed (n=90). Pre operative routine blood and urine investigations, X-ray KUB, CT KUB/CT IVU (as per serum creatinine), post operative X-ray KUB, blood investigations. Parameters analyzed were demography, co- morbidity, presentation, CT findings, stone density (Hounsfield units), hydronephrosis, duration of surgery, puncture by fluro/ USG guidance, number of tract made, hemoglobin drop, need for blood transfusion (number of units), hospital stay (in days), analgesic requirement, pain score on first post operative day (Visual analogue scale), complications, need for staged procedure, delayed follow up. Standard steps of PCNL followed, and stone cleared with 3.4 mm Olympus shock pulse probe. Results: Average age was 47.8 years, 67 male & 23 female patients, average stone size 3.1 cm, average duration of surgery 48.3 minutes, average number of tract needed were 1.4, average stone density (1195 HU), average hemoglobin drop was 1.3 gm% but none needed blood transfusion, stone free rate on 1st POD and 1 month follow up was 93.8% and 96.2% respectively. Auxiliary procedure needed in 7 patients (4 PCNL and 3 RIRS), overall complication rate was 7.6%. Conclusion: Olympus shock pulse is a safe and feasible option for management of large renal stone burden disease to achieve stone clearance in single sitting with fewer numbers of puncture less operative time and fewer complications.

   MP 01-06: Metachronous renal pelvic urothelial metastases from clear cell renal cell carcinoma: A diagnostic dilemma and therapeutic challenge Top

Pankaj Panwar, Wael Asaad, Helen Thursby, Anurag Golash, Herman S. Fernando

Royal Stoke University Hospital, UHNM, Stoke on Trent, UK

Introduction: The incidence of urothelial metastases for ccRCC in autopsy series has been reported to be around 1%. Only few cases have been reported in the English literature. However the urothelial metastases to pelvicalyceal system are relatively unknown. More so in our case the equivocal imaging findings, bilateral RCC, previous ipsilateral RFA treatment and solitary kidney made it quite challenging to manage the case. Case Summary: A 61 year old lady diagnosed with right renal mass on CT colonogram in September 2014. Subsequent right laparoscopic radical nephrectomy revealed ccRCC. Another equivocal left renal lesion showed increased growth to 13 mm on follow up CT and MRI scan after 6 months, which on biopsy suggested ccRCC. Subsequent CT guided RFA of the left renal lesion was done in October 2015. Follow up CT scan in January 2018 showed new two enhancing lesions in the left renal pelvis/proximal ureter. Holmium laser excision and extraction of these lesions with using semirigid ureterorenoscopy (URS) was done. Histology showed it to be a ccRCC with negative CD10, in keeping with the profile of ipsilateral ccRCC. Conclusion: Urothelial metastases from RCC are rare and can cause diagnostic dilemma in view of differential with urothelial cancers. Immunohistochemical studies are often helpful. Treatment is not defined due to rarity of the condition and often has to be tailored according to individual patient. Endoscopic treatment is feasible and often should be used as first line measure to optimise the chances of preserving renal function especially in the metachronous setting.

   MP 01-07: Role of metalic stent in reducing cancer morbidity in malignant ureteric obstruction - A preliminary study from western India-long term result from single institution Top

Bonny Shah, Rajeev Chaudhary, R. K. Shimpi, Satyadeo Sharma, Priyank Shah, Darsan Patel

Ruby Hall Clinic, Pune, Maharashtra, India

Introduction: Ureteral obstruction caused by extrinsic compression is commonly associated with intra-abdominal malignancy for which Internal drainage with ureteral stents is typically the first-line therapy. The limitation of polymeric ureteral stents is easy compresion and recurrence of obstruction. The metallic stents were introduced to improve the patency rates, obviating the need for frequent stent exchanange Materials We described the functional outcomes of a Resonance metallic ureteral stent in patients with malignant ureteral obstruction. Methods: Cancer patients with malignant ureteric obstruction who received Resonance stents for malignant ureteral obstruction, between Mar 2014 and Mar 2017 were included in study. Stent failure was detected by clinical symptoms, imaging studies, renal function test and functional duration. Results: A total of 27 stents (all retrograde) successfully inserted in 20 patients with malignant ureteral obstruction. After insertion of Resonance metallic stents, hydronephrosis subsided or remained stable in 89% (24/27) of the ureteral units. Serum creatinine decreased or remained stable in 90% (18/20) of these patients. In 15% ureteric units (3/27) metallic stents were required to be removed or changed. The Resonance stent exhibited a mean increase in functional response at minimal 1 yr follow up. Conclusion: Metallic ureteral stent placement is a technically feasible procedure with minimal complications and is well tolerated among patients. Metallic stents can be left in situ for longer durations and provide a significant financial benefit compared to frequent polymer stents replacements. Preference of metallic stent as alternate to nephrostomy reduce morbidity and better quality of life for terminally ill patients.

   MP 01-08: Role of triple D score to predict the stone free rate post shock wave lithotripsy: Our experience Top

Vikas Garg, Arvind Ganpule, S. B. Sudarshan, Gopal Tak, Abhishek Singh, R. B. Sabnis, M. R. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Introduction and Objective: To predict the efficacy of primary Extracorporeal shock wave lithotripsy (ESWL) stone free rates using Triple D scoring system in the era of Miniperc/RIRS. Materials and Methods: A retrospective analysis was performed over a period of 2 year from 2016 to 2018, retrieving 100 cases of renal and upper ureteric stones who underwent ESWL with available preoperative CT scan. In all the cases stone density, ellipsoid stone volume (ESV) and skin to stone distance (SSD) was determined and triple D score was calculated. The ROC curves were established to determine the cut off value for each parameter. Results: Seventy two out of 100 patients (72%) who underwent ESWL were stone free after single session treatment. ESV, SSD, and stone density were significant predictors of ESWL success. Based upon the ROC curves, cutoffs of <150 mm3 for ESV, <110 mm for SSD, and <900 HU for stone density were established. A Triple D Score of 0, 1, 2, and 3 correlated with ESWL success rates 50.0%, 68.4%, 80% and 87.5% respectively. Conclusion: The Triple D Score appears to be a useful predictor of ESWL treatment outcomes. The use of ESWL in patients with score 2 or above shall allow us to improve operative outcomes and guide us for suitable patient identification.

   MP 01-09: Successful treatment in endourology for stones-(STONE-FECTA) – Novel concept of outcome reporting Top

Rajanikant Joshi, Gopal Tak, A. Ganpule, A. Singh, S. B. Sudharsan, R. B. Sabnis, M. R. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Introduction: Even after first description of percutaneous nephrolithotomy in staghorn calculi in 1983 treatment of staghorn stone still remains challenging task forurologist. Technologicaladvancements have improved outcomes of PCNL in staghorn calculi. However prediction of outcome of PCNL forstaghorn calculiis not universalized. We attempt to present novel method for reporting outcomes asSuccessful treatment in endourology for stones (STONE-FECTA). In present study we find out potential factors affecting the STONE- fecta. STONE-FECTA is defined as Patients who attained simultaneously a stonefree rate in one procedure, no urinary infections and no urological complications. Materials and Methods: We retrospectively reviewed case records of patients who underwent PCNL for staghorn calculi during the period of january 2011 to December 2017. Total 200 patients were included. Pre and postoperative investigations, operative records, followup data included. Correlation of the variables with number of tracts and stone size as classified by stone morphometry was assessed. Statistical analysis were performed with SSPS 18.0. Results: Mean age (ąSD) was 42.49ą15.33 years. Division of staghorn stones as per morphometry classification were type 1-21%, type 2A-41%, type 2B- 22%, type 3-16%. Mean tract number was 1.68ą1.12. STONE-Fecta was achieved in 55% patients at 3 months followup (type 1-73.80%, 2A-65.85%, 2B-40.9%, 3-21.875%). Conclusion: Stone morphometry was found to be independent variable affecting STONE-fecta. Complex is the stone morphometry, worse the STONE Fecta achievement probability.

   MP 01-10: Ureteric hemangioma: A rare entity presenting with hematuria Top

Priyank Shah, Shirish Yande, Krutik Raval, Kunal Borade, Bonny Shah

Ruby Hall Clinic, Pune, Maharashtra, India

Urethral cavernous hemangiomas are rare benign tumors that most commonly present as urethral bleeding. There are hardly any clinical signs for their indication. The hemangioma focued in this study is the cavernous type. Hemangiomas are rarely found in the female population. A 66 year old female presented with the complain of intermittent hematuria and occasional clots in the urine sample provided. For diagnostic purposes a Computer tomography (CT) report was taken which reveled Intraluminal isodense, pedunculated lesion at mid-ureter level just proximal to the level of iliac crossing measuring approx. 19 mm X 12 mm (diameter) Ureteroscopy, and Laser Excision of the mass with right DJ stenting done. Cases of similar presentation should be screened for the presence of hemangiomas as it is often difficult to diagnose during the initial examination on the basis of history alone.

   MP 01-11: Staged B/L PCNL in 2.5 year old child: Our experience Top

Amit Kumar Devra, Manoj Agarwal Lok Prakash Chaudhary

Jaypee Hospital, Noida, Uttar Pradesh, India

Introduction: Paediatric endoscopic stone management is safe and effective way of dealing large stone burden and now a days it has been widely practised in a tertiary care centre where good expertise and instruments are available. Materials and Methods: Here we present, 2.5 years male child from Turkistan who presented to our hospital with complaints of vague pain abdomen. Physical examination was unremarkable. On initial evaluation ultrasound suggested left hydroureteronephrosis with bilateral multiple renal stone. The blood tests and renal function were normal. CT scan showed right hydronephrotic kidney with partial staghorn calculus and multiple lower calyceal stones. The Left kidney had moderate hydoureteronephrosis with large 1.5 cm lower ureteric stone and multiple renal stone. DTPA was suggestive left poor functioning kidney (22%) with total GFR 80 ml. A detailed metabolic evaluation and nephrology consultation was made to rule out renal tubular acidosis. However no definite metabolic abnormality was found. Child was planned for staged left followed by right endoscopic stone clearance surgery. First we did left URS + Stage I PCNL. After 2 days child was ported for stage II PCNL + Left DJ stenting. The child was discharged two days after 2nd surgery. The child was readmitted for right side stone clearance we performed staged PCNL for right side. The child was stone free and was discharged after 2 days with B/L DJ stent in situ. Conclusion: PCNL in young child is safe and effective.

   MP 01-12: Chyluria in young child: A rare presentation Top

N. K. Dharmaprakash, S. N. Sankhwar, Apul Goel, Vishwajeeth Singh, B. P. Singh, Rahul Janak Sinha, Manoj Kumar

King George's Medical University, Lucknow, Uttar Pradesh, India

Introduction and Objective: Chyluria, a chronic manifestation of lymphatic filariasis, is uncommon in children. It requires a high index of suspicion to diagnose this condition in children as it mimics nephrotic syndrome. Methods: We report an unusual case of a 7-year-old child who presented with chyluria to our department. Results: A 7-year-old boy hailing from a filarial endemic region presented with intermittent passage of milky urine and. few episodes of haematuria with renal colics for the last 3 months, which on evaluation was diagnosed as parasitic chyluria. The child showed remission after medical management that persisted until 1 year of follow-up. Conclusion: Parasitic chyluria is very rare in children and needs high index of suspicion for diagnosis. The prognosis seems to be good for children with few recurrences and complete remission with medical management.

   Moderated Poster Session 2: Uro Oncology Top

   MP 02-01: Transpubic cystoprostatectomy for leiomyosarcoma of prostate: A rare surgical approach for a rare tumor Top

Mohd Hamid Shafique Ahmed, Ajit Sawant, Prakash Pawar, Sunil Patil, Amandeep Arora

LTMMC and LTMGH, Sion Hospital, Mumbai, Maharashtra, India

Prostate sarcoma originates from the prostatic stroma and it is an extremely rare neoplasm that accounts for less than 0.1% of primary prostate malignancies; globally, less than 200 cases have been reported in the literature. Leiomyosarcoma is the most common primary prostate sarcoma in adults and constitutes 38–52% of them. It has an aggressive clinical course. Surgery with or without chemotherapy/radiotherapy would appear to be the mainstay of treatment for leiomyosarcoma of the prostate for operable cases. We present a case of leiomyomasarcoma of prostate diagnosed on transrectal ultrasonography guided biopsy of the prostate. MRI Abdomen and and pelvis showedan organ-confined 9.3 x 8.5 x 7.6 cm mass lesion arising from the prostate. There was noevidence of metastasis on PET CT. Patient underwent transpubic cystoprostatectomy with pelvic lymphadenectomy and ileal conduit. On exploration, the mass was occupying the entire pelvis with no space between the mass and the pelvic lateral wall. So, a transpubic approachin the form of superior trans pubectomy was done to gain control of dorsal venous plexus and to reach the apex of prostate. Post-operative recovery was uneventful. Histopathology revealed a high grade leiomyosarcoma (650 gms) arising from the prostate with no extra-prostatic extension. On Immunohistochemistry, smooth muscle actin strongly and desmin was focally and faintly positive. We suggest that transpubic approach may be used without serious complications in the setting of large prostatic mass to facilitate resection and to contemplate cure.

   MP 02-02: The predictive accuracy of hypoechoic lesion on transrectal ultrasound in diagnosis of prostate cancer Top

Manas Sharma, R. B. Nerli, Shridhar Ghagane, Neeraj Dixit

JN Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India

Aim: To investigate the predictive accuracy of hypoechoic lesion on Transrectal Ultrasound (TRUS) at different levels of raised PSA, in patients undergoing TRUS guided 12-core prostate biopsy. Methods: Patients presenting to Urology Dept. with LUTS having elevated PSA level above 4 ng/ml or suspicious DRE findings were included in the study. They were subjected to TRUS and TRUS guided 12 core biopsy of prostate. The clinical parameters including age, DRE findings, Sr. PSA, prostate gland volume, PSA density, TRUS findings and HPR including Gleason's grading were recorded from 81 patients. Results: There were 56 patients (69.1%) with no visible hypoechoic lesion and 25 patients (30.9%) with hypoechoic lesion on TRUS. Total cancer detection rate was 44.4%. Out of 25 patients with hypoechoic lesion, TRUS guided 12-core biopsy revealed malignancy in 22 patients (88%). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of hypoechoic lesion for carcinoma prostate in all patients were 61.1%, 93.3%, 88% and 75% respectively. The predictive accuracy of hypoechoic lesion for prostate cancer also varied among different PSA intervals. Hypoechoic lesions were also inclined to be detected in patients with higher Gleason's score. Conclusion: Hypoechoic lesion on TRUS has high specificity for prostate cancer detection hence we conclude that it could improve the predictive accuracy for diagnosis of prostate cancer which also varies with PSA intervals.

   MP 02-03: Leydig cell tumour of testis presenting as primary infertility: A rare presentation Top

Dalvi Mayur, Jadhao Vivek, Nimje Rohit, C. Pancholi, M. G. Andankar, R. K. Garg, S. W. Thatte

Bombay Hospital, Marine Lines, Mumbai, Maharashtra, India

Introduction: Leydig cell tumors of testis contribute to only 1 - 3 % of all testicular tumors and 75- 80% of sex cord stromal tumors. They usually present as painless mass or with features of hormonal excess. Incidence of infertility in Leydig cell tumors is uncertain. We, therefore present a case of Leydig cell tumor, presenting as infertility. Our case - 45-year male, presented with infertility and right scrotal pain. Initial scrotal ultrasound was suggestive of right epididymo-orchiditis with left epididymal cyst and was treated for the same other center. Semen analysis done twice showed severe oligo-asthenospermia. The patient underwent treatment for infertility with 2 cycles of IVF which eventually failed. Repeat scrotal ultrasound, showed vascular heterogeneous island of tissue in right testis. A high inguinal orchiectomy was done owing to high index of suspicion. Conclusion: Patients with Leydig cell tumor of testis can rarely present as infertility.

   MP 02-04: Prospective comparison of the immunological response following minimally invasive and open surgery for renal cell carcinoma Top

Angesh Thakur, K. Mete Uttam, Aggarwal Ritu

PGIMER, Chandigarh, India

Introduction and Objective: Major surgical procedures like nephrectomy (partial/radical) initiate physiological stress on the body's immune system which depends on the extent of invasiveness of surgery. To compare the systemic acute cytokine response, between open and minimally invasive surgery in patients with renal cell carcinoma (RCC) undergoing nephrectomy/NSS. Methods: The patients with RCC were prospectively allocated into two groups. Group 1 underwent open surgery and group 2 underwent minimally invasive surgery (laparoscopic/robotic). Serum analysis of interleukin IL-1β, IL-1 ra, IL-6, and TNF– α was done preoperatively (time point T0), and after 24 and 72 hours postoperatively (time points T1 and T2) by ELISA technique. Results: The median tumor size for open surgery was significantly higher compared to minimally invasive surgery group (open 9.70±2.85 cm; laparoscopic 7.77±1.99 cm; robotic 5.36±1.99 cm; p=0.009). No significant differences in serum IL-1ra, IL-1β and TNF-α were demonstrated between the surgical procedures as well as at different time points in the same group. The changes in dynamics of serum IL-6 with time were found to be statistically significant in all the groups i.e. open (p=0.003), laparoscopic (p=0.007) and robotic (p=0.002). Additionally, on an intergroup comparison, there was the significant drop in levels of IL-6 at 72 hours in the robotic group in comparison to the laparoscopy group (p=0.048). This indicates lesser interference of immune system which translates as a more rapid functional recovery in patients of robot-assisted NSS/nephrectomy. Conclusion: IL-6 may be an objective marker of the surgical stress response. Robot-assisted NSS elicits an attenuated immunological response compared with laparoscopic nephrectomy.

   MP 02-05: Management of B/L inguinal regional skin necrosis in case of modified inguinal lymph node dissection in CA penis Top

Paragmani Talukdar, T. K. Mandal, T. K. Majhi, S. Choudhury, R. Kumar

Nilratan Sircar Medical College and Hospital, Kolkata, West Bengal, India

Primary penile cancer is a rare neoplasm. Its frequency varies in Western countries. It is estimated between 0.3% to 0.5% of human cancers in the USA with an estimated incidence of less than 1 per 100,000 in Europe. However penile cancer is one of the most common genitourinary cancers encountered in developing countries like India. Surgical management of inguinal lymphnode is disappointing as it results in morbidity to the patient. We present this interesting case of Ca penis who undergone total penectomy first then B/L modified inguinal lymph node dissection in separate procedure. Post operatively patient had extensive B/L inguinal region skin necrosis with HPE reports showing pT3 N2 Mx with positive margin and managed later on with residual urethrectomy with bladder neck closure with on table frozen section biopsy with B/l lateral circumflex femoral artery perforator based fasciocutaneous flap and permanent SPC and adjuvant chemotherapy.

   MP 02-06: Renal cell carcinoma in a patient with job's syndrome: A rare case report Top

B. Sai Vijay, N. Manikandan, A. V. Shanmughadas, A. T. Rajeevan, K. M. Dineshan, A. V. Venugopalan, Felix Cardoza

Government Medical College, Kozhikode, Kerala, India

Renal cell carcinoma accounts for approximately 90% of all renal malignancies and is one of the commonly encountered urological malignancy in association with genetic syndromes. Currently, about ten inherited cancer susceptibility syndromes are associated with inherited risk of kidney cancer with von Hippel Lindau disease, Birt Hogg Dube syndrome, Tuberous Sclerosis complex being the common types. Job's syndrome or Buckley syndrome is an autosomal dominant variant of Hyperimmunoglobulinemia E syndrome (HIES), which is a heterogeneous group of immune disorder characterized by frequent episodes of eczema, and recurrent cutaneous and pulmonary infections along with raised serum IgE levels. In this report, we present a case of renal cell carcinoma (RCC) found in a 20 year old male with Job's syndrome. There has been only one such documented association so far in the literature. Both HIES and RCC have an immunological basis for their pathophysiology and may involve common pathways. Further research and studies need to be performed to delineate any possible relationship with immunodeficiency disorders that has not yet been defined. Our findings present the need for careful consideration of RCC in immunodeficient patients especially among the ones with risk factors of RCC.

   MP 02-07: A rare case of prostatic adenocarcinoma presenting as an isolated inguinal lymphadenopathy without pelvic lymph nodes Top

J. Mohammed Farooq, K. Saravanan, P. R. Saravanan, Ezhil Sundar, K. Subramanian, Sivabalan

Institute of Urology, Madras Medical College, Chennai, Tamil Nadu, India

Introduction: Prostatic adenocarcinoma (CaP) is the most common cancer in males and nearly 65% of patients present with metastasis, with regional lymphadenopathy and bone mets being the most common presentations. CaP metastasizing to inguinal lymph nodes in the absence of pelvic lymphadenopathy or other metastases is very rare. Case Presentation: A 70-year-old gentleman presented with isolated left inguinal lymphadenopathy of 3 months duration. There was no history of lower urinary tract symptoms, bone pain or cough with expectoration. Clinical examination revealed a 3 cm hard fixed left horizontal group of inguinal lymph node but did not reveal any abnormal findings with normal external genitalia and only an unsuspecting grade 1 smooth firm prostatomegaly. Investigations: CECT abdomen showed only mild prostatomegaly. FNAC of the lymph node revealed adenocarcinamtous deposits. Colonoscopy was done to rule out any colonic pathology and it did not reveal any abnormal findings. Serum PSA was done and was found to be elevated -159 ng/dl. Transrectal ultrasound biopsy revealed adenocarcinoma (Gleason score 3+4=7) and Multiparametric MR imaging showed prostatic nodules suggestive of CaP with seminal vesicles and bladder base involvement. Bone scan was done and was negative for any metastatic bone disease. Treatment: The patient's clinical stage was pT4N0M1; bilateral subcapsular orchiectomy was carried out and patient was put on antiandrogen therapy (bicalutamide). Outcome and Follow-up: The patient is doing well on anti-androgen therapy since one year. This case underscores the importance of PSA testing and high index of suspicion for CaP in old age patients.

   MP 02-08: Metastatic nonischemic priapism due to Ewing' Sarcoma: A rare case report Top

Panda Rakesh, S. K. Panda, F. Haquae, S. Panda, G. P. Singh, D. Hota

SCB Medical College, Cuttack, Odisha, India

Introduction and Objective: Priapism is defined as full or partial erection persisting beyond four hours after sexual stimulation and orgasm. The term malignant priapism describes persistent, nonsexual erections caused by invasion of malignant cells into the cavernosal sinuses. Penile metastases commonly arise from the genitourinary tract, but due to Ewing Sarcoma has not been reported. we report this unique case to highlight the need for diagnosis and aggressive multimodality treatment to improve survival in these patients. Methods: A 03 yr male attended Urology OPD for persistent painless erection of penis for last 2 months with h/o coincidental trauma to the perineum. Patient had no difficulty in passing urine. On evaluation on Colour Doppler USG, high flow nonischemic priapism was found. In CECT a heterogeneously enhancing expansile lytic mass lesion with soft tissue component originating from right bony pelvis, with contiguous tumoral infiltrative nodular soft tissue lesion (7.9x3.6x4.6cm) in root and shaft of penis. In CT Thorax patient had multiple nodules in B/L lungs mostly metastatic nodules. Results: On L/E penis is soft, indurated, erect, nontender with multiple nodules. In USG guided trucut biopsy from the bony pelvis soft tissue mass & penile corpora, it came to be Round cell tumor most probably Ewing's Sarcoma. Patient was planned for chemotherapy, now symptomatically improved. Conclusion: Ewing's Sarcoma rarely presents with malignant priapism. The prognosis and life expectancy in penile secondaries is poor, but in Ewing's Sarcoma with malignant priapism & lung metastases early diagnosis & aggressive multimodality treatment can salvage these patients.

   MP 02-09: Lip metastasis secondary to extremely rare divergent differentiation in renal cell carcinoma Top

Manjeet Kumar, Santosh Kumar, Kalpesh Mahesh Parmar, Tushar Aditya Narain, Asish Khanna, Ritambra Nada

PGIMER, Chandigarh, India

Introduction: Renal cell carcinoma present in 25% of patients with metastasis. The metastasis to the skin can present before the diagnosis of the primary site but are typically found after the initial primary tumor identification and management. Renal cell carcinoma commonly metastasizes to lungs, liver, bone, adrenal glands, and the brain. We present a case of Renal cell carcinoma with extremely divergent differentiation with lip metastasis. Case Summary: A 75 year's man presented with swelling in upper lip. The patient had the history of Radical nephrectomy 3 months back with histopathology suggestive of positive margins with extensive Divergent histopathology. The histopathology included predominantly sarcomatoid histopathology, some areas of squamoid differentiation, and few foci of osteosarcoma with osteoid producing cells. On examination, the patient was having a palpable lump in the abdomen. The wedge biopsy was taken from the lesion from the upper lip and CECT abdomen was done. Biopsy suggestive of a sarcomatoid variant of Renal cell carcinoma from lip. CECT abdomen was suggestive of recurrence in the right renal fossa. The patient started on Pazopanib however the disease progressed and the patient was started on everolimus. Conclusion: Divergent histopathology of Renal cell carcinoma is a highly aggressive variant. In spite of radical treatment, these patients have the dismal prognosis. The response of tyrosine kinase inhibitors is poor. Lip metastasis is a very rare presentation of Renal cell cancer with only a few case reports. In conclusion, surgery is rarely the first option when treating RCC patients with multiple metastases.

   MP 02-10: Perineal angiomyxoma masquerading as a erectile corporeal body swelling: A case report Top

Anuj Sharma, Ravimohan Mavuduru, Shantanu Tyagi, Arup Mandal

PGIMER, Chandigarh, India

A 44-year-old male noticed a painless swelling in the perineum, gradually increasing in size over 4 months. Swelling became prominent with erection and vigorous physical activity. On physical examination there was a firm, non tender, non pulsatile, irreducible, non compressible mass in the anterior perineal area, on the left of the raphe. Patient underwent imaging with subsequent CEMRI that revealed a T1 hypointense and markedly T2 hyperintense lesion (4.6 ×2.5 ×5 cm) midline in relation to corpus spongiosum, with progressive enhancement on dynamic contrast. USG guided FNA from mass was suggestive of a nerve sheath tumour. Patient underwent excision of the mass. Histopathology of excised specimen revealed angiomyxoma of anterior perineal triangle positive for desmin, smooth muscle actin, muscle-specific actin and vimentin. After 3 months follow up, patient is asymptomatic with no signs of reccurence. Perineal Angiomyxomas especially in males (M:F-1.6:1) are extremely rare with around 150 overall reported cases till date. MR imaging is current gold standard in imaging with lesions usually hypo-intense on T1 weighted, hyper-intense on T2 weighted and a whorled appearance after contrast. The trademark of aggressive angiomyxoma is vascularity of variable calibre dispersed irregularly throughout the parenchyma with occasional mitotic figures. To the best of our knowledge this is the first reported case of angiomyxoma of the anterior perineal triangle in a male, presenting with prominence of perineal swelling with penile erection masquerading as a swelling arising from corporeal bodies.

   MP 02-11: Primary gastrointestinal stromal tumor of prostate with an unusual presentation as a giant prostate (1230 cc): A case report and review of the literature Top

Ashish Sharma, S. N. Sankhwar, Apul Goel, Vishwajeet Singh, B. P. Singh, R. J. Sinha, Manoj Kumar

King George's Medical University, Lucknow, Uttar Pradesh, India

Introduction: The gastrointestinal stromal tumor (GIST) originates from the interstitial cell of Cajal, an intestinal pacemaker cell in the gut. These cells are known to express the KIT gene (detected as the cluster of differentiation [CD]117 antigen), which is important for distinguishing GIST from other mesenchymal neoplasms. The extragastrointestinal stromal tumors (EGISTs) that originate primarily outside the gastrointestinal tract are relatively rare soft tissue neoplasms and are known to arise from various anatomic sites, such as the omentum, mesentery, retroperitoneum and gall bladder. To the best of our knowledge, there have been only five cases of primary prostatic GISTs reported in literature. Giant prostate defined as weighing more than 500 g may also be a rare presentation of benign prostatic hyperplasia or prostatic neoplasm. In our case, the prostate was massively enlarged measuring 1230 cc, the second largest reported prostate in world literature. GIST should be considered in cases of prostatic tumors with a spindled or epithelioid morphology, and immunohistochemistry and possible molecular studies are recommended to aid in diagnosis and guide treatment decisions. Surgery remains the standard treatment for primary resectable EGISTs. Whenever possible, complete en bloc removal of the tumor and the surrounding organs that are involved is required. The available methods include radical prostatectomy, cystoprostatectomy and total pelvic exenteration. Conventional chemotherapy and radiotherapy are ineffective in the treatment of EGISTs and GISTs, whereas Imatinib myesylate, a tyrosine kinase inhibitor of c kit, and PDGFRA as methods of adjuvant therapy, have been proposed as treatment for advanced, unresectable and metastatic GIST. Case Report: A 75 year old male presented to us with acute urinary retention for 1 day and voiding LUTS for last 6 months. He had episode of coronary artery disease 5 years back for which angioplasty was performed elsewhere. A digital rectal examination revealed hugely enlarged hard lobulated prostate with rectal intraluminal protrusion and bimanually palpable suprapubic hard lump. The prostate specific antigen (PSA) level was 12.3 ng/ml; serum carcinoembryonic antigen (CEA) was 3.2 ng/ml. The other laboratory investigations were unremarkable. Computed tomography (CT) showed a hugely enlarged homogenously enhancing prostate filling whole of the pelvic cavity and measuring 16.3x12.5x11.5 cm (1230 cc volume) with lost fat plane with anterior rectal wall. Further evaluation with sigmoidocolonoscopy revealed large anterior mass measuring 12 cm, fixed to rectal mucosa and filling 90% of rectal lumen. TRUS guided 12-core prostate biopsy was suggestive of spindle cell neoplasm consistent with extra-gastrointestinal stromal tumor. The immunoprofile, morphology, and molecular findings are most consistent with a primary prostatic EGIST. The patient is planned for radical prostatectomy with Imatinib adjuvant therapy in due course after pre-anesthetic fitness and surgical optimization. Conclusion: The patients presented with a “giant prostate”, EGIST should be considered in the differential diagnosis. The current case presents an extremely rare case of EGIST arising from the prostate and considered to be aggressive tumors in behaviour. The radiological imaging, histopathology examination, immunoprofile, and molecular findings are usually required to diagnose the primary prostatic EGIST. Surgery and adjuvant tyrosine kinase inhibitors (Imatinib myselate) remain the standard treatment for primary resectable EGISTs.

   MP 02-12: Outcome of partial nephrectomy for stage T1 renal cell carcinoma: An initial experience Top

Md. Selim Morshed, Hafiz-Al-Asad, Mohammad Saruar Alam, Abu Naser Md. Lutful Hasan, Md. Towhid Belal, A. K. M. Shahadat Hossain

Dhaka Medical College and Hospital, Dhaka, Bangladesh

Introduction: RCC accounts for 85% of all solid tumours of the kidney. For many years, radical nephrectomy was the stanŹdard treatment for RCC. However, with increased awareness of the risk for chronic kidney disease after radical nephrectomy, there has been increased support for treatments that preserve renal function. Partial nephrectomy has gradually replaced radical nephrectomy over the past decade, especially for T1 stage RCC. While there is no doubt that partial nephrectomy has a surgical advantage for small RCC, but the benefit of partial nephrectomy on oncologic outcomes is still controversial specially for T1b. But emerging evidence suggests that it might be possible to achieve similar result to those in tumours of T1a. So, this study was done to see the outcome of partial nephrectomy for T1 renal mass. Objectives: To find out the clinical and functional outcome of partial nephrectomy. Methods: This is a observational study. This study was done in urology department from the period March 2013 to March 2018. A total 33 patients underwent partial nephrectomy during this period with renal mass. RCC was diagnosed from clinical history and radiological investigations. Preoperative renal functional status was assessed with serum creatine and GFR and compared during post-operative follow up period. After proper counseling and clinical evaluation, all patients underwent partial nephrectomy under general anesthesia by retroperitoneal approach. Follow up was done for 9 months. Results: Total 33 patients under went partial nephrectomy. Among them 21 were men and 12 were women. Mean age of the patients at surgery was 56ą 3.84 (48 to 59 years) years. Tumour size was in a range of 3-7 cm. Average operative time was 90 minutes (90-130 min). Mean ischeamic time was 16.49ą 2.6 minutes (14.5 to 21 minutes). Blood loss was minimum with no transfusion required during the procedure. Histopathology revealed malignancy in 30 cases and benign renal mass Renal functional status was not impaired and recurrence of tumour noticed in 3 patients during follow up period. Conclusion: The aspect partial nephrectomy is gradually increasing. It has gradually replaced radical nephrectomy for T1 tumours which located in a suitable location. Still there is some controversy regarding oncological outcome for T1b tumours. So, more clinical study should be conducted in different centers to recommend partial nephrectomy for T1 tumours.

   Moderated Poster Session 3: Endourology - Lower Tract - Bladder, Prostate, Urethra Top

   MP 03-01: Use of indigenous bovine pericardial graft for surgical correction of Peyronie's disease Top

Amit Tripathi, Rupin Shah, Monish Patil, Uday Chandankhede, Sumeet Agarwal, Pawan Rahangdale

Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Introduction: Surgical correction of severe curvature due to Peyronie's disease would involve incision and grafting. One of the most widely used graft material is bovine pericardium with excellent results, however, this material was not available in India till now. We present here a case report on correction of Peyronie's curvature using this indigenous bovine pericardial graft (SynkroScaff @ SynkroMax Biotech Pvt Ltd.) which is recently manufactured and licenced in India. Materials and Methods: Graft material: Bovine pericardial patch (SynkroScaff) is acellular, crosslinked, with no antigenicity and high strength upto 18 Mega Pascal. It does not undergo fibrosis after implantation, is resistant to enzymes and never contracts. Surgical Technique: Surgery was performed using standard technique. Penis was degloved, dorsal neurovascular bundle was dissected, severity of curvature was assessed. Tunica albuginea over the plaque was incised in a H- shaped pattern and penis stretched out to correct curvature. Defect was repaired using indigenous bovine pericardial patch. On discharge patient was taught to apply pressure dressing for next 4 weeks. Results: Material was easy to handle, could be cut to the requisite size and complete correction of the chordee was achieved. At 3 months follow up 15 degrees of residual curvature was seen. But no subsequent recurrence was seen on further follow up. Conclusion: Indigenous bovine pericardium patch appears to be a safe, affordable and pliable tissue for tunica albuginea grafting in surgical correction of Peyronie's disease.

   MP 03-02: Effect of penile low intensity shock wave therapy in selected patients of erectile dysfunction: An interim analysis Top

Y. P. Singh Rana, Aditya Pradhan, Harish Sinha

BLK Super Speciality Hospital, New Delhi, India

Introduction: Low intensity shock wave therapy holds promise in restoring natural erection but there is paucity of evidence which can guide a physician for the number of shocks and sessions of therapy used for optimal benefit to a patient. Aims and Objectives: To evaluate overall efficacy of a short course treatment of LiSWT in vasculogenic erectile dysfunction patients (cardiovascular and Diabetic patients). Materials and Methods: This study was done as a pilot project from Jan 2017 to Jan 2018. A total of 15 patients were included out of 120 patients of erectile dysfunction attending the Andrology OPD. All the patients were diabetics and 80% had concomitant Coronary Artery Disease. All patients had previously PD5 inhibitors with inadequate response. In all cases the IIEF 5 scores were recorded pretreatment We offered these patients with a short aggressive therapy protocol of weekly LiSWT for 3 weeks with adjuvant Tadalafil 5 mg for 4 weeks Three sessions one week apart, total 14400 shocks were given (5000+5000+4400). A Wolfe piezoelectric machine was used in all the patients. Post treatment IIEF 5 scores were recorded at 3, 6 and 9 months. Results: Mean age was 59 +/- 10.3 months. Mean ED Duration was 65 (36-84) months. 12/15 patients had cardiovascular disease and 15/15 were diabetic. Mean initial IIEF ED domain score was 11 (6-13). Based on changes in IIEF-ED domain scores, 60% of all males had a significant clinical improvement after 6-9 months. Conclusion: In this study we found that LiSWT – 3 cycles of weekly treatment amounting to 14400 shocks resulted in satisfactory enhancement in the IIEF from 11 to 19 at a mean follow up of 9 months in this group of patients.

   MP 03-03: A rare case of Zinners syndrome presenting as LUTS in young adult managed laparoscopicaly Top

P. Sahare, S. Shah, T. Singh, D. Pawar, A. Goel

Department of Urology, BJ Medical College, Ahmedabad, Gujarat, India

Introduction: Seminal vesicle cysts producing lower uriary tract in males are uncommon. Zinners syndrome is a rare triad of Congenital seminal vesicle cysts with ipsilateral renal agenesis and ejaculatory duct obstruction. Less than 100 cases have been reported in literature. Small seminal vesicle cysts are usually asymptomatic, whereas the larger cysts will cause lower urinary tract symptoms in form of Voiding difficulty, reccurent UTI, Hematospermia, pain while ejaculation and preineal pain rarely. Methods: We present a 45-year-old man who suffered from voiding difficulty and irritating voiding symptoms since 1 year. He had two episodes of UTI, treat with antibiotics. Patient was married and having two children. Digital rectal examination revealed a palpable large cystic mass behind the prostate. Uroflowmetry showed Maximal and average flow rate 12 m/sec and 4 ml/sec respectively. RGU was normal. Diagnostic imaging showed a right seminal vesicle cyst with an intravesical protrusion. The ipsilateral kidney and ureter were absent. We had performed Laproscopic Right seminal vesiculectomy. Patient is in follow up. Results: Patients symptoms were releived & the maximal and Average urinary flow rates increased from 12 to 18 mL/s and from 4 to 10 mL/s, respectively. Conclusion: We advocate Laparoscopic approach for managing Symptomatic large Seminal vesical cyst.

   MP 03-04: Unusual variant of zinner syndrome presenting as cause of infertility in young male Top

Monish Patil, R. Shah, S. Shah, A. Tripathi

Lilavati Hospital, Mumbai, Maharashtra, India

Introduction and Objective: Mesonephric duct in male is paired developmental organ that develops mainly into trigone, bladder neck, part of urethra, seminal vesicle, vas difference and epididymis. The ureteric bud initially develops as outpouching from the mesonephric duct. So, congenital malformations of the accessory reproductive organs may be associated with abnormalities of upper urinary tract. We present here, an unusual variant of zinner syndrome comprising of unilateral renal agenesis, ejaculatory duct obstruction and large intra-prostatic cyst. Materials and Methods: 32 years old male patient came with inability to conceive since 5 years. On further enquiry, he revealed orgasmic anejaculation. on examination we found undescended right testis. Left testis, vas difference and spermatic cord were normal. Ultrasound examination showed absence of right kidney. Unable to find out cause of anejaculation, we did Magnetic Resonance Imaging of pelvis. It revealed large intra-prostatic cyst with dilatation of right seminal vesicle. Post coital urine showed presence of sperms. Trans- urethral management of prostatic cyst was planned. Cystoscopy showed a large obstructing intra- prostatic cyst. Ureteroscope was introduced into the cyst through the seminal colliculus. The cyst was filled with calculi presumed to be formed from the obstructed semen. They were fragmented using laser and evacuated by giving per-rectal prostatic massage. The cyst was left open for drainage. Results: On 6 weeks follow-up, patient was able to achieve ejaculation. Conclusion: Developmental anomalies of urogenital system should be considered while evaluating a case of primary infertility. Appropriate imaging should be done for accurate diagnosis of mesonephric duct abnormalities.

   MP 03-05: A study of effect of combinig buprenorphine to bupivacaine during spinal anaesthesia on rate of erection in patients undergoing uro-endoscopic procdures Top

Purushothama Acharya

Srinivas Institute of Medical Sciences, Mangalore, Karnataka, India

Objecive: To study the effect of combinig buprenorphine to bupivacaine during spinal anaesthesia on rate of erection in patients undergoing uro-endoscopic procdures. Materials and Methods: 25 randomly selected patients of the age group of 20 to 40 years needing uro endoscopy who received spinal anaesthesia with bupivacaine alone (group A) were compared with 25 randomly selected patients needing uro endoscopy receiving spinal anesthesia with bupivacaine mixed with varying doses of buprenorphine (group B) with regard to the presence or absence of erection immediately after recieving spinal anaesthesia. Results: 20 of the 25 patients in group A had erection where as only 1 of 25 in group B had erection (p<0.05). Conclusion: Addition of buprenorphine to bupivacaine in spinal anaesthesia has significant advantage of reducing the possibility of erection in uro endoscopic procedures. Its use in other surgeries where erction can hinder the proper surgery (such as urethroplasty) and also its use in treatment of priapism needs to be explored.

   MP 03-06: Prospective comparative study between virtual reality and fruit tissue (Apple) based TURP simulator Top

Shailendra Gupta, Arvind Ganpule, Abhishek Singh, S. B. Sudarshan, V. Mohankumar, R. B. Sabnis, M. R. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Purpose: TURP is commonly performed surgery for benign prostatic hyperplasia, purpose of study to compare that which model is more beneficial to an urosurgeon for learning and development of skill. Materials and Methods: 13 residents and urosurgeons with variable level of skill and experience in TURP performed TURP on simulator and Apple model independently. Operative time and adequacy of channel were noted by independent observer. Subjective experience was noted using a set of questionnaire. Standard statistical comparison was done to find out which technique fared well. Results: Mean operative time in Simulator model was 22.54 min and for Apple model was 21.85. Adequacy of channel in both model have no significant difference. There were no significant difference in mean operative time, and variety of scenario and model preparation. In Apple model trainee experience is better for tissue feel and overall assessment (p<0.005). Trainees also have more resemblance of real life TURP after training in Apple model then Simulator (Likert scale mean score 2.69 vs 4.00, p <0.005), however Simulator have significant better control of bleeding (Likert scale mean score 3.96 vs 2.71, p < 0.005). Conclusion: Simulator have better control of bleeding but other factors like realistic resemblance to real life TURP and tissue feel in Apple model makes it a better model for training.

   MP 03-07: Comparative analysis of safety and efficacy of silodosin and silodosin + bethanechol for trial with out catheter in a patient with acute urinary retention Top

Arun Kumar Dwivedi, Vinay Tomar, S. S. Yadav, Shivam Priyadarshi, Nachiket Vyas, Neeraj Agarwal

SMS Medical College, Jaipur, Rajasthan, India

Introduction: AUR is an urological emergency in men and requires urgent catheterization. In the absence of internationally agreed outcome measures for the success of a trial without catheter, success was defined as the return to satisfactory voiding without need for re-catheterisation within 24 hours. Alpha blockers relax prostatic smooth muscle cells thereby improve urinary symptoms Bethanechol is a muscarinic agonist with no nicotinic effects used to increase smooth muscle tone in urinary retention in the absence of obstruction. Methods: This prospective study will be conducted over 120 patients with AUR due to BPH. Patient having large median lobe, prostate size > 100 ml, with recurrent UTI, gross hematuria, renal insufficiency, suspected carcinoma prostate, neurogenic bladder, holding > 800 ml urine, and any bladder or urethral disease were excluded, patient who were catheterized but were not on alfa blocker therapy, were categorized into three equal groups, given placebo, silodosin and silodosin with bethanechol. Voiding trial given after three days of therapy. And successful case were assessed with uroflowmetry. Results: The received drugs were well tolerated by patients and none of them have discontinued the prescribed drugs. The incidence of successful catheter free voiding trial was significantly higher in the combined treatment group compared to SILODOSIN AND PLACEBO group. Among those who had a successful voiding, peak flow rate were also significantly better in combined group. Conclusions: Patients with AUR due to BPH can be treated safely with a combination of SILODOSIN and BETHANECHOL to get a better success rate.

   MP 03-08: Detrusor preleak point pressure: A more reliable parameter to predict the risk to the upper urinary tracts? Top

Priyank Shah, Shirish Yande, Krutik Raval, Bonny Shah, Darshan Patel

Ruby Hall Clinic, Pune, Maharashtra, India

Detrusor Leak Point Pressure (DLPP) is a relatively established urodynamic parameter to predict the risk to the upper urinary tracts in patients of Neurogenic Bladder Dysfunction. However the parameter is not sufficiently standardised till date. Besides there are potential technical errors in its measurement due to the presence of urodynamic pressure catheter in the urethra during measurement. We at our centre, have designed a method of measuring the leak point pressure by withdrawing the catheter at the point of leakage and reintroducing it as the leak stops. The pressure measured at this point is the natural bladder pressure to which the upper urinary tracts are exposed to prior to leakage. We called this pressure Detrusor Preleak Point Pressure (DPLPP). Measuring both DLPP and DPLPP in 42 consecutive patients of Neurogenic Bladder Dysfunction, we are able to correlate our findings to the upper tract damage and suggest revised parameters to predict the risk to the renal function in these cases. DPLPP is thus a new parameter. However when used in conjunction with other important parameters like total detrusor compliance, vu reflux, Detrusor Overactivity and bladder capacity it may potentially add accuracy in prediction of the upper urinary tract deterioration in patients with neuropathic bladders.

   MP 03-09: Role of laparoscopic unilateral nephrectomy in the treatment of refractory nephrogenic hypertension: A case series Top

Yaser Ahmad, Sajad Malik, Rouf Khawaja, Arif Hamid, Saleem Wani

SKIMS, Srinagar, Jammu and Kashmir, India

Introduction: Hypertension affects millions around the world. In selected cases of renal disease, nephrectomy may allow adequate BP control. Advancement of laparoscopic nephrectomy may lead to decreased morbidity and faster recovery. Materials and Methods: Patients referred to us have been treated for hypertension for more than 3 years. Indication for nephrectomy was uncontrolled hypertension with recurrent UTI or poorly functioning kidneys. Total of 5 patients underwent laparoscopic nephrectomy. Pre-operative BP was 165 ą 35 mmHg systolic and 102 ą 29 mmHg diastolic. 3 patients were on three and 2 were on four antihypertensive medications. Results: Mean blood loss was 50 ml, mean operative time 120 min and mean hospital-stay 2.5 days. HPE of nephrectomy specimens showed renal atrophy due to chronic hydronephrosis in 3 patients, nephrosclerosis in 2 other patients. Postoperatively, blood pressure was 121 ą 9 mmHg systolic and 72 ą 6 mmHg diastolic in 3 patients who stopped all antihypertensive. 2 patients had partial response with reduction in the number or the dose of antihypertensive medications. There were no complications and no conversion to open surgery. Conclusion: Patients with unilateral renal abnormality and hypertension may benefit from early nephrectomy, to reduce the morbidity from high blood pressure and hypertensive medication. Before the advent of minimally invasive surgery, nephrectomy was a major undertaking with some patients left with a large scar and having still to take antihypertensives (partial or non-responders), however patients need to understand the surgical risks as well as small risk of failure to treat hypertension.

   MP 03-10: 46, XX, SRY negative phenotypic male with infertility: An uncommon case Top

Devprakash Choudhary, Manoj Kumar, Rima Dada, Rajeev Kumar

AIIMS, New Delhi, India

Introduction: One of the rare chromosomal causes of disorder sex development (DSD) is the 46-XX karyotype. Most such men are SRY gene positive which explains their male phenotype. Male phenotype with absence of SRY gene is extremely uncommon and most such men have ambiguous genitalia. We report two cases of 46-XX DSD who were SRY negative but had normal male phenotype. Methods: Two men aged 27 and 28 years presented with infertility to our tertiary care hospital. They had mature male external genitalia with descended but small testes, sparse body hair and bilateral mild gynecomastia. Semen analysis showed azoospermia. Serum FSH was elevated in both the cases with low testosterone. Ultrasound abdomen and pelvis did not reveal any mullerian derivatives. A chromosomal analysis and genetic screening was ordered. Results: G-banding karyotypic analysis revealed a pure 46 XX pattern in both patients. Molecular studies showed that both patients were SRY gene negative. Y chromosome was absent and thus AZFa, AZFb and AZFc regions microdeletion tests were positive. Genetic and psychological counseling was done for both the patients and testosterone supplement started in consultation with endocrinologist. Donor insemination was advised for fertility. Serial self examination with regular gonadal USG was advised to check the risk of malignancy. Conclusions: 46 XX DSD with SRY negative is a very uncommon cause of male infertility. These subjects may be raised as males due to normal external genitalia. Screening for katyotype is indicated, followed by screening for remnants of mullerain ducts and for malignant transformation in dysgenetic gonads.

   MP 03-11: Revisiting penile venous ligation: A case report with review of literature Top

Anwar Ali

SMS Medical College, Jaipur, Rajasthan, India

Introduction: Erectile dysfunction (ED), inability to achieve and maintain penile erection sufficient to perform sexual intercourse is present in varying degrees in 52% of population. One of the most common types of vascular ED is corporoveno-occlusive dysfunction (CVOD) also known as venogenic ED. This usually does not respond to phosphodiesterase inhibitors and has a poor response to intracavernosal injection therapy. Penile venous ligation is a fair option to treat this condition. Hsu et al have reported a success rate of 90.4% with venous ligation in their well selected patient group. Case Report: A 20 years old male presented with primary erectile dysfunction, having never experienced penile erection. All secondary sexual characters, genitalia and libido were normal. He did not respond to phosphodiesterase inhibitors and underwent three failed attempts of intracavernosal pharmacostimulation. He was normotensive, non smoker with no history of any penile trauma or radiation. Parameters (blood sugar, testosterone, prolactin, leutenising hormone, serum creatinine, lipid profile) were normal. His post pharmacostimulation penile Doppler determined PSV of 59 cm/s, EDV of 10 cm/s with RI value 0.82, indicating venous leak, confirmed by cavernosogram showing leak at dorsal vein and crural veins. Stripping of deep dorsal vein with ligation of circumflex and crural veins with crural plication was performed. At follow up of one year patient had good rigid penile erection. Conclusion: Although, most guideline panels criticise long term results, penile venous ligation after identifying and confirming the venous leak is a viable option for young patients with primary venous leak.

   Moderated Poster Session 4: Uro Oncology, Transplantation and Miscellaneous Top

   MP 04-01: Management of a rare case of pelvic solitary fibrous tumour: Combined approach using Da Vinci Xi Robotic System Top

Kinjal Banerjee, Y. Qadri, S. Joshi, M. Kumar, R. Maheshwari, Anant Kumar

Max Superspeciality Hospital, New Delhi, India

Introduction: Solitary Fibrous Tumours, first described in 1870 by Wagner, are tumors of mesenchymal origin of unknown etiology. They usually occur in the extremities. The term SFT is favored by soft-tissue pathologists to describe a rare, heterogeneous group of benign and malignant neoplasms along a morphologic continuum. Malignant forms exhibit hypercellularity, mitotic activity (>4/10 hpf), cytologic atypia, tumor necrosis, infiltrative margins. Metastasis is usual cause of death and occurs via hematogenous route to lungs. Methods: Sixty four year old male presented with a history of obstructive LUTS since one year. Examination revealed a bimanually palpable pelvic mass and digital rectal examination showed hard, nodular mass not separately palpable from prostate. MRI showed large heterogenous mass in retroprostatic space with loss of surrounding fat planes. CT guided biopsy revealed extrapleural SFT and whole body PET-CT showed no metastasis with mass's SUV max 9.4. Patient then underwent Robot assisted pelvic dissection converted to open abdomino-perineal tumour resection (due to dense adhesions and bleeding from pelvis) on 9/11/17. Abdominal drain was removed on POD4 and patient was discharged on POD7. Results: Biopsy revealed SFT without any malignant features with negative margins. - On follow-up MRI after 3 months, no recurrence was noted. Conclusion: Extrathoracic SFT is a rare disease. - During minimally invasive approach for pelvic tumours, if excessive adhesion/bleeding is encountered, then a combined abdominoperineal approach gives good result including complete tumour excision and acceptable cosmesis.

   MP 04-02: Transitional cell carcinoma in cross fused renal ectopia: A rare entity Top

Renish Patel, Pranjal Modi, Jamal Rizvi, Bipin Pal

IKDRC and ITS, Ahmedabad, Gujarat, India

Introduction: Cross fused renal ectopia is a rare congenital anomaly, with incidence of 1:1300 to 1:7500. Its association with malignancy is extremely rare, with Renal Cell Carcinoma being most frequent tumor type. Very few case reports of its association with TCC is published. Case Description: A 72 years old male presented with left flank pain and hematuria with normal serum creatinine. CT scan:Right to left cross fused ectopia with (5.5 x 3 x 3.8) cm right pelvic mass. Diagnostic cystoscopy was unremarkable. Laparoscopic nephroureterectomy with open bladder cuff excision done. HPE report showed low grade papillary TCC of renal pelvis. Till date there is no recurrence. Discussion: Nephroureterectomy with bladder cuff excision is standard treatment of upper tract TCC. To ablate the involved kidney from its conjoint mate is a challenging task due to complex blood supply and fused ectopic position. Conclusion: Laparoscopic nephroureterectomy can be done safely with prehensive vascular anatomy in experts hand.

   MP 04-03: Migrated double J stent into inferior vena cava and right atrium Top

Pratihar Sarbartha Kumar, T. P. Rajeev, Baruah Saumar Jyoti, Barua Sasanka Kumar, Bagchi Puskal Kumar, Sarma Debanga, Phukan Mandeep

Department of Urology, Gauhati Medical College and Hospital, Guwahati, Assam, India

Introduction: Ureteric stents are widely used in urologic practice since its introduction. Ureteric stent has got various complications like stent syndrome, encrustations, urinary tract infection. Case: Presenting here a 55 years old female presented with pain in the right side of abdomen for 1 year with history of right pyelolithotomy and DJ stenting one year ago. Imaging evaluation revealed the presence of DJ stent in right renal vein, IVC and right atrium with impaired right renal function. Patient underwent right simple nephrectomy and DJ stent was extracted. During operation DJ stent was found in the right renal vein. Conclusion: Intracardiac migration of DJ stent is a rare phenomenon. DJ stent should be employed under fluoroscopic or ultrasound guidance to prevent such complications. No standard modality of treatment for intracardiac migration of DJ stent. It can be managed endovascular, percutaneous or open approach.

   MP 04-04: A rare cause of ascites: Spontaneous urinary bladder rupture Top

Tushit Rai, Vignesh Manoharan, Giridhar Singh Bora

PGIMER, Chandigarh, India

Case Summary: Thirty two year old male presented with fever, loss of weight and appetite from last one month and abdominal distension from last seven days. On evaluation, he was diagnosed with tubercular ascites with gastrointestinal tuberculosis. In view of left hydronephrosis and persistent ascites after treatment, he was reevaluated and was diagnosed with spontaneous urinary bladder rupture which was managed with per urethral catheterization and intraperitoneal drainage. This case report emphasize on rare cause of ascites secondary to spontaneous bladder perforation.

   MP 04-05: Recurrent giant vesical calculus Top

Vignesh Manoharan, Khwairakpam Amit K. Singh, Aditya P. Sharma, Kalpesh Parmar, U. K. Mete, S. K. Singh, A. K. Mandal

PGIMER, Chandigarh, India

Introduction: Though urolithiasis is a common problem worldwide, Vesical calculi are rare. Giant calculus weighing more than 100 gm are very rare. We report a case of recurrent giant vesical calculus with b/l HDUN in a young male. Case Details: A 35 year old male with a past history of open cystolithotomy in 2014 for vesical calculus, presented to us with complaints of strangury, dysuria, intermittency for past 3 months. There were no features of neurogenic bladder or outlet obstruction. On evaluation he was found to have a large vesical calculus of size. USG also showed B/L mild HDUN. There was no calculus in the upper tracts. But his creatinine was 1.1 mg/dl. Calcium, Phosphorus, Uric acid, Sodium, iPTH and Vit D were all within normal limits. Urine routine examination showed few pus cells. Urine culture was sterile. We did an extraperitoneal open cystolithotomy. The bladder was thickwalled. Stone was broken into fragments using chisel and hammer keeping deavers retractor inside the bladder as counterbalance mechanism to avoid injury to the bladder wall. The removed fragments weighed 493 gm. SPC and PUC were removed after 3 weeks and the patient is voiding well at present. Conclusion: Patients can develop Giant vesical calculi even in the absence of secondary causes. Complete clearance is the key for prevention of recurrence. Early detection by surveillance will avoid the unnecessary morbidity.

   MP 04-06: Role of thrombectomy in the salvage of arteriovenous fistula: Does timing of intervention influence the outcome? Top

R. Kumar, R. Manikandan, L. N. Dorairajan, K. S. Sreerag, S. Kalra, V. Khelge

Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Introduction and Objective: In general, a blood flow of 500 ml/min and a diameter of at least 4 mm are a prerequisite for an AVF to support dialysis therapy. Thrombosis is one of the common cause for AVF failure. The aim of this retrospective study is to review our experience in surgical salvage of failing AV fistulas by adoption of thrombectomy in appropriate circumstances. Methods: Between Jan 2017 to Jan 2018, 18 patients underwent surgical thrombectomy. Out of 18, 10 were radio-cephalic, 7 were brachio-cephalic and 1 was brachio-basilic AV fistula. The time between the diagnosis of thrombosis and admission to the operative suite were recorded. The patients were divided into two groups based on intervention time (Group 1<24 hours and Group 2 >24 hours) and the outcomes were assessed. The mean operative time was around 122 minutes. The main outcome measure was technical success rate. Results: A total of 10 patients underwent thrombectomy in Group 1 and, 8 patients in Group 2. Successful recanalization was achieved in 90% (9/10) in Group 1 and 37.5 % (3/8) in Group 2. These fistulas were successful to cannulate at 6 months follow up. Conclusion: Surgical salvage of thrombosed AV fistulas by thrombectomy should be strongly encouraged to be performed early (preferably within 24 hrs of thrombosis). Attempt for thrombectomy should also be considered even beyond 24 hours as the fistulas can be salvaged successfully in one third of cases.

   MP 04-07: An intresting case of hematuria Top

Shivendra Singh Tiwari, R. Ravichandran, V. Konanki, D. P. Vincent, Anurag Dubey, A. Santosh Kumar

Meenakshi Mission Hospital and Research Centre, Madurai, Tamil Nadu, India

Introduction: Hematuria per se is not a disease, it is regarded as symptom if gross & sign if microscopic. Retroperitoneal non-hodgkin's lymphoma is extremely rare cause of hematuria. Due to uncommon anatomical location, diagnosis and subsequent management of these patients tend to be difficult. Case Report: A 62 yrs/Male, came with C/O hematuria which was painless, intermittent with clots since 5 month. He had no other voiding symptoms /pain abdomen / fever. We proceeded with cystoscopy, clot evacuation and bilateral ureteroscopy. Operative findings were active bloody efflux from left ureteric orifice and multiple clots in left ureter & Pelvicalyceal system, vascular ectatic lesions around papillae with active bleeder. CT abdominal angiogram showed retroperitoneal mass infiltrating right kidney & renal vessels, with IVC thrombus. Finally diagnosis was made as lateralising hematuria from left kidney due to renal venous hypertension & identified cause was retroperitoneal non-hodgkin's lymphoma involving right kidney with IVC thrombosis. We did bilateral DJ Stenting and chemotherapy (R-CHOP regimen) was started. Conclusion: Basic goal in dealing with a case of hematuria is to recognize and confirm finding of hematuria & Identify common etiologies. Renal vein hypertension (pressure gradient of > 4 cmH2O between the IVC & renal vein) have been documented as a rare cause of gross hematuria. Increased venous pressures may result in communications between forniceal venous sinuses & terminal branches of minor calyces causing hematuria. While managing case of hematuria, in conditions associated with abnormal clinical/laboratory/ imaging, treatment may be necessary, as appropriate, with the primary diagnosis.

   MP 04-08: Synovial sarcoma of kidney with IVC thrombus – Case report and review of literature Top

G. K. Shreedhar, B. Priyank, P. Ginil Kumar, T. Appu

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Introduction: Synovial sarcoma is a very rare type of soft tissue sarcomas affecting the extremities commonly. They are also reported in lungs, mediastinum, head and neck regions. Less than 50 cases of synovial sarcoma in the kidney has been described in the literature. Only 4 cases of synovial sarcoma of kidney with IVC thrombus are reported. Here we report a young lady with right renal mass and IVC thrombus which turned out to be a synovial sarcoma in histopathology. Case Report: A 39 year old female has presented with compliants od difficulty in breathing and pedal edema. On examination she had 10x12 cm right loin mass which was ballotable. She was evaluated with USG elsewhere which showed a large right renal mass. Her blood parameters were normal except for anemia. CECT abdomen and chest showed a large exothytic mass arising from lower pole of right kidney with multiple calcific specks. There is invasion of tumor thrombus into the right renal vein and extends into the IVC upto its entry into the right atrium, and a tumour thrombus in pulmonary artery. A provisional diagnosis of Right RCC with IVC thrombus was made and she underwent Right radical Nephrectomy with IVC thrombectomy under cardiopulmonary bypass. Post procedure patient had uneventful recovery. Biopsy and IHC was suggestive of spindle cell neoplasm – Primary synovial sarcoma. RT PCR was also done which was confirming synovial sarcoma. She was started on Palliative chemotherapy (fosfamide and Adriamycin). Discussion: Sarcomas are rare neoplasms of kidney accouting for less than 1% of tumors of kidney. Out of sarcomas Leiomysarcomas, rhabdomyosarcoma, chondrosarcoma, osteosarcoma, liposarcoma, angiosarcoma and hemangiopericytoma occur commonly than the synovialsarcoma. They usually occur during the second decade of the life and predominantly in males. Clinically they cannot be differentiated from other solid tumours of kidney. Pathologically they have distinct morphology and genetically characterized by the chromosomal translocation t(X;18) (p11;q11). Immunohistochemistry shows positivity for Bcl2, CD99/Mic2, CD56 and Vimentin. Surgery is the mainstay if the management. Chemotherapy with Ifosfamide and Adriamycin is offered as primary treatment in patients non amenable for surgery. Synovial sarcomas, in particular poorly differetiated varieties have aggressive clinical course and poor outcomes. Conclusion: Primary synovial sarcomas of kidney have shown to have aggressive clinical course and poor outcomes. There are no guidelines for the treatment of primary synovial sarcoma of kidney due to the rarity of cases. Surgical management forms the mainstay of treatment. Although synovial sarcomas of kidney is rare, it presenting with IVC thrombus is very rare with very few cases reported. One such case is reported here.

   MP 04-09: Continence after radical prostatectomy: It's not just nerve preservation Top

Vikas Garg, S. B. Sudarshan, Arvind Ganpule, V. Mohankumar, Abhishek Singh, R. B. Sabnis, M. R. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Introduction and Objectives: Incontinence is distressing complication of Radical prostatectomy (RP). No standardized protocol exists for improved continence following RP. In this study we demonstrate our protocol for maximal continence following Robot assisted Radical Prostatectomy (RARP). Materials and Methods: We conducted a prospective study on 150 patients posted for RARP. The parameters such as age, BMI, co-morbidities, pre-operative Pelvic floor muscle (PFM) status and Trans-rectal Ultrasonography (TRUS) were done and saved in database. Preoperative PFM exercises (PFME) were started for minimum 4 weeks (50/half hour, maximum 1000/day). Intra-operatively, nerve preservation, bladder neck preservation, maximal possible urethral length preservation and musculo-fascial reconstruction were done as required. Post-procedure Faradic stimulation (SF) of PFM (50-100 Hz, 0.1-1 ms for 10 minutes) was done till catheter removal along with PFME. The patients were followed at 1, 3, 6, 9, 12 months. Full continence was defined as no pad usage. Results: Age (>75 years), BMI>34 kg/m2 and uncontrolled diabetes were negative predictors of continence. Urethral length preservation, nerve preservation, bladder neck preservation and musculo-fascial reconstruction resulted in earlier continence (within 3 months) but did not affect final continence at 1 year (96% vs 94.8%). SF and Biofeedback significantly improved the earlier return of continence in our experience. Patients with membranous urethral length >18 mm, increase of length by >4 mm on TRUS upon PFM contraction and strict adherence to PFME resulted continence rates of 58%, 76%, 91% at day 1, 1 month, 3 months respectively after catheter removal. Conclusion: It is possible to give total continence with rigorous preoperative PFME, adequate preservation of length of urethra and continued postoperative exercises. Nerve preservation, bladder neck preservation, musculo-fascial reconstruction and SF resulted in earlier continence.

   MP 04-10: Robotic vs. open renal transplantation- match pair analysis Top

Rajanikant Joshi, A. Singh, S. B. Sudharsan, A. Ganpule, R. B. Sabnis, M. R. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Introduction: Renal transplantation (RT) is recognized treatment for end stage renal disease. With advent of robotics, there is growing interest for robotic RT. Although significant literature of robotic RT is now available, studies comparing open vs robotic transplant is lacking. We present match pair analysis of open vs robotic RT. Materials and Methods: We retrospectively reviewed casesheets of patients who underwent RT from 2013 to 2017. 12 patients with BMI≥ 22 kg/m2 who underwent robotic RT included in robotic arm. 12 patients with open renal RT were matched for demography, body mass index (BMI), comorbidities and native kidney disease. Variables assessed were operative time, total ischemia time, haemoglobin drop, nadir creatinine at 1 month and complications. Results: Mean operative time was 293.6ą65.06 minutes in robotic arm and 253.64ą18.178 minutes in open arm. Total ischemia time in robotic arm was 116.ą23.47 minutes and 67.36ą23.11 minutes in open arm. Haemoglobin drop was 1.15ą0.82 gm/dl in robotic arm and 1.82ą0.86 gm/dl in open arm. Nadir creatinine at 1 month was 1.39ą0.376 mg/dl in robotic arm with 1.39ą0.96 mg/dl in open arm. 2 patients from robotic arm had perigraft collection treated conservatively. Three patients from open arm developed wound infection. Conclusion: Except total ischemia time all other variables were comparable. Neither of arms had vascular complications. Robotic arm patients had no wound complications. None of the studied parameters affected long term graft outcomes at 1 year followup. We conclude that robotic modality is non inferior to open surgery for RT, though long term prospective comparative studies need to be done.

   MP 04-11: Primary synchronous malignancy with concordant genitourinary malignancies: A review of 7 cases Top

Utsav Shah, Hariharasudhan Sekhar, Sriram Krishnamoorthy, Natarajan Kumaresan

Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India

Introduction: Metachronous malignancies are common in urological practice. Synchronous dual primary malignancies are unusual. They are usually considered to be a metastasis from the other. The purpose of this manuscript is to highlight the fact that such synchronous malignancies though rare in occurrence, should always be kept in mind while treating these patients. Materials and Methods: A retrospective study was done in all patients who presented to our urology department and diagnosed to have synchronous double malignancies, of which one malignancy in all patients was in genitourinary tract. We report a series of such patients who had dual primary malignancies. Results: Seven patients presented with synchronous double malignancies with each having a primary from genitourinary tract. One had ipsilateral renal cell carcinoma (RCC) and contra-lateral Transitional cell carcinoma of the renal pelvis. Another patient had unilateral RCC and Sigmoid colon adeno-carcinoma. Third patient presented with a uterine endometrial carcinoma along with a RCC. Other 3 patients had carcinoma prostate with huge hilar renal mass in one, adenocarcinoma of colon in the second and squamous cell carcinoma of hypopharynx in the third patient. A 50-year-old female who had ureteral sarcoma and uterine sarcoma was the highlight of our series. Conclusions: It is well known that individuals who have developed one malignancy are at greater risk of developing the second. Two malignancies of different histology occurring at the same time is a rarity. A strong index of clinical suspicion, adequate imaging and multidisciplinary treatment is necessary in such cases.

   MP 04-12: Additional anaesthesia techniques prior to transrectal prostate biopsy- do they really help Top

Nimje Rohit, Jadhao Vivek, Dalvi Mayur, C. Pancholi, S. W. Thatte, R. K. Garg, Kashikar Rupesh

Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India

Purpose: PSA screening has led to significant rise in transrectal ultrasound guided prostate biopsies. Most common anaesthesia technique before prostate biopsy is the Periprostatic nerve block (PPNB). Patients still have significant peri procedural pain and discomfort limiting the number of biopsies. We compared PPNB, PPNB plus periapical block and PPNB plus 2% rectal lidocaine gel instillation for better peri procedural pain and discomfort control Materials and Methods: From January 2017 – June 2018, a total of 70 patients underwent trans rectal ultrasound guided prostate biopsies. They were randomized into 3 groups- 25 patients received PPNB, 25 patients PPNB plus periapical block and 20 patients PPNB plus rectal lidocaine gel instillation. A Visual analog scale was used to asses peri procedural pain. Results: Mean visual analog pain scores were 2.4 for PPNB group, 2.3 for PPNB plus periapical group, 2.1 for PPNB plus rectal lidocaine gel group. Peri procedural pain was least for PPNB plus lidocaine group but no statistically significant difference was seen in all the three groups. Conclusions: PPNB is standard prior prostate biopsy. Additional apical infiltration did not improve patient discomfort further. The combination of PNB plus rectal gel provided better peri procedural analgesia compared to other groups. However, no statistically significant difference was found between any of the methods.

   Moderated Poster Session 5: Reconstructive and Female Urology Top

   MP 05-01: Extended boari flap for management of complete avulsion of ureter from vesioureteric junction: A case report Top

Kishore Wani

Kidney Care Hospital and Research Centre, Nashik, Maharashtra, India

Introduction: Ureteral avulsion during ureteroscopy is a challenging condition. Occurs in 0.06–0.45% of patients. Inappropriate management of ureteral avulsion often leads to undesirable complications. We report a case of post ureteroscopy lower ureteric complete avulsion with ischemic lower & middle part of ureter repaired by extended Boari flap technique. Materials and Methods: 30 yrs male diagnosed to have ureteric avulsion while undergoing ureteroscopy for impacted upper third 12 mm ureteric calculus. PCN kept that time. 4 weeks later patient came to us with PCN insitu. Preop routine haematological & urine test were normal. CT urography done showed complete avulsion of lower end of ureter with upper ureteric calculus in situ. Left ureteric orifice not seen properly at Cystoscopy. Capacity urinary bladder was normal. Explorartion by modified Gibbson incision done. Impacted upper ureteric calculus removed. Avulsed & ischemic middle & lower part of ureter excised & extended Boari flap created & upper normal part of ureter anastomosed to upper end of Boari flap & rest of flap tuburalized with 5-o vicryl. DJ kept. Results: Toal operative time 3:30 hrs. Insignificant blood loss. Drain removed on 4th POD. Foley removed on 8th POD. Patient discharged on 8th POD. DJ removed after 6 weeks. At the time of DJ removal, left RGP & Diagnostic URS done showed good caliber left entire ureter without stricture or leakage. Post procedure IVP done showed normal renal function without hydronephrosis. Conclusion: Repair of complete ureteral avulsion following endoscopic surgery is a challenging task which should be tailored according to the individual situation. Boari flap is a versatile technique in the repair of severe ureteral defects.

   MP 05-02: Management of complex uretero-pelvic junction obstruction in the robotic era: An algorithmic approach Top

Abhishek Chandna, Santosh Kumar, Kalpesh M. Parmar, Ashish Khanna, Shantanu Tyagi, Dharmender Aggarwal

PGIMER, Chandigarh, India

Introduction: Uretero-pelvic junction obstruction (UPJO) occasionally present with complex problems such as giant hydronephrosis (HDN), atypical uretero-pelvic anatomy, unavailable ureter (long segment ureteric strictures/ previous ureteric anastomosis) and secondary UPJO. We aim to present an algorithmic approach in management of these patients along with our experience in robotic repair of complex and atypical UPJO. Materials and Methods: From 2015 to 2018, 7 cases (8 renal units) such cases were operated robotically by a single surgeon. Four patients with giant HDN underwent 'Santosh-PGI' tubularized flap pyelovesicostomy in 5 renal units. One patient with giant HDN in a solitary kidney with multiple secondary calculi underwent calicovesicostomy. Another female underwent robot assisted boari flap calicovesicostomy following failed robotic ureterocalicostomy for secondary UPJO. A young female with long segment upper ureteric calculus underwent ileocalycovesicostomy. All patients were drained pre-operatively by percutaneous nephrostomy (PCN) and the anastomosis were tubularized over a 16 Fr foleys catheter placed suprapubically. The mean operative time was 180 minutes with an average blood loss of 100 ml. Results: All patients demonstrated good gravity dependent drainage with no leak or narrowing. On a follow-up period ranging from 4 months to 3 years, all patients are asymptomatic with no worsening of renal function. The patients were advised double voiding and are on regular follow up. Conclusion: The advent of robotic surgery has made complex reconstructions for the management of complex and atypical UPJO feasible and simple with minimal morbidity. A wide gravity dependent drainage forms the basis of these repairs.

   MP 05-03: Recurrent large urethral stones in case of scrotal skin flap urethroplasty: A nightmare Top

Mayur Dalvi, Vivek Jadhao, Rohit Nimje, C. Pancholi, H. M. Punjani, Umesh Oza, M. G. Andankar

Bombay Hospital Institute of Medical Science, Mumbai, Maharashtra, India

Introduction: The initial era of urethral reconstruction had witnessed wide use of scrotal skin flap for augmentation urethroplasty. Its use fell out of practice owing to multiple complications. Currently use of buccal mucosa is the standard of care for urethral augmentation. However, it's not rare to find patients with scrotal skin graft urethroplasty done in 1980's. Our Case: We report a case of post traumatic stricture augmentation urethroplasty done using scrotal skin flap. Patient had undergone endoscopic urethral stone removal 10 years back. He now presented with perineal pain. Investigations revealed a large stone (>4 cm) in diverticulum of reconstructed bulbar and membranous urethra. Patient underwent excision of diverticulum and hair bearing skin with removal of the stone.

   MP 05-04: Record breaking calculi in neo bladder – 2 case report Top

S. P. Yadav

Pushpanjali Hospital, Gurgaon, Haryana, India

Introduction: Bladder stone formation in orthotopic neo bladder is known delayed complication 2 patients who under went radical cystectomy and orthotopic neo bladder substitution 10 & 14 years back. Devolved calculi of 750 gms and 1125 gms is presented. Giant vasical calculus weighing more then 100 gms is a rare entity. The largest casical calculus is of 6294 gm reported by arthure et al. we reported 2 cases of bladder calculi weighing 750 gms and 1125 gms. Case Report: 64 years male underwent radical cystectomy and orthotopic bladder substitution in 1994 presented with supravesical mass investigation revealed huge vesical calculi. open surgical procedure carried out to remove the stone. It weighed 750 gms and 2nd patient 62 years old who underwent the same procedure 10 years back. He was having recurrent dysuria, X-Ray shows huge bladder calculi. Stone removed by cystolithotomy. It weighed 1125 gms. Discussion: Radical cystectomy and orthotopic neo bladder reconstruction is well establised surgical procedure for Ca Bldder. Stone formation is a known late complicatio. However both patients reported huge multiple calculi with minimal clinical signs. Bio chemical parameters of the patients were normal. Open cystolithotomy was the only choice. Post operative catheter was removed after 2 weeks they are now stone free from last 5 years. Conclusion: Giant bladder calculi are rare. Such big stone are much rarer. However stone formation in neo bladder is a known complication.

   MP 05-05: Modified cantwell- ransley repair for isolated continent epispadius in adult: A rare case report Top

Pravin Patne, V. Akkalwade, Jaykar, Devraju

Siddeshwar Multi Speciality Hospital, Solapur, Maharashtra, India

Introduction: Isolated epispadius with continence is a very rare entity comprising less than 10% of all epispadius cases. Reported incidence is 1 in 11,700 cases. In adult it is extremely rare since such anamolies are treated surgically in childhood. Surgical repair in case of adult epispadius remain an challenge to all reconstructive surgeon. Many surgical procedures have been described for the repair of which Modified Cantwell-Ransley procedure has become procedure of choice. So I would like to present this rare case report of an isolated continent epispadius in adult.

   MP 05-06: Paraurethral leiomyoma: A histological surprise Top

Raghu, Mujeeburahiman, Nischith D'Souza, Altaf Khan, Vinit Singh

Yenepopya Medical College, Mangalore, Karnataka, India

Introduction: Paraurethral mass includes an extensive list of pathologies arising from structures of both of urologic and gynecologic origin. They range from asymptomatic to a severely impacted quality of life. Examples include urethral diverticuli, vaginal wall cysts (including Skene's gland cysts), urethral prolapse/caruncles, and urethral leiomyoma. If symptomatic, surgical excision of the mass is typically undertaken with the procedure performed dictated by the pathology. Here we are describing an incidentally found paraurethral leiomyoma in a middle age women. Case Report: A middle aged women was referred to urology clinics for a mass per vagina. Patient complained of difficulty in passing urine and decreased urinary stream. Examination noted a 4 cm x 3 cm, ovoid mass protruding from the vaginal introitus adjacent to urethral meatus. The mass was non tender to palpation and urethral opening was seen on the left side of the mass. Patient underwent USG of abdomen & pelvis which was normal. Patient was posted for urethrocystoscopy & excision of mass. Procedure was uneventful and there was no urinary disturbance post operatively. Discussion: Paraurethral leiomyomas are a rare cause of periurethral masses and often grouped in studies with other smooth muscle tumors of the lower urinary tract. Urethral and paraurethral lieomyoma make up just 5-7% of periurethral masses. Surgical resection requires detailed knowledge of location of the mass and female urethral anatomy to facilitate dissection and reconstruction of urethra.

   MP 05-07: A case of distal hypospadias masquerading as megameatus intact prepuce Top

Praveen Kumar Yadav, Sameer Swain, Sumit Panda, Anunay Singh, Arsad Hasan, Md. Faizul Haque, Gaurab Kundu

SCB Medical College, Cuttack, Odisha, India

Hypospadias is an abnormality in which the urethral opening is ectopically located on the ventrum of the penis as far down as in the scrotum or perineum. It occurs in 1 to 300 live births. Classic hypospadias is characterized by the triad of ventral urethra defect, absence of dorsal prepuce and chordee. A megameatus with intact prepuce (MIP) is an unusual variant of an anterior hypospadias that accounts for 3% of hypospadias repairs. It is characterized by a widely splayed coronal or subcoronal meatus, a deep glanular groove, a normally conformed prepuce, and no chordee. We here report a case which was diagnosed as MIP clinically but found to be a hypospadias intraoperatively.

Keywords: Chordee, hypospadias, megameatus with intact prepuce

   MP 05-08: Mullerianosis of the urinary bladder in a patient with Mayer-Rokitansky-Küster-Hauser Syndrome: A rare case report Top

Rakesh Panda, S. K. Panda, F. Haquae, S. Swain, G. P. Singh, D. Hota

S C B Medical College and Hospital, Cuttack, Odisha, India

Introduction and Objective: Mullerianosis is a very rare and complex tumor-like lesion, composed of at least two out of three mullerian tissues such as endometrial, cervical, and tubaric. This is very rare in patient with Mayer-Rokitansky-Küster-Hauser syndrome. The rarity of this lesion may cause misdiagnosis, its correct identification is tremendously important for appropriate management, since patients may benefit from hormonal therapy. Methods: A 20 year old unmarried lady presented with complaints of cyclical hematuria with mild abdominal pain for past 7 years, with absence of normal menstrual flow. Patient had not attained menarche with no known bleeding disorder. Abdominal examination was normal and per speculum examination showed blind vagina. Cystoscopy showed a 3x3 cm raised papilliferous area in the posterior wall of bladder. ON diagnostic laparoscopy, B/L rudimentary uterine horns were present, lt horn attached to UB wall, cervix not visualised, proving it to be MRKH syndrome. Results: Histopathological examination of the transurethrally resected bladder biopsy specimen revealed endometrial glands and stroma along with endocervical type of glands and glands lined by ciliated cells in the bladder. These findings indicate that the bladder lesion was mullerian in nature with endometriosis, endocervicosis and endosalpingiosis. Postoperatively patient was treated with medroxyprogesterone. The patient was asymptomatic on follow up. Conclusion: High index of suspicion with proper imaging modalities and extensive histologic evaluation will lead to the diagnosis of mullerianosis. Correct diagnosis is of great value to patients who do not want to undergo surgery primarily because it is responsive to hormonal therapy.

   MP 05-09: Quality of life in patients with perineal urethrostomy Top

Kanishk Dokania, H. K. Nagaraj, D. Ramesh, M. Prasad, S. M. L. Prakash, J. Tarun, P. Sandeep

MS Ramaiah Medical College, Bengaluru, Karnataka, India

Introduction and Objective: Perineal Urethrostomy (PU) provides temporary or definitive solution to stricture urethra, in patients in whom other reconstructive procedures fail. This study evaluated the quality of life in patients treated with perineal urethrostomy for urethral stricture disease. Methods: Retrospective study included 190 patients who underwent perineal urethrostomy using flap technique over a period of 15 years (2003 to 2017) as part of staged urethroplasty repair for complex anterior urethral stricture or permanent urethrostomy as initial surgery. A questionnaire was used to evaluate the quality of life and satisfaction. Outcome was considered failure when postoperative instrumentation was needed. Median follow up period was 60 months. Results: Etiology was unknown in 45.2% cases, lichen sclerosis 18.8%, catheter 15.2 %, and miscellaneous 20.8%. Of 190 patients, 102 underwent prior failed urethroplasty. PU success was seen in 74 patients (72.54 %) and failure in 28 patients (27.46). 88 patients didn't undergo any prior urethroplasty and PU success was seen in 64 patients (72.7 %). A total of 52 PU were failures, requiring postoperative instrumentation or revision of perineostomy. AUA score pre and post-surgery was Mild 21 to 156; Moderate 45 to 28; and severe 124 to 13 respectively. SHIMS scores pre and post-surgery for Mild ED, Mild to Moderate ED, Moderate ED, Severe ED were: 11 (22.91%), 16 (28.08%); 25 (52.08%), 29 (50.87%); 7 (14.59%), 7 (12.28%); 5 (10.42%), 5 (8.75%) respectively. A total of 151 patients were satisfied with surgery and 143 refused to undergo second stage of urethroplasty. Conclusions: Perineal Urethroplasty is a satisfactory procedure for complex anterior urethral stricture.

   MP 05-10: Study of different tecnique of ileal neobladder Top

D. N. Patel, R. K. Shimpi, K. Raval

Ruby Hall Clinic, Pune, Maharashtra, India

Today, the goals of urinary diversion have developed from simply diverting the urine and protecting the upper urinary tracts. Contemporary objectives of urinary diversion should include a form of reconstruction which provides a safe and continent means to store and eliminate urine, with efforts to improved the quality of life of the individual. We performed ileal orthotopic neobladder using hautmann technique in 47%, Camey 2 in 35% and Studer in 18%. In our study, we found that all three reconstruction techniques can be safely performed in men and women with acceptable morbidity and good functional outcome. Early complications were noted in 31% patient and late in 18% patient. The neobladder capacity was seen to increase with time, maximum with hautmann technique. Only 12.5% patient required CISC as post void residue was more than 100 cc, all other patient learnt emptying bladder with abdominal straining and pelvic floor relaxation. The pressure at maximum capacity was more in camey 2 than hautmann and studer, though none were statistically significant. All the patients were continent at the end of 1 year. No urethral or pelvic recurrence was found in 3 year follow up. All patients were satisfied in terms of body image, travelling, bathing, and quality of life. If there is no contraindications, the ileal neobladder is preferred as a urinary diversion after radical cystectomy. We believe that ileal neobladder is attractive option for male and female than ileal conduit.

   MP 05-11: Combined uretero calicostomy with BMG ureteroplasty in complex upper ureteric stricture Top

Akshay Nathani, Date, Shivde, Patwardhan, Akhil, Gopal

Deenanath Mangeshkar Hospital, Pune, Maharashtra, India

Bowel interposition and auto-transplantation of kidney, thought to be a major undertaking, remain the traditional option for the treatment of major and complex ureteric lesions. Buccal mucosa, a well known tissue for urethral reconstruction, can be used safely for the repair of ureter. However, this has been reported poorly in the literature. Also Combined Uretero calicostomy + BMG Ureteroplasty in complex upper ureteric strciture, never reported in literature Here we report a case of long length stricture found in the upper ureter measuring approximately 8 cm. It was successfully repaired by Combined Uretero calicostomy + free buccal mucosal patch graft over a Double J stent. Our experience is encouraging and merits wider application in complex ureteric lesion.

   MP 05-12: Placenta percreta – Challenges in management Top

G. Desai, M. R. Prabhudesai, R. Singh, N. B. Talwadker, P. R. Lawande, U. Oza

Goa Medical College, Goa, India

Aim: To demonstrate usefulness of planned multidisciplinary approach in placenta percreta management. Materials and Methods: Retrospective study of 3 cases of placenta percreta over one year. Results: Case 1: (Urologist not involved preoperatively) Emergency LSCS in booked patient. No pre-op MRI done. Arterial line, CVP & ureteric catheters not placed before induction. Urologist called on table, post-delivery, to control life threatening hemorrhage obscuring pelvic anatomy. Ureters inadvertently included in ligatures. Bilateral internal iliac ligation with tamponade by sterile packs needed. Hysterectomy and removal of ureteric ligatures with bladder repair done. Intra-op BP<90 systolic persisted for >45 min. Normal urine output resumed after 2 hours. Peri-op 24 units of packed cells transfused. Deranged APTT, INR corrected by FFPs. Metabolic complications (hypocalcemia & metabolic alkalosis) seen. Case 2 & 3: (Urologists involved in pre-op evaluation and planning) Antenatelly diagnosed patients underwent Pre-op MRI and surgical risk counseling. Routine LSCS done. Arterial line, CVP and bilateral ureteric catheters placed prior to LSCS. Internal iliac arteries not ligated and ureters preserved. Hysterectomy with partial cystectomy and bladder repair done. Intra-op BP<90 systolic for <10 min. Peri-op urine output >1 ml/kg/hr maintained. 8 units of packed cells transfused. No evidence of coagulopathy and metabolic complications. All patients recovered. Conclusion: Placenta percreta is rarest among placental adhesive disorders, with potential for life threatening obstetric hemorrhage requiring massive blood transfusion. Timely antenatal diagnosis, pre-op evaluation of the extent of invasion, and consultation with urologist reduces genitourinary injuries, blood loss and risk to life of the patient.

   Unmoderated Video Session Top

   UMV 01: Laparoscopic excision of seminal vesicle tumour Top

K. Senthil, M. Ramalingam, N. Sivasankaran

Urology Clinic, Coimbatore, Tamil Nadu, India

Introduction and Objective: Seminal vesicle cyst excision in laparoscopy is techinically demanding more so when there is a tumour in situ. We illustrate the technique of excision of seminal vesicle cyst. Methods: 47 year old male presented with irritative LUTS. His digital rectal examination revealed a globular mildly tender prostate. Ultrasound showed a cystic lesion in the retroprostatatic region. MRI showed seminal vesicle cyst with no infiltration of adjacent structures. Laparoscopy showed well defined cystic lesion involving the right seminal vesicle burrowing into the prostatic capsule. With meticulous dissection excision of the cyst in to was achieved. Results: Patient had smooth recovery and voided with a better stream. Histopathology revealed unusual cystic mixed epithelial and stromal tumour. Conclusions: Meticulous dissection in laparoscopy is essential for a complete removal of seminal vesicle cyst.

   UMV 02: Ueteroscopy and stone Top

Dhaval Patel

Gayatri Hospital and Research Center, Ahmedabad, Gujarat, India

The past century has seen a continues development of the URS alonside diversification of it's use. Current American and European urology Association stone guidelines summarised the current evidence base treatment for stone size and location. The position of the stone in ureter directly reflect in success procedure. More distal stone have highest success rate when treated with rigid ureteroscope compare to the more proximal stone. Indeed proximal stone can fall back into kidney therefore they often required a concurrent flexible ureteroscope to achieve good stone free rate.

   UMV 03: Isolated congenital penile torsion repair Top

Sumeet Gopal Agrawal, Hemant R. Pathak, Uday Chandankhede, Pawan Rahangdale, Amit Tripathi, Monish Patil

Lilavati Hospital, Mumbai, Maharashtra, India

Penile torsion can be a congenital, or an acquired lesion after trauma, circumcision or urethral reconstruction. Congenital penile torsion can occur in association with hypospadias, Congenital chordee, Hooded prepuce or as a single deformity. It might be due to abnormal skin attachment, or abnormal development of the dartos fascia that causes disorientation of the penile shaft and corporeal rotation around its longitudinal axis. The penis is almost always rotated to the left (counter-clockwise). The severity of the deformity is based on the degree of glanular angulation into mild (<45o), moderate (45-90o) or severe (>90o). The indication for interventions are cosmetic and functional. Deformities greater than 60o should be considered for corrective surgery in the absence of associated hypospadias or chordee. We present a case of 6-year-old child with isolated moderate degree of congenital penile torsion towards left side (counter-clockwise). Penile degloving with complete urethral mobilization and dorsal dartos flap was done.

   UMV 04: Retroperitoneal nephrectomy – A single centre experience Top

Naveed Khan, Sajjad Nazir, Muneer Khan

Kidney Hospital, Srinagar, Jammu and Kashmir, India

Introduction: Nephrectomy is indicated for benign as well as malignant conditions of the kidney. Be it simple, radical or partial. In our series from Jan 2005 to Jan 2018 a total no of 140 patients underwent a nephrectomy of which 120 by the retroperitoneal and 30 by the transperitoneal approach. Materials and Methods: standard approach and ports for retroperitoneal nephrectomy were made. The advantages with the transperitoneal approach easily recognizable anatomy, larger working space, better visibility. Results: The retroperitoneal nephrectomy had mean operative time 95 min, blood loss 96 ml, oral intake 26 min, drain removal, blood transfusions etc. The success rate for retroperitoneal approach were 115/120 (95%). Conclusion: To conclude Laparoscopic nephrectomy should be considered the 1st line treatment option for all simple nephrectomies. we prefer retroperitoneal route with shorter operative time, less dissection needed, direct access to renal vessels, decreased risk of visceral injury and early commencement of oral feeds.

   UMV 05: Safety and efficacy of superior calyceal access versus inferior calyceal access for pelvic and lower calceal stones Top

A. Mohan, A. Chawla

Kasturba Medical College, Manipal, Karnataka, India

Introduction: Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large renal stones. The success of PCNL is highly related to optimal renal access. Two approaches are commonly employed to gain access to the stones located in the pelvis and lower calyx which consist of superior calyx approach or inferior calyx approach. Superior calyceal puncture being more difficult and more demanding have relatively few studies presented. Aims and Objectives: This prospective study was carried out to evaluate the effectiveness and safety of superior calyceal versus inferior calyceal puncture for the removal of pelvic and lower calyceal stones. Materials and Methods: A total of 126 patients underwent PCNL for stones in pelvis and lower calyx were studied. Sixty three of them underwent inferior calyceal, while 63 underwent superior calyceal puncture. The two approaches were compared as per total duration of surgery, intraoperative blood loss, infundibular/pelvic tear, rate of complete clearance and rate of postoperative complications (pulmonary, bleeding, fever and sepsis). Results: In our study, the success rate was 65.54% for those in the Inferior, 78.95% for those in the superior calyceal access group. Thoracic complications (hydrothorax) occurred to 1 patient in superior calyceal access group. Bleeding requiring blood transfusion happened to 8 patients in inferior calyceal access and 1 in superior calyceal group. Conclusion: We conclude that superior calyceal puncture is a feasible option minimizing lung/pleural rupture and gives a better clearance rate. We suggest that there should not be any hesitation for superior calyceal puncture in indicated patients.

   UMV 06: Use of rigid nephroscope in open pyelolithotomy in the PCNL era – A video presentation Top

Nagesh Kamat, Saurabh Jambu, Arnav Kamat

Kamat Kidney and Eye Hospital, Vadodara, Gujarat, India

Introduction: We describe our experience of using a rigid nephroscopes for extracting inaccessible calculi during open pyelolithotomy. Materials and Methods: (1) A 28 year patient with a single kidney with a complex partial staghorn calculus, extending from a long, deep inferior calyx was planned for open pyelolithotomy. Intra operatively, due to an intra renal pelvis, exposure of the calyces was very poor. As a bail out procedure, a mini nephroscope was introduced and the stones were cleared, with use of pneumatic lithotripsy included. (2) A post bariatric surgery patient with poor cardiac function preventing prone positioning and PCNL, was taken for open pyelolithotomy. Severe periureteric and perinephric adhesions did not allow optimal exposure of the calyces. Both standard and mini nephroscopes were used to clear the calculi. Results and Discussion: In both the patients, the stone clearance was good and there were no residual fragments. There were no damage to the pelvis or the parenchyma due to insertion of the nephroscope. Traditional instruments used in the pre PCNL era included the Leadbetter nephroscope for open surgery nephroscopy, but this instrumentation is rarely available nowadays. Standard and mini nephroscopes can be used with relative ease. Entry to certain anterior calyces could be difficult or impossible. A flexible nephroscope could be used, and entry into certain calyces would be possible but retrival of calculi fragments would be faster with the rigid nephroscope. Conclusion: We present our experience of intra operative rigid nephroscopy in open pyelolithotomy.

   UMV 07: Robotic uretero-ureterostomy for proximal ureteric stricture in adult: A new add in robotic armmammentarium Top

Sanjay Parashar, Saurabh Chipde, Vinayak Vajpayee, Jaisukh Kalathia, Udit Mishra, Anurag Tyagi, Shweta Arora

SAIMS, Indore, Madhya Pradesh, India

Introduction: Ureteric stricture is a complication of ureteroscopy with incidence ranges from 0.5- 3.5%. This data increases with use of dormia basket for impacted stones extraction. Objective of this case study is to demonstrate that Robotic technology is one of the alternative for dealing with such cases. Materials and Methods: A 35 yr old male reported with left 1.9 cm upper ureteric stricture, at L-4 level with moderate hydronephrosis. Patient underwent Left ureteroscopic stone extraction, 9 month ago. Dormia stone basket entrapment injury happened during stone extraction, open ureteric repair done over double j stent. In follow up patient has to undergo re stenting thrice, whenever stent was removed because of acute loin pain. Patient diagnosed as a case of proximal ureteric stricture and posted for robotic ureteroureterostomy. Patient was placed in 60° flank position with the ipsilateral arm positioned on the side of the patient. Five ports were placed in a straight line configuration lateral to the rectus muscle and the robot was docked. After colonic mobilization ureterolysis was done strictured segment recognised and excised After spatulation of ureteric ends ureteric anastomosis was done with interrupted sutures over double j stent. Results: Patient withstood the procedure well without any complications. Operative time- 5 hours including console time Estimated Blood loss- 70 ml, drain removed after 3 days. Patient was discharged after 5 days the Double j stent removal was done after 6 weeks. Patient is asymptomatic in his follow-up of 6 months post operative renal us scan on fourthmonth is showing subsidence of ureteropelvic dilatation. Conclusion: Robotic ureteroureterostomy is a feasible and safe surgical option for the proximal ureteric stricture repair.

   UMV 08: Robotic assisted surgeries pelvic surgery in obese patients Top

M. Gopichand, Shantivardhan, Kalyan Chinibilli, Vinay, T. Neil, Upendra, P. Arvind, Francis

KIMS Hospital, Secunderabad, Telangana, India

Background and Objectives: The purpose of this study was to present strategies for performing robotic assisted pelvic surgery in the morbidly obese patient. Methods: This was a prospective, institutional review, descriptive feasibility study conducted at a tertiary hospital. Seven morbidly obese patients with a body mass index of 40 kg/m2 or greater were selected to undergo robotic-assisted surgeries. Robotic-assisted pelvic surgery like vesicovaginal repair, ureterovaginal fistula repair, robotic radical prostatectomy were done. Results: The median estimated blood loss was 250. The mean length of stay in the hospital was 5 days and the complication rate was 0%. The rate of conversion to laparotomy was nil. The median surgical time was 210 minutes. Conclusion: Robotic-assisted surgeries is a safe and effective method of performing pelvic in select morbidly obese patients, allowing them the opportunity to undergo minimally invasive surgery without increased perioperative complications.

   Unmoderated Poster Session Top

   UMP 01: Ureterectomy in a female child with ectopic ureter with a single system- presenting as an ureteric abscess post nephrectomy: A case report Top

Ajit Patel, Hemant Pathak, Mukund Andankar, Amit Sharma, Tarun Jain

Topiwala National Medical College, Mumbai, Maharashtra, India

The incidence of ectopic ureter is 1 in 1900 in pediatric age group. 80 % are associated with a duplex collecting system. In females the upper moeity generally opens in the urethra or the vestibule distal to the external sphincter. Prenatal diagnosis is possible via ultrasound. Numerous cases with duplex collecting system which were managed by upper pole nephrectoureterctomy are there in past literature. We hereby present a case report for ureterectomy done for ureteric abscess in case of single ectopic ureter. 4 month old female child antenatally diagnosed to have hydronephrosis presented with fever with chills. Dtpa scan was suggestive of nonunctioning kidney. Left sided pcn gram was done which had minimal output. Intraop pcn gram was suggestive of ectopic ureter with opening into urethra. Left nephrectomy was done. Patient recovered well and was discharged. After 14 months child presented with fever, tenderness, warmth and swelling just below the left flank incision. Ultrasonography was suggestive of abscess in the retroperitoneal periureteric region 62 x 50 mm size extending into the muscular plane. Ct was suggestive of tortuous ureter with periureteric collection and internal echoes. Ureteroscopy revealed ectopic ureteral opening in urethra with scope not negotiable beyond distal ureter. Incision and drainage of the subcutaneous abscess with interval left ureterectomy was done. Patient had uneventful post op recovery. Single ectopic ureters can present as a diagnostic dilemma which may require urecterectomy in addition to nephrectomy.

   UMP 02: Genitourinary tuberculosis – The biggest masquerader Top

Bharath Kumar Nagarajan, Irshad A. Khan

Base Hospital, Delhi Cantonment, New Delhi, India

Introduction and Objective: Genitourinary tuberculosis (GUTB) is the second most common extrapulmonary tuberculosis. Despite all the technological advancements, the diagnosis of tuberculosis remains clinical mostly. We present a case of delayed diagnosis of GUTB and its attendant complications. Methods: A 33 years old male had presented elsewhere in 2013 with recurrent urinary tract infection. Investigations revealed non obstructive bilateral hydronephrosis with no vesicoureteric reflux (VUR). Cystoscopy did not reveal organic bladder outlet obstruction. Urodynamic study was suggestive of small capacity poorly compliant bladder. Patient was diagnosed as non-neurogenic dysfunctional voiding and managed with alpha-blockers and antimuscarinics. Later patient developed subacute intestinal obstruction in October 2016, was diagnosed as abdominal tuberculosis and started on antituberculous treatment. During follow-up in May 2017, serum creatinine was 1.5 mg/dl; imaging revealed bilateral hydroureteronephrosis with marked cortical thinning and a complex cystic lesion in rectovesical pouch. Diuretic renography revealed a non-functional left kidney and hydronephrosis of right kidney with subnormal cortical function. Cystoscopy, retrograde pyelography and cystogram revealed small capacity bladder with patulous right ureteric orifice, obliterated left ureteric orifice and grade 5 passive VUR on right side. Results: Patient underwent Laparotomy, adhesiolysis of the extensive small bowel adhesions, drainage of pus from rectovesical pouch and bladder augmentation of thimble bladder. Postoperative recovery was uneventful and presently patient is on clean intermittent catheterization with a bladder capacity of 300 ml. Conclusion: GUTB has remained one of the greatest imitations of all times. A very high clinical suspicion is required to promptly diagnose and treat GUTB, thus avoiding the myriad complications.

   UMP 03: Postoperative pancreatic fistula after left cytoreductive nephrectomy Top

Bharath Kumar Nagarajan, Sanjeev Tandon

Base Hospital, Delhi Cantonment, New Delhi, India

Introduction and Objective: Pancreatic injury during nephrectomy is a rare complication with a reported incidence of 2.1% in laparoscopic left radical nephrectomy. It has not been described in the setting of cytoreductive nephrectomy and we present one such case. Methods: A 61 years old male presented with gross, total, painless hematuria. Imaging revealed a large upper polar left renal mass with ill-defined fat planes with tail of pancreas, distal spleen and left adrenal gland, along with multiple bilateral lung nodules and mediastinal lymph nodes. Patient underwent left cytoreductive nephrectomy through flank approach and intraoperatively found to have a large upper polar left renal mass, closely abutting the tail of pancreas. Results: On 5th postoperative day, there was spontaneous expulsion of the retroperitoneal drain, two days after which patient developed serous discharge of about 25-30 ml per day from the drain site which later became purulent associated with high grade fever. Imaging revealed bulky tail of pancreas and fluid collection in the surgical bed tracking down to drain site. Drain fluid amylase and lipase were raised and culture grew Pseudomonas. Patient was managed with pigtail drainage of the collection, culture sensitive antibiotics and subcutaneous injection of octreotide. Patient improved gradually and drain was removed on 80th postoperative day with no adverse events. Conclusion: Conservative management of postoperative pancreatic fistula after nephrectomy in the form of drainage of retroperitoneal collection, antibiotics, somatostatin analogues, discontinuing oral diet and total parenteral nutrition is successful in 30-50% of cases. Intervention in the form of endoscopic sphincterectomy, prosthetic restoration of Wirsung's duct, fistulojejunostomy or resection of tail of pancreas is required in recalcitrant cases.

   UMP 04: Forgotten ureteral stents: Single stage management Top

Puneet Aggarwal

Command Hospital, Kolkata, West Bengal, India

Introduction and Objectives: Ureteral stents are an integral part of urological practice. However, stents that migrate, fragment or are forgotten pose a management and legal dilemma and often require multiple procedures for removal of these retained ureteral stents. We present our series of retained ureteral stents which were successfully managed. Methods: Our series consists of 5 patients with duration of forgotten stents varying from 1 yr to 7 yrs. Of the forgotten stents 2 (40%) were calcified, 1 (20%) were fragmented, and 2 (40%) were non-calcified. Procedures to render the patient stent-free were cystoscopic laser lithotripsy, ureteroscopy and percutaneous nephrolithotomy 2 (40%), ureteroscopy and percutaneous nephroscopy in 1 (20%) and cystoscopic double J stent removal in 2 (40%). Results: 3 patients had complex retained ureteral stent, 2 calcified and 1 fragmented. These patients were managed successfully with single sitting of procedure without any significant post-operative morbidity or mortality. Non-calcified retained ureteral stent managed successfully with cystoscopic removal. Conclusions: Forgotten ureteral stents can be managed successfully with single stage procedure. Stent registry and computer based reminder system can prevent such complications.

   UMP 05: Corellation between clinical outcome and residual prostatic weight ratio after transurethral resection of prostate for benign prostatic hyperplasia – A prospective study Top

V. Arul, K. Saravanan, Vezhavendhan

Madras Medical College, Chennai, Tamil Nadu, India

Background: The Aim of the study is to determine whether the residual prostatic weight ratio has an impact on the outcome following TURP for Benign Prostatic Hyperplasia. The outcome is measured in terms of subjective parameters like improvement in IPSS system score and quality of life score and also objective parameters like peak flow rate on non-invasive uroflowmetry. Methods: The study is conducted in the Institute of Urology for the period from June 2017 to May 2018. Clinical history, examination, basic blood and urine examinations were done. Transabdominal USG was done and prostate volume is found using the standard ellipsoid formula and further the prostatic weight is calculated. IPSS questionnaire & Quality of life Score was done to obtain the subjective assessment of the patient symptoms. Patients with moderate and severe symptoms were taken up for the surgery. Uroflowmetry parameters like PFR, Mean flow rate & Post voidal residual urine were recorded. During surgery resection time was noted. Dry weight of the resected prostatic chips was measured by an electronic weighing machine. The residual prostatic weight ratio is calculated. The study group is separated to RPWR<50% & RPWR>50%. Patients were followed up after one month. IPSS score and QOL index was calculated for all patients. Uroflowmetery is also done. Statistical analysis is done using SPSS software. Results: 100 patients were taken up for the study. Group 1 with RPWR < 50% had 65 patients. Group II with RPWR > 50% had 35 patients. Mean age of patients is 64.52 in group 1 and 64.78 in group 2. Conclusion: The amount of tissue resected have a positive correlation with the clinical outcome. When the residual weight is less than 50%, the improvement in IPSS scores and PFR, subjective and objective measures of outcome is significant.

   UMP 06: Conservative management of renal artery pseudoaneurysm following percutaneous nephrolithotomy Top

M. S. Faridi, R. Yadav, A. K. Sharma, V. Sharma

Rajiv Gandhi Super Speciality Hospital, New Delhi, India

Introduction and Objective: Percutaneous nephrolithotomy (PCNL) is a standard, safe, and efficient method for removing large renal calculi. Despite development of endourologic equipment, complications of the PCNL are still prevalent. The most important complication is haemorrhage. The haemorrhage may be either arterial or venous. Venous haemorrhage is usually treated conservatively whereas the arterial one might require trans arterial embolization. Methods: 24 years old male presented with intermittent Left flank pain. NCCT KUB showed left renal pelvic calculus of size 19.7 x 10.7 mm with multiple small calculi left mid and lower calyx and 10 x 8 mm calculus in left mid ureter. Left supine PCNL with URSL done. On post-operative day 10, patient presented with clot retention after an episode of frank haematuria. CT renal angiography was performed which showed 5.8 x 4.3 mm pseudoaneurysm arising from lobar branch of left postero-inferior segmental artery without active extravasation of contrast. Haemoglobin was 11.8 gm/dl. Results: Patient vitals were stable all through the period of admission. So, conservative treatment was done with close monitoring of vitals and haemoglobin. The haematuria settled spontaneously after 72 hours and repeat imaging showed resolution of the pseudoaneurysm. No further interventions were undertaken and at the four month follow-up visit, no further episodes of haematuria had occurred. Conclusion: In a patient with bleeding from a renal artery pseudoaneurysm who is hemodynamically stable without a life threatening degree of haemorrhage, a trial of watchful waiting under close observation may allow for cessation of the bleeding without intervention.

   UMP 07: Intraoperative ureter loss replaced by yang monti procedure Top

Avreen S. Shah

Dr. DY Patil Medical College and Hospital, Pune, Maharashtra, India

History: A 51 yr old female with complaints of pain lower abdomen and history of gradually increasing swelling in the abdomen for the past 1.5 months presented to surgery department. On examination she had a 15 cmx15 cm mass felt at the LIF, irregular, solid nontender, not mobile, extending to left lumbar and hypogastrium. Imaging: MRI was suggestive of Mesenchymal/Stromal tumor?? GIST of size 12x12 cm with mass effects on ureter causing hydronephrosis The patient was taken up for sigmoidectomy and tumor removal by surgery department, we (urology team) were given an intraoperative call that a length of ureter had to be removed while removing the tumor. On examining around 6-7 cm length of ureter was removed with approx. 3-4 cm of distal normal ureter preserved. Intraoperative decision of doing a yang Monti procedure for replacing the segment was done. 2 segments of ileum were taken, opened up longitudinally on antimesenteric border, stitched together, and then closed transversely to create an appropriate length tube which was to be used as a replacement of ureter. End to end anastomosis was done with a DJ Stent kept in situ Following the procedure, the patient is on follow up. Discussion: Yang monti is an effective method to substitute mid-ureter segments as compared to psoas hitch or boari flap which are the traditional methods for not so extensive ureter loss.

   UMP 08: Micropapillary variant of TCC in a young adult: A rare case report Top

Ghanghoria Ashish, T. P. Rajeev, Baruah Saumar Jyoti, Barua Sasanka Kumar, Bagchi Puskal Kumar, Sarma Debanga, Phukan Mandeep

Department of Urology, Gauhati Medical College and Hospital, Guwahati, Assam, India

Introduction: Micropapillary carcinoma (MPC) of urinary bladder is an uncommon variant of urothelial carcinoma with high metastatic potential. The presence of this component in bladder biopsies should make one vigilant about its aggressive behaviour. The incidence is only about 0.7% among bladder tumours. Around 500 cases of MPC of bladder have been reported in literature as a special variant since its first depiction by Amin et al (1994). MPC of the bladder occurs in elderly patients, mostly in men. Here we report a case of MPC in a young adult male. Methods: A 40-year-old man presented with macroscopic hematuria. Cystoscopy showed a multiple polyploidal mass over anterior, right lateral bladder wall upto neck. A transurethral biopsy of mass and prostatic urethra demonstrated a high-grade TCC. Laparoscopic cystoprostatectomy with pelvic lymph node dissection was performed. Microscopically, the malignant cells of irregular nuclear outline and high mitotic activity, were arranged in small papillary clusters lying in clear spaces. There was no extension beyond bladder wall and no lymphadenopathy was present. Conclusion: MPC of bladder is considered a rare variant of TCC. There is a biphasic pattern with high-grade components in the deeper portion which are likely to be missed in superficial biopsies. There is a high propensity towards lymph node metastasis. All these contribute towards aggressive behaviour. The presence of an MPC component in bladder biopsies should alert the urologists to this unusual but aggressive disease and deep-muscle biopsies should be recommended.

   UMP 09: Urothelial carcinoma presenting as gross hydronephrosis with secondary calculi: An unusual presentation Top

P. Niranjan Raj, Hariharasudhan Sekar, Sriram Krishnamoorthy, Natarajan Kumaresan

Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India

Background: Renal stones associated with Squamous cell carcinoma are a common phenomenon. Renal stones with Gross hydronephrosis with underlying urothelial malignancy are a rare occurrence. We present one such rare case of Urothelial carcinoma, masquerading as secondary pelvi ureteric obstruction with impacted renal calculi and gross hydronephrosis. Case Scenario: A 65-year-old hypertensive male presented initially with symptoms of obstructive LUTS and one episode of macroscopic hematuria. USG revealed multiple left renal calculi with Hydronephrosis and moderate prostatomegaly. Uroflow revealed obstructive pattern. Computed tomography scan picked up an abrupt narrowing of upper ureter at L3 – L4 level. TURP was done first in view of bothersome symptoms. DMSA scan done 4 weeks revealed a salvageable kidney with a split function of 18%. Patient underwent Left PCNL & Double J stenting. Pyeloplasty was not contemplated in view of secondary PUJ and edematous PUJ. Three weeks later he presented with fever, loin pain and gross Hydronephrosis. Nephrostomy drained frank pus. He subsequently underwent nephrectomy. Biopsy report was suggestive of urothelial carcinoma. Conclusion: Squamous differentialtion is a much more common association with renal stone disease. Urothelial cancers involving renal pelvis and ureter are extremely uncommon in such a setting. To the best of our knowledge, this is the first ever case to be reported in Indian Literature. This case is presented for its rarity. A high index of clinical suspicion is imperative for the clinicians to make an earlier diagnosis of such uncommon associations and offer them an appropriate treatment.

   UMP 10: Recurrent silent paraganglioma of urinary bladder: An extremely rare misdiagnosed clinical entity Top

Chirag Doshi, T. D. Girisha, R. Vijaya Kumar, D. Sachin, Raghavendra Kulkarni

JSS Medical College, Mysore, Karnataka, India

Introduction: Extra-adrenal phaechromocytoma are known as paragangliomas. Bladder paragangliomas are extremely rare tumours with an incidence of <0.06 % of all bladder tumours and accounting for less than 1% of all phaechromocytomas. The paraganglioma of the Urinary bladder are tumours of the Chromaffin tissue originating from the sympathetic innervations of the urinary bladder wall. Being functional in most cases they have characteristic presentation of hypertensive crisis and post micturition syncope. Case Report: Here we are presenting a case of one such silent paraganglioma in a 66 year old female who presented with single episode of hematuria without any symptoms of catecholamine excess. She had extra vesical recurrence of tumor after 1 year of trans-urethral resection of the primary tumor and underwent partial cystectomy and excision of the tumor. Conclusion: A silent presentation of a bladder paraganglioma is very unusual but quite dangerous as they are often misdiagnosed. The distinction of Paraganglioma from Urothelial Carcinoma is critical because of differences in clinical management. Life-long follow-up is necessary to detect late recurrences. There is no consensus about the frequency of these measures; however, we suggest that there should be at least an annual follow-up for these patients if they are asymptomatic or whenever clinically indicated.

   UMP 11: Unusual presentataion in metastatic ca bladder as skeletalmuscle involvement Top

Gopal Rathi, Subodh Shivde, J. Date, Patwardhan, Akhil, Akshay

Deenanath Mangeshkar Hospital, Pune, Maharashtra, India

High-grade papillary urothelial carcinoma usually invades the bladder wall, adjacent prostate, seminal vesicles, ureters, vagina, rectum, retroperitoneum, and regional lymph nodes. In advanced stages, it may disseminate to the liver, lungs, and bone marrow. On rare occasions, unusual metastatic foci like skin/heart/nail have been reported in few case reports. The incidence of urothelial carcinoma has increased with associated rise in variants of urothelial carcinoma and unusual metastatic foci. It is imperative that urologists and pathologists are aware of the unusual variants and unusual metastatic locations to expedite the diagnostic process. Hereby we report an unusual case of secondary involvement of thigh/gluteal muscles by urothelial carcinoma. we found this on retrospective evaluation of muscle disease which was suscpected to be polymyositis/muscle abcess. Patient had presentation of muscle stiffness, minimal lower urinary symptoms, difdiculty in walking and was under evaulation of hip pathology.

   UMP 12: Nephron sparing surgery for large extra renal angiomyolipoma in 1st trimester of pregnancy Top

Deepak Vamsi, Priyank Bijalwan, Appu Thomas

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Neoplasms are rare in pregnancy; they present a challenge because of the special considerations and implications in treatment. Renal angiomyolipoma [AML] is a rare tumor that can be either sporadic or found together with tuberous sclerosis or pulmonary lymphangioleiomyomatosis. Renal AML when present were mosly reported in 3rd trimester and very rarely reported in 1st trimester. These tumors are hormone sensitive and therefore tend to grow during pregnancy and their main complication is the risk of rupture resulting in sometimes torrential hemorrhage. Optimal management still remains an enigma owing to scarcity of cases reported in literature. We report a large AML in a 27 year old lady, who presented in the 1st trimester of pregnancy. Owing to the size and risk of life threatening hemorrhage and high chances of Intrauterine death during anaesthesia, it was decided to terminate pregnancy after discussing with obstetrician. Case was managed by nephron sparing surgery.

   UMP 13: Advanced penile carcinoma: Management, complications and it's outcome: A case report Top

Priyatosh Dey, R. K. Dey, S. Basu, R. K. Das, S. Mondal, S. K. Tewary, S. Das

R. G. KAR Medical College, Kolkata, West Bengal, India

Introduction: Penile cancer is an uncommon malignant tumor, accounting for less than 0.5% of all cancers. Unfortunately, its incidence continues to increase in parts of Asia. The prognosis of advanced penile carcinoma is poor, especially in patients with more than 2 inguinal LN metastases. Mortality markedly increases when pelvic LN metastasis develops. Case Report: 50 years old male patient presented with fungating ulceration and necrosis of penis and scrotum. Incision biopsy s/o well differentiated scc. As there is involvement the scrotal skin and bulbar urethra involvement, total penectomy with radical cystoprostatectomy and PNLD and ileal diversion was done and also scrotectomy with b/l orchidectomy. On POD6 bowel leak suspected, patient was re-operated and ileostomy was done but now there was increased drain output. After confirmation right uretero-ileal anastomosis leak with contrast study and drain creatinine, right pcn was done. Drain decrease gradually and taken out. B/L ILND was done, meanwhile vac dressing applied over perineal wound after POD25 and perineal wound contracted after 10 days of vac therapy. Patient was on follow-up for 6 months and doing well and received chemotherapy. Discussion: Resection of lesions and repair of large area skin defects can dramatically improve quality of life, especially, that of patients with locally advanced disease without distant metastasis. Conclusion: We recommend multimodality therapy, but in some cases surgery could be performed firstly to improve quality of life.

   UMP 14: Penile fracture after priapism due to sildenafil ingestion: Out of frying pan into the fire Top

Deepanshu Sharma, Manoj Kumar, Apul Goel, S. N. Sankhwar, B. P. Singh, Manmeet Singh

King George's Medical University, Lucknow, Uttar Pradesh, India

A 36-year-old man presented to our department with complaints of swelling, pain and deformed penis for 2 days. He had a history of 100 mg Sildenafil ingestion following which he sustained a prolonged erection that persisted even after sexual intercourse. He tried vigorous masturbation to relieve it but he failed. After all this exercise, while he was sleeping, his child mistakenly fell over his erect penis following which he developed sudden severe pain in his penis and lost tumescence. On examination, he had a swelling and ecchymosis on right posterolateral aspect of his penis. There was no haematuria or blood at meatus. On the basis of history and physical examination, a diagnosis of penile fracture was made. Ultrasound revealed a tear in lateral wall of right corpora cavernosa with a large haematoma. Patient was taken for emergency exploration. Intraoperatively, a defect of approximately 1 x 1 cm was visualised in lateral wall of right corpora cavernosa with a large overlying hematoma. Hematoma was evacuated and corporeal tear was repaired. Patient was followed up at 3 and 6 weeks. He sustained normal erections and there was no residual deformity. Penile fracture is a relatively rare condition, most frequently reported as a result of trauma during vigorous intercourse. Surgical repair, which was first done by Fetter and Gartman in 1936, is the most advocated treatment in this condition. PDE-5 inhibitors, which are nowhere described as a predisposing factor for penile fracture, proved to be one in this case.

   UMP 15: Kidney preservation in emphysematous pyelonephritis in 10 cases Top

Omar Salim Akhtar, Masood Tanvir Bhat, Syed Sajjad Nazir, Tanveer Iqbal, Mir Imran, Shahnawaz

Super Speciality Hospital, GMC, Srinagar, Jammu and Kashmir, India

Introduction: Emphysematous pyelonephritis (EPN) is a severe, necrotising infection characterised by the presence of gas in the renal parenchyma. Earlier, emergent nephrectomy was the treatment of choice depending on the grade of EPN and state of the patient. We present a case series of 5 patients of Grade 3 and Grade 4 EPN (Huang criteria) in whom the kidney was preserved. Methods: Patients who presented between March and June 2018 at a single hospital, who had EPN Grade 3 and above, who were diagnosed as having gas in the parenchyma of the kidney (EPN) radiologically, and whose kidneys were preserved were included in the study. Results: A total of 5 patients made the criteria. All were female and diabetic. The presenting symptoms were fever (100%), pain in the flank (100%), and dysuria (80%). Grade 4 EPN was present in 2 (40%), making a total of 7 kidneys. One patient (20%) required a perinephric drain for a collection. Two (40%) required ureteral stenting. All pateints were treated by broad-spectrum antibiotics before culture-specific antibiotics could be started. Glycemic control was initiated. All patients survived and were discharged to follow-up. At mean follow-up for 4 weeks, all patients were doing well. Complete radiological resolution was demonstrated in 4/5 (80%) patients through CT scan. Discussion: Due to the wide availability of broad-spectrum antibiotics, CT scans, and intensive-care units, the conservative management of EPN can be done in selective cases. Kidney preservation should be a goal in most cases of EPN, considering that underlying diseases like Diabetes adversely impact kidney function in the long-run.

   UMP 16: Management of penile fracture and follow up at 6 months Top

A. Yevale, D. K. Jain

Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India

Introduction: Penile fracture is the traumatic rupture of the tunica albuginea of the corpora cavernosum resulting from increased intracavernous pressure The most common etiology of fracture of the shaft of the penis is trauma during sexual relations It could occur due to forceful manipulation, vigorous intercourse or masturbation, gunshot wounds, trauma that causes forcible bending of an erect penis Sporadic reports of penile injury give the impression that it is rare; however, it is likely under-reported or hidden due to social embarrassment. Methods: The patient was found to present with intense local pain. On history patient recalled hearing a cracking (pop-up) sound, followed by rapid detumescence of the erect penis. Hematoma, bruising, and deformity ('eggplant deformity') of the penis followed. A palpable tunical defect with a 'rolling sign' are usually considered pathognomonic features for this condition. Managing penile fracture involves immediate surgical exploration by degloving incision, evacuation of the haematoma, and repair of the rent of the tunica albuginea. Results: On 6 month follow up no unsatisfactory penile curvature, erection, stricture, fistula were noted. Conclusion: Penile fracture is a urological emergency necessitating prompt treatment. Although diagnosis is clinical, in occult injuries and concomitant uretheral; injuries, imaging modalities like USG, MRI and RGU play an important role. Surgical correction is the treatment of choice and concomitant uretheral injury should be diagnosed pre operative and repaired at the time of surgery It is important to remember that in cases of fracture of shaft of penis, early intervention gives better outcomes.

   UMP 17: Risk factors for urinary incontinence in patients undergoing holmium laser enucleation of prostate: Our experience with 50 patients Top

Sudipta Kumar Singh, Aashu Anshuman, Bahal Bandhan, Gupta Prashant, P. K. Sharma, S. N. Mandal

Calcutta National Medical College and Hospital, Kolkata, West Bengal, India

Purpose: To investigate the factors associated with the occurrence of urinary incontinence after holmium laser enucleation of the prostate (HoLEP). Urinary incontinence is defined as a patient complaint of urine leakage, regardless of the type. Materials and Methods: From January 2017 to May 2018, 50 patients treated with HoLEP for benign prostatic hyperplasia were enrolled. Information regarding age, prostate volume, Patients had either of these- stress incontinence, urge incontinence. Or mixed incontinence International Prostate Symptom Score, peak urinary flow rate, postvoid residual urine, and operation time was collected. Stastical analysis of data was done to look for the risk factors responsible for urinary incontinence after HoLEP. Results: Urinary incontinence after HoLEP occurred in 17 patients (34%), 13 patients of whom (77%) showed recovery within three months. Stress and urge urinary incontinence and postvoid dribbling occurred in 3 patients, 6 patients, and 8 patients, respectively. Age and total operation time were factors that significantly affecting the occurrence of urinary in continence. Conclusions: Age and total operation time were associated with the occurrence of postoperative incontinence. Prostate volume was not a determining factor for incontinence. We suggest that a decrease in the occurrence of postoperative incontinence is possible by considering age in preoperative candidate selection, and also by reducing the operation time based on the development of operative skills and know-how.

   UMP 18: Effect of drinking water composition in formation of renal stone: A retrospective study Top

Krishnendu Biswas, P. Sonawane, S. B. Sudharsan, A. Ganpule, R. B. Sabnis, M. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Purpose: Urolithiasis is a worldwide common problem and intake of adequate drinking water is the frequent advice of all treating physicians. Impact of drinking water composition in renal stone formation is a matter of debate in literature. Our study aims to address this issue to resolve to a more definitive inference. Materials and Methods: Data collected retrospectively from 30 consecutive renal stone follow-up patients, with respect to the stone composition, 24-hour urinary metabolite analysis and physicochemical analysis of the drinking water consumed daily since last 5 years. These parameters were analysed to find out any association between drinking water composition with renal stone formation. Results: Average age of stone formers is 40.8 years (range 20 to 58 years) with male to female ration 3:2. Calcium oxalate stones (71%) are the most common stones; however staghorn stones are common in females. Of the stone formers, 16 patients (53%) consumes soft or slightly hard water and 14 patients (47%) consumes moderate to very hard water. 66.6% and 80 % of the patients have low magnesium (< 30 mg/dl) and low calcium (< 75 mg/dl) level respectively in their drinking water. Overall 46.6 % patients have hypomagnesuria (< 75 mg/day) and 40 % of low magnesium water consumers have hypomagnesuria. Conclusion: Drinking water composition, particularly hardness of water does not have significant impact in stone formation. Low magnesium and low calcium level in drinking water may facilitate stone formation (particularly oxalate stones); however larger population multicentric study is required for validation.

   UMP 19: Disseminated mucormycosis: Is it always fatal? Top

Amit Agrawal, Deepak Kumar, S. Tripathy, T. Murari

Command Hospital, Pune, Maharashtra, India

Introduction: Mucormycosis is any fungal infection caused by fungi in the order Mucorales. The disease is often characterized by hyphae growing in and around blood vessels and can be potentially life-threatening in immunocompromised individuals. We present such a rare case who had a successful outcome. Case Report: This 60 year old diabetic was admitted with poorly controlled diabetes along with fever and cough along with progressive dyspnoea. Initially was suspected to have Pulmonary TB and was started on ATT. However during the hospital stay developed DKA and suspected Pulmonary embolism. While being managed for the same also developed AKI. A CT scan abdomen and chest revealed a Pulmonary fusiform aneurysms in apical segments of LLL and Rt lateral basal segment, Enlarged Lt Kidney with large perinephric collection, dilatation of PCS, proximal ureter with large non-enhancing area ?Infarct. FNAC from the kidney and the lung lesions confirmed disseminated Mucormycosis. He was started on antifungals to which the response was poor. A nephrectomy was then done to reduce the mucour load and surprisingly the patient responded to the surgery and with continued anti-fungals the lung lesions started regressing. Presently the patient has been discharged from the hospital and is on regular follow up. Discussion: Disseminated mucormycosis is often diagnosed late and is associated with high mortality. Management is prolonged and frustrating at times. Options have to be weighed against the risks. In our case, a thorough assessment and aggressive management resulted in a successful outcome.

   UMP 20: Prostatic urethral transitional cell carcinoma: A case report Top

R. S. Batra, S. L. Paul, M. A. Rajput, S. Saikia, S. K. Singhania, P. M. Deka

Dispur Hospitals Pvt. Ltd., Guwahati, Assam, India

Introduction: Transitional cell carcinoma (TCC) is a multifocal disease of the urinary tract that can also involve the prostatic urethra (PU). The exact incidence of primary involvement of the PU in patients with TCC is not well known. Bladder TCC may involve the prostate which may include urethral mucosa, ducts, acini, and stroma of the gland, which has been shown to affect the outcome. Risk factors for superficial urothelial cancer in the PU are high-grade, multifocal bladder TCC and presence of carcinoma in situ (CIS) in the bladder. Case Report: We report a case of a 65 year male patient, heavy smoker who presented to us with three episodes of terminal hematuria. Cystoscopy revealed a large papillary growth in the prostatic urethra. Resection of the lesion and biopsy showed low grade papillary TCC with deep chips showing presence of tumour cells. Completion resection was done in the form of TURP which did not show any residual malignancy. Patient was given BCG immunotherapy and is on follow up without any recurrence. Discussion: Visible tumors of PU are easy to detect and resect but controversy exists regarding the optimal technique to treat prostatic urethral TCC. Currently, there is increasing recognition of conservative treatment options with intravesical agents like intravesical bacillus Calmette-Guerin (BCG) if there is superficial involvement of the PU. In high-risk patients or patients with prostatic stromal involvement, cystoprostatectomy is recommended.

   UMP 21: Bilateral renal oncocytosis – A clinical surprise Top

R. Shree Vishnu Siddarth, Appu Thomas

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Oncocytomas are benign renal neoplasms that are typically unilateral and single. Multiple and bilateral oncocytomas are rare and can have genetic association. We present a case of incidentally detected multiple large bilateral oncocytomas. A 69 year old woman was evaluated for right loin pain with associated generalised weakness and loss of appetite. Physical examination revealed bilateral loin masses which were ballotable. CECT revealed bilateral heterogenously enhancing 9 cm mass lesions in the kidneys. Biopsy on the left kidney was suggestive of renal oncocytoma. Oncocytomas are benign neoplasms that are often asymptomatic and diagnosed incidentally on imaging. They are rarely bilateral and multifocal, but when present they can be a part of genetic syndrome with limited differential diagnosis that includes tuberous sclerosis and Birt-Hogg-Dube syndrome. A coexisting renal cell carcinoma or a hybrid tumour can be present in some patients. The management of these patients include nephron-sparing partial nephrectomy in addition to close surveillance.

   UMP 22: Results of ventral onlay BMG urethroplasty for bulbar strictures – A retroprospective, observational study Top

H. S. Harsha, Kumar Prabhu, Venkatesh Krishnamoorthy

NU Hospitals, Bengaluru, Karnataka, India

Introduction and Objectives: Urethral strictures most frequently occur at the bulbar urethra. When a bulbar stricture is encountered for the first time in a patient, a direct vision internal urethrotomy can be offered. When these patients want to be cured from their stricture disease, an operative approach has to be offered. It is probably better to offer this approach sooner than later. From a surgical point of view, less spongiofibrosis will be found and from an economical point of view, early surgery is probably more cost effective. Objective of the study is to assess the success rates of ventral onlay BMG urethroplasty for bulbar strictures. Methods: This is a retro-prospective, observational study. Retrospective arm was from May 2012 to May 2016 and Prospective arm from May 2016 to June 2017. Preoperative workup of Prospective cases will be done with urine analysis, urine culture, Ultrasound abdomen with pre and post void volumes, Uroflowmetry, Retrograde Urethrogram (RGU) and Micturating Cystourethrogram (MCU) in all cases. Post Foley removal uroflowmetry, USG for pre and post void volumes was done. Subsequent follow up visit at 2 weeks after Foley catheter removal for Urine culture if earlier urine culture was positive. Later visits at 3rd month, 6th month and 1 year for Uroflowmetry and urine analysis. If poor flow or UTI then patient will be evaluated with UFM, RGU, MCU or Cystoscopy. Then annual follow-ups. Results: 26 patients were included in the retrospective arm and 22 patients in prospective arm. In our series, most of the strictures were idiopathic. Patients ranged from 18 years to 78 years. There was mild pain (VAS was 5 or less) at the operative site in 30 (71.4%) patients but only 10 (23.8%) patients had pain (6 or more on VAS) needing additional analgesics. Pain was more in the donor site than at the perineal site. Bleeding from the donor area was seen in 3 (7.1%) patients, two were conservatively treated and one patient needed suturing under Local anaesthesia. The mean Q-max in the pre-op period was 5.7 ml/sec. The mean Q-max at 3 weeks, 3 months, 6 months, and at 1 year were 24.9 ml/sec, 22.7 ml/sec, 22.2 ml/sec and 21.21 ml/sec respectively. Failure of surgery, which was predefined as need for any additional procedures, was seen in two cases. Both patients had proximal anastomotic recurrence Post VIU both patients had good flow and their urine became sterile. The success rate of the study was 95.2%. Conclusion: The ventral onlay should be considered for bulbar strictures because the ventral approach involves minimal mobilisation of the urethra and gives better exposure to the stricture segment.

   UMP 23: Cystitits glandularis maquerading as urinary bladder neoplasm Top

Anand Apurva, Joshi S. Vinod, Rawoot Suhaib, Punatar Chirag

PD Hinduja National Hospital and Research Centre, Mumbai, Maharashtra, India

Background: Cystitis glandularis is a rare proliferative lesion of the bladder, usually caused by chronic irritation and inflammation. It is caused by the hyperplasia of the submucosa and proliferation of von brunn nests of the bladder. Though usually benign, it is considered to have some malignant potential. Our objective is to describe a case of cystitis glandularis in a 24-year-old male who presented as painless hematuria and was suspected to be bladder neoplasm on imaging. Methods: 24-year-old male, presented with difficulty in micturition, 2 episodes of hematuria. Laboratory investigation showed urine routine showed RBCs, with pyuria. Urine AFB was negative. Renal and coagulation test were normal. Abdominal ultrasound showed bilateral hydroureteronephrosis with urinary bladder mass covering both Vesico-ureteric junction. Contrast enhanced Computer tomography scan suggested 2.3*2*1.5 cm urinary bladder mass posterio-inferiorly. Neoplastic etiology was suspected but there was no peri-vesical spread. TUR of bladder mass was done which was reported as cystitis glandularis. Patient was started on Tablet wysolone and is currently on follow up. Follow up cystoscopy showed no evidence of any similar growth in the bladder. Results and Conclusions: Cystitis glandularis is a rare condition which can present with lower urinary tract symptoms or as simulating bladder carcinoma with painless haematuria. While investigating it should be kept in mind. Cystoscopy and biopsy is often diagnostic. Lesions require resection while those with symptoms of UTI can be managed medically. Oral steroid have played an important role in remission. Long-term follow-up is required because of the malignant potential.

   UMP 24: A simple triple marker test for predicting outcome of medical expulsive therapy for distal ureteric calculus Top

R. Vasantharaja, S. Darsan, R. Sunil, K. P. Nirmal, M. K. Manu, G. Venugopal

Department of Urology, Government Medical College, Thiruvananthapuram, Kerala, India

Introduction: Symptomatic ureteric stones cause surrounding inflammation and edema promoting obstruction. C-reactive protein (CRP), white blood cell (WBC) count and neutrophil percentage (NP) tend to rise after an inflammatory response. Factors predicting stone passage during medical expulsive therapy (MET) can help in decision making regarding early intervention decreasing morbidity. Here, we assessed the role of CRP, WC and NP in predicting success of MET. Methods: Patients with distal ureteric calculus of size 5-10 mm planned for MET were included in this prospective study. CRP, NP and WC were measured on day 1, 7 and 14 of MET. Serially monitored values were analyzed and correlated with stone passers. Results: 151 out of 192 patients (78.6%) passed stone after MET. Mean CRP values on day 1, 7 and 14 in stone passers were 3.13, 1.37 and 0.31 showing decreasing trend compared to non passers with decreasing trend but elevated values of 8.56, 7.04 and 6.88. Mean WC in stone passers were 7231, 6380 and 5942 compared to non passers with static but elevated values of 9814, 9554 and 9645. Similar to WC, mean NP values were 61, 56 and 53 in stone passers compared to non passers with values of 70, 70 and 71. Conclusions: Decision making regarding when and who to intervene with invasive procedures during the course of MET to avoid complications is still confusing. We conclude that low value at diagnosis and serial decrease in these markers during the course of MET implies that the stone is likely to pass.

   UMP 25: PSMA uptake in hepatocellular carcinoma Top

Sharwan Kumar, Venkatesh Kumar, Malik Abdul Rouf, Sharwan Kumar, Vaibhav Sood, Mahendra Kumar Sharma, Anshuman Agarwal

Indraprastha Apollo Hospital, New Delhi, India

68Ga-PSMA based integrated PET/MRI is emerging as a novel imaging technique for the staging of prostate carcinoma. We report a case of a 77-year-old man with raised prostate-specific antigen who presented to us for Glu-NH-CO-NH-Lys-(Ahx)-[68Ga-(HBED-CC)] (68Ga-PSMA) simultaneous PET/MRI scan for prostate cancer evaluation. A PSMA avid hepatic lesion on the background of cirrhotic liver was noted apart from PSMA avid lesion in the peripheral gland of the prostate. On histopathological examination, the hepatic lesion turned out to be hepatocellular carcinoma.

   UMP 26: Personal experience of laparoscopic management of retrocaval ureter Top

S. P. Yadav

Pushpanjali Hospital, Gurgaon, Haryana, India

Introduction: A retrocaval ureter is an unusual congenital anomaly that results in outer ureteral compression by the inferior vanacava. Though open pyelopyelostomy or ureteroureterostomy procedures are the standard procedures, a laprocscopic technique is being used with the same good results with all advantages. Materials and Methods: A total of 5 patient underwent laparoscopic correction of retrocaval ureter by ureteroureterostomy from 1998 to 2018. 3 ports were used -10 mm umbilical camera port, two 5 mm ports in right mid–clavicular line. The retrocaval segment of ureter was mobilized and transposed anterior to the inferior vena cava. Follow up was done with IVP after 6 and 12 months. Results: All operations were completed laparoscopically without conversion to open surgery. The mean operative time was 70 mints. The blood loss was minimal. All patient achieved uneventful recovery. At a mean follow up of 12 months. Remarkable improvement in the renal drainage was observed. Conclusion: Laparoscopic ureteroureterostomy is safe and effective procedure and an excellent minimally invasive treatment option for retrocaval ureter.

   UMP 27: Uncommon presentation of renal cell carcinoma and its management Top

Rohit Kumar, T. K. Mandal, T. K. Majhi, S. Choudhury, S. Dhanuka, M. Mandal, P. Talukdar

Nilratan Sircar Medical College, Kolkata, West Bengal, India

Metastasis of Renal cell carcinoma (RCC) is uncommon to the brain. Brain metastases as the primary presentation of renal cell carcinoma are extremely rare. We present a case of renal cell carcinoma that was primarily manifested by right frontal lobe Space occupying lesion (SOL) with no other organ involvement and no past history of RCC. Patient was managed by right frontal craniotomy & excision of sol. Histopathology and Immunohistochemistry was suggestive of metastatic adenocarcinoma of renal origin. Patient was further evaluated and found to have Left renal sol, for that patient had undergone cytoreductive nephrectomy which came out to be clear cell RCC. Patient had been started with pazopanib & still on follow up of 6 month. Though brain metastasis in RCC is very rare primary presentation, it should be kept in mind as a differential diagnosis in a patient with sol in brain and it can be surgically managed.

   UMP 28: Iatrogenic ureterocolic fistula: A case report Top

T. Singh, S. Shah, P. Sahar, D. Pawar, A. Goel

B J Medical College, Ahmedabad, Gujarat, India

Introduction: Ureteroenteric fistula connects the ureter to the alimentary tract. Ureterocolic fistula is the most common type of ureteroenteric fistula. Etiologies include colorectal malignancy, post pelvic surgery, radiation therapy and spontaneous fistulas. Patients can present with abdominal or flank pain, hematuria, recurrent urinary tract infection, pneumaturia, fecaluria and diarrhea. Methods: We report a case of 38 year old female who underwent abdominal hysterectomy for dysfunctional uterine bleeding and then came to our institution with complains of left abdominal pain and altered bowel habbits. Ultrasonography was suggestive of left moderate hydronephrosis. We had decided and tried ureteroscopy but due to complete block at lower ureter we have inserted left percutaneous nephrostomy. Diagnostic investigations were suggestive of distal ureter seen communicating with sigmoid colon through irregular tract opening in anteriolateral wall of rectum on Left Side suggestive of Ureterocolic fistula. Patient undervent Laparoscopic left ureteric reimplantation with primary closure of the sigmoid colon. Intraoperative and immediate post operative course was uneventful. DJ stent was removed after 2 months. Results: patient is now on regular follow up with no complains at present with normal bowel and bladder habbits. Conclusion: Ureterocolic fistulas are serious complications of pelvic surgery presenting with non specific signs and symptoms. Early diagnosis with divertion and meticulous surgery is necessary for correction of the condition.

   UMP 29: RIRS in calyceal diverticulum stone Top

S. K. Ranjith Kumar, S. M. Kumar

Kumar and PPK Hospital, Kanyakumari, Tamil Nadu, India

Introduction: Calyceal diverticula are rare outpouchings of the upper collecting system that likely have a congenital origin. Stones can be found in up to 50% of calyceal diverticula, 96% of patients presented with stones. Diagnosis is best made by intravenous urography or computed tomography urogram. Methods: 30 yrs old male with Left loin pain since 2 yrs, on and off. CT diagnosed as Left Renal Upper calyceal diverticular stone of 1 cm. Patient underwent RIRS with Laser Incision and fulguration with fragmentation of stone. Post operatively, patient improved well. Results: RIRS with LASER is best option for Calyceal Diverticular stone. Drawbacks to RIRS include difficulty in identifying the ostium. Conclusion: Percutaneous nephrolithotomy remains effective in the management of upperpole diverticula. Recently, a strong trend towards endoscopical (RIRS) treatment in renal abnormalities such as calyceal diverticula is growing. RIRS is best suited for management of anteriorly located mid- to upperpole diverticular stones easily and more safer.

   UMP 30: Adenocarcinoma of seminal vesicle Top

K. N. Kishore

AIMS, Kochi, Kerala, India

Primary malignancy arising from seminal vesicle is very rare, so much so that only around 100 cases have been reported so far. Here i am presenting one such case, a 63 year old gentleman who presented with severe LUTS to our OPD. on examination found to have hard growth adjacent to prostate. He underwent TRUS guided biopsy which showed poorly differentiated adenocarcinoma arising from right seminal vesicle. on immuno-histochemistry it was found to be positive for CK7 and Negative for CK20, CD31, CD34, TTF1. Patient is planned for palliative Chemotherapy with or without radiotherapy.

   UMP 31: Massive rectal bleed after TRUS biopsy of prostate: Not a case for pressure Top

Pankaj Panwar, Helen Thursby, Wael Assad, Suranga Wijayarathna, Shuvro Roy-Choudhury, Herman S. Fernando

Royal Stoke University Hospital, UHNM, Stoke on Trent, UK

Introduction: Massive rectal bleed after TRUS biopsy is rare complication and only occasional case reports have been described. The bleeding is usually from rectal wall and can resolve with conservative measures. We report a unique case of massive rectal bleed after TRUS biopsy where the source of bleeding was from an iatrogenic AV fistula in the prostate. Case Summary: A 71 year gentleman with known history of pulmonary embolism on Apixaban (NOAC) underwent a TRUS biopsy of the prostate. The NOAC was stopped 48 hours before procedure, a total of 15 cores were taken (12 +3 from anterior aspect on right). The procedure was uncomplicated and the patient was discharged. He presented to the emergency department 5 days later with massive rectal bleeding and hypotension. After stabilising, he had a CT Angiogram of the pelvis which revealed an AV fistula in the prostate along the line of the biopsy track with evidence of active bleeding. He underwent an emergency angiography and embolization of the right inferior vesical artery which was feeding the 'pseudaneurysm' in the prostate gland. The procedure was successful and he was discharged after 48 hours. His histology unfortunately confirmed a Gleason 4+3=7 disease. Conclusions: Massive rectal bleeding after TRUS biopsy of prostate is an urological emergency. It is crucial to identify the source of bleeding as treatments are different. Whilst compression and endoscopic injection of adrenaline are options for rectal wall bleeding, angioembolisation is required for an AV fistula in the prostate.

   UMP 32: Penile gangrene – A rare complication of intravesical therapy with bacillus calmette guerin Top

Shekhar Baweja, M. K. Chhabra, Pradeep K. Sharma, Vikas Aggarwal

S. N. Medical College, Jodhpur, Rajasthan, India

Bacille Calmette Guerin (BCG) immunotherapy is widely used treatment for patients with non muscle invasive bladder cancer (high grade). This therapy may cause many side effects mainly due to local and systemic inflammatory effects. Serious systemic side effects are less frequent. Though there are many case reports published as complications of BCG immunotherapy but penile gangrene complication is very rare. We report a case of a 64 yr old male patient with non muscle invasive urothelial carcinoma who developed gangrene on his penis as a complication of intravesical BCG immunotherapy after 24 hours. He was treated initially with serial debridement and penile urethrostomy was made.

   UMP 33: Penile hanging with acute retention of urine: A case report on penile strangulation injury and its follow up with surgical reconstruction Top

Panda Sumit Kumar, F. Haque, R. K. Panda, S. Swain, G. P. Singh

SCB Medical College, Cuttack, Odisha, India

Introduction and Objectives: Entrapment or strangulation of the penis is a rare emergency that can lead to a wide range of vascular and mechanical injuries. The result may range from loss of part or whole of the penile tissue to urinary obstruction to erectile dysfunction or dyspareunia. The role of early surgical reconstruction to restore the maximum structural or functional integrity of penis as a rule, is highlighted in this case report. Case Presentation: A 7 year-old male presented with acute retention of urine, after 12 hours of abrupt penile constriction by a string tied to the distal penile shaft. On Examination there was partial avulsion of glans penis, with disruption and separation of urethra just proximal to the corona glandis. Associated penile edema with necrotic patches on glans penis was noted. Ultrasound Doppler of penis showed haematoma involed both corpora cavernosa and spongiosum with disruption of tunica albugenia of distal penile shaft from proximal part with extra albugenial extention of haematoma proximally. Methods Surgical Intervention: Gentle attempt of Foleys catheterization failed, and diversion suprapubic cystostomy was done. A dorsal slit with functional reconstruction of penis was done over an infant feeding tube as urethral stent and SPC maintained. Results: Patient followed up regularly, glans vascularity and vitality regained and the patient voided normally with good stream. He also has good erection on subsequent visits. Conclusion: Functional reconstruction of penis is an emergency and viable option if performed early on selected cases of severely strangulated and distal penile avulsion injuries.

   UMP 34: Holmium laser ureterotomy in a case of upper ureteric stricture Top

Bandhan Bahal, Prashant Gupta, Anshuman Aashu, Sudipta Kumar Singh, P. K. Sharma, S. N. Mandal

Calcutta National Medical College, Kolkata, West Bengal, India

Background and Objectives: Holmium laser has a short absorption depth and possesses good ablative and hemostatic properties. We performed ureterotomy using holmium laser in a case of upper ureteric stricture. Case Report: A 43 years old female presented with moderate left flank pain. Patient had a past history of left ureterorenoscopic lithotripsy. On evaluation patient was found to have short segment left upper ureteric stricture with proximal left hydroureteronephrosis with preserved renal function. The stricture was incised with holmium laser using a 365 ľm fiber, with an energy of 1 joule/pulse at the rate of 10 Hertz. After completion of incision ureter was catheterized with two 5.5 Fr/26 cm Double J stents. Double J stents were left in situ for 6 weeks. Results: The follow up imaging at 6 months showed resolution of the ureteric stricture. Conclusion: Holmium laser ureterotomy is an easy to perform, safe and effective procedure in the management of short segment ureteric strictures.

   UMP 35: Human urinary myiasis by psychoda albipennis: A case report and review of literature Top

Darshan Patel, R. K. Shimpi, K. Raval

Ruby Hall Clinic, Pune, Maharashtra, India

Human myiasis is defined as “the infestation of the tissue of living human with dipterous larvae”. A large number of fly species may cause urinary myiasis. Larvae of Fannia scalaris is the most frequent cause of urinary myiasis. Few cases of urinary myiasis were caused by larvae of P. albipennis worldwide. It had never been reported before in our region. Poor sanitation and unhygienic domestic environments, including adverse living conditions, overcrowding, poor ventilation, and inadequate sewage systems, create higher risks for urinary myiasis. We report on the first case of human urinary myiasis caused by Psychoda albipennis in India.

   UMP 36: Emphysematous pyelonephritis – A single center experience Top

K. Ravi Chandran, Manjunatha Gowda

JJM Medical College, Davanagere, Karnataka, India

Emphysematous pyelonephritis (EPN) is a life-threatening, fulminant, necrotizing upper urinary tract infection associated with gas within the kidney and/or perinephric space. With extensive use of ultrasound and computed tomography (CT) in the evaluation of patients with symptoms and signs of complicated urinary tract infections, more cases of EPN are being recognized and reported. Between June 2012 and October 2016, a total of 34 patients were admitted with emphysematous pyelonephrits. All the patients were studied with respect to the clinical features at presentation. Computerized tomography was done in all cases to confirm the diagnosis and for classification. All the patients were thoroughly investigated, and the risk factors (as proposed by Huang and Tseng) were evaluated. The patients were followed up for 6 weeks. Female to male ratio of 2:1. 90% of cases were associated with Diabetes mellitus. The most common presentation was Fever (100%), Renal angle tenderness (85%), Flank pain (60%), Dysuria (56%). Majority of cases were Class 3 Huang and Tseng classification. Most of cases were managed with IV antibiotics with DJ stenting. Mortality of 4 (11%). With early diagnosis, availability of more potent antibiotics and advances in critical care support systems, an increasing number of patients can be managed with conservative approaches along with DJ stenting/ Percutaneous nephrostomy.

   UMP 37: Characteristics and management of ureteral stump syndrome: Our experience and contemporary literature review Top

Krishnendu Biswas, S. Agarwala, S. B. Sudharsan, A. Singh, A. Ganpule, R. B. Sabnis, M. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Introduction: Ureteral Stump Syndrome (USS) is defined as recurrent flank pain, haematuria, urinary tract infection (UTI) in patients following nephrectomy with subtotal ureterectomy. Incidence of USS in literature is low (0.8-1%), hence diagnosis may be delayed in view of low suspicion. We share our experience of USS and try to characterise the key features and management of USS. Materials and Methods: Three patients with USS treated at out centre were retrospectively analysed for their clinical presentations, investigations and management done including follow up till date. Results: USS may present with variable clinical presentations. Case 1 had recurrent UTI with flank pain and abscess formation, case 2 had persistent haematuria and case 3 had non-healing uretero-cutaneous fistula. All patients underwent completion ureterectomy, 2 with laparoscopy and one with open surgical technique. On follow up all are free from signs and symptoms of USS. Conclusion: Post-nephrectomy persisting symptoms pertaining to the ipsilateral side should prompt investigations to diagnose USS. Correct diagnosis is the key to successful treatment. Both conventional open and minimal access surgical options are valid treatment options.

   UMP 38: Sporadic papillary renal cell carcinoma in a young female: A rare case report Top

A. Goel, S. Shah, A. Shah, A. Veerwal

BJ Medical College, Ahmedabad, Gujarat, India

Objective: Rare disease Introduction: Papillary renal cell carcinoma (PRCC) is a rare disease and is a carcinoma of the renal tubular epithelium, comprising only 10–15% of all renal cell carcinoma cases. The majority of cases occur in the sixth decade of life. PRCC rarely occurs before the fourth decade in the absence of family history. We describe a sporadic case of PRCC in a 18-year-old female without family history and no risk factors. Case Report: A 18-year-old female was admitted for Left Flank Pain for 3 months, Radiological studies revealed, 45x40 mm, mass at Left Lower Pole With Moderate Enhancement, and bilaterally normally excreting Kidneys. RENAL Nephrometry score was estimated to be 7p. She underwent Left Laparoscopic Partial Nephrectomy, Post operative course was uneventful, histologically the mass proved to be a papillary carcinoma with abundant psammoma bodies, surgical margin free of tumor, ISUP Grade 2, Stage pT1bNoMo. Conclusions: PRCC rarely occurs in the second decade of life and even then, most such early cases occur in family clusters, making this case a rare presentation which was managed laparoscopicaly.

   UMP 39: Mucinous transitional cell cancer of renal pelvis and ureter, a rare entity Top

Anshuman Aashu, Sudipta Kumar Singh, Prashant Gupta, Bandhan Bahal, P. K. Sharma, S. N. Mandal

Calcutta National Medical College, Kolkata, West Bengal, India

Introduction: Transitional cell cancer (TCC) is a tumour with various patterns and variants. TCC with abundant myxoid stroma is a newly described and extremely rare entity. This is a case of renal pelvic and ureteric mucinous TCC that presented atypically. Case Report: A 68 years man presented to us with dull-aching intermittent pain in the right flank for last 2 months. He had a history of gross total hematuria with passage of wormiform clots intermittently over the last 6 months. On evaluation, the ultrasonography of the abdomen showed an enlarged right kidney with multiple SOL with lobulated outline. There was no associated hydronephrosis and the rest of the scan was within normal limits. Contrast enhanced CT scan was performed which revealed a right renal pelvic and distal ureteric enhancing mass with hydroureteronephrosis. Right sided radical nephroureterectomy was performed after excluding urinary bladder tumour by cystoscopy. The histopathology revealed mucinous TCC of the renal pelvis and distal ureter with invasion into the renal parenchyma. Conclusion: Mucinous TCC maintains an immunophenotype characteristic of TCC and usually present with high stage disease. Only a few case series and reports are available in the literature and most of them had urinary bladder as the site of tumour. We here have presented this histopathology in a renal TCC that presented to us with a perinephric hematoma which makes it a still rarer entity.

   UMP 40: Unusual coexistence of right renal and right testicular mass Top

Vaibhav Sood

50 year old male presented with right scrotal mass, USG revealed mass in right testis and incidentally detected mass in right kidney. CT urography revealed 4*5*5 cm right lower pole mass. FDG PET reveal FDG vid lesion in right testis and spermatic cord with FDG non avid lesion in right kidney. Patient underwent right robotic radical nephrectomy with right high inguinal orchiectomy Histopathology revealed clear cell type of RCC of size 4 cm with stage pT1aNxMx. Orchiectomy specimen revealed high grade BCell Non Hodgkin Lymphoma consistent with diffuse large B cell lymphoma with direct infilteration into spermatic cord This is an interesting case of double malignancy where work up of one lead to detection of other and treatment of both can be done simultaneously.

   UMP 41: IS CT scan necessary for diagnosis of ureteric calculi? Top

Jain Anuj, Kadam Swapnil, Guru Nilesh, Patil Santosh, V. S. Kundargi, S. B. Patil

Shri B M Patil Medical College and Hospital, Vijayapur, Karnataka, India

Introduction: The incidence of stone disease is increasing in India and worldwide. Ureteric colic is a common emergency dealt by the urologist. X-RAY and Ultrasound KUB (kidneys, ureters and bladder) are primary investigations and Computed Tomogram KUB is the gold standard imaging investigation for establishing a diagnosis and guiding management, but its high cost and limited availability is a concern in India. Aims: 1. To assess accuracy of ULTRASOUND, X-RAY and CT KUB in diagnosing ureteric calculi. 2. To compare X-RAY and USG KUB with CT KUB. Materials and Methods: 398 patients admitted in urology department from June 2015 to June 2018 with ureteric calculus were included in the study. It's a prospective study. Diagnostic accuracy of X-RAY, USG and CT KUB was determined with sensitivity, specificity, positive predictive value. Results: 283 males and 115 females had ureteric calculus. In 222 cases calculus was present in lower ureter. 90 cases had mid ureteric calculus and in 95 cases calculus was present upper ureter. X-RAY KUB detected calculus in 266 cases. It had sensitivity of 66.83% and positive predictive value 100%. USG KUB detected calculus in 273 cases. It had sensitivity of 68.59%, positive predictive value 100%. The sensitivity of USG and X Ray KUB together was 83.67%. CT KUB had sensitivity of 100%. Conclusion: The CT will detect more lithiasis, but the combination of X-ray KUB and USG, with more efforts, will obtain similar practical results, with lower X-ray dose to the patient.

   UMP 42: Role of intraoperative culture of urine and stone during P.C.N.L to shorten antibiotic course Top

Amit Kumar, Gaurav Kalra, Suraj Hegde, T. P. Rajeev

K S Hegde Medical Academy, Nitte (Deemed to be University), Mangaluru, Karnataka, India

Introduction: There is wide variation in utilization of periprocedural antimicrobial prophylaxis, including inappropriate selection of agents, improper timing of administration, and excessive duration of prophylaxis. The injudicious use of antibiotics may result in the emergence of Extended Spectrum Beta Lactamases resistant strains. The purpose of this study is to evaluate and establish a short antibiotic course for P.C.N.L by performing an additional culture analysis of urine and stone during the procedure. Methods: Patients with negative preoperative urine culture were included in the study. The first dose of Ceftriaxone is given intravenously at the time of induction of anesthesia. During the procedure renal urine samples will be obtained by ureteric catheterization and sent for culture. The stone culture analysis done in all cases. Perioperative antibiotic continued till the culture report available (two more doses) and continued if infection present. Results: Total 167 patient with negative preoperative urine culture inducted from March 2017 to July 2018. 135 (80.8%) Intra Operative Renal Urine are culture negative and 32 (19.2%) culture positive. 135 (80.8%) Intra Operative Stone are culture negative and 32 (19.2%) culture positive. There is a significant number of bacterial nidus detection in P.C.N.L patients who are preoperatively sterile. Most of our patients are managed by 3 doses of antibiotics. Conclusion: Intraoperative stone and urine culture are a good tool in early detection of P.C.N.L sepsis, selection of antibiotics and in reducing the surgical morbidity.

   UMP 43: A case of right sided testicular carcinoma with bilateral inguinal lymphadenopathy Top

Hari Ram, Nisar Ahmed, Lokesh Sharma, Devendra Choudhary, Puneet Singh, R. G. Yadav, Rajeev Mathur

National Institute of Medical Sciences, Jaipur, Rajasthan, India

Germ cell tumors of the testis are the most common cancer in young men between the ages of 15 and 35 years. The most common his- to pathological types are seminoma with incidence of 30 - 60%; pure embryonal carcinoma 3 - 4%, although it include 40% of nonseminoma; 5-10% teratoma and 1% pure choriocarcinoma. We present a case of 41 year old male who came to our hospital with complaints of swelling over right scrotum and pain & swelling over the right inguinal region. We found bilateral enlarged inguinal lymph nodes. Evaluated with CECT Abdomen and Thorax suggestive of mass in rt testis with bilateral inguinal lymphadenopathy (rt >lt), aorta and IVC – normal, CT Thorax -normal The criteria for diagnosis includes presence of cellular smears exhibiting primitive pleomorphic disperse cells. Alfa fetoprotein and beta-HCG was raised. Biopsy confirmed the diagnosis and early treatment was given to the patient.

   UMP 44: Milky Urine…..Chyluria – An enigma: Case-series Top

P. S. Katti, V. S. Tomar, R. K. Saran, M. K. Chhabra

SN Medical College, Jodhpur, Rajasthan, India

Introduction and Objective: Whitish discolouration of urine is an embarrassing and perturbing ailment to patient. In endemic areas, people through word of mouth would be aware of the same where as in non-endemic, it is pretty distressing to the patient. Often classified as parasitic and non-parasitic, with parasitic being more common. Medical management is the main modality of treatment but at times can be fraught with poor outcomes. Methods: A retro-prospective study of patients who presented in the last 3 years with chyluria were included. All patients were thoroughly worked up with respect to demographic profile, severity of symptoms, associated symptomatology, general outlook, conservative and therapeutic management undertaken and their response. An attempt is made to assimilate all of this information for better understanding of the medical condition, its course, response to treatment and the effect it bears on patient's life. Results: Symptom duration cystoscopy medical treatment sclerotherapy complications 8 months Positive Failed Successful Nil 6 months Positive Failed Successful Nil 15 months Positive Successful Not required Nil 9 months Positive Failed Successful Nil 24 months Positive Failed Successful Nil. Conclusion: Chyluria remains a distressing and serious condition to the patient, which can be managed successfully with combination of conservative modality and retrograde intra-renal sclerotherapy. In safe hands sclerotherapy has excellent outcomes with no long term serious complications.

   UMP 45: Perineal angiomyxoma masquerading as a erectile corporeal body swelling Top

Subhajit Mandal, Arup Kumar Mandal, S. M. Ravimohan, G. S. Bora, S. K. Devana, Aditya Prakash Sharma, Shantanu Tyagi

PGIMER, Chandigarh, India

Introduction: Perineal angiomyxomas are extremely rare with around 150 reported cases till date. It has a strong female preponderance. Here we report a case of angiomyxoma of perineal region in a young male. Materials and Methods: A 44-year-old male presented with a gradually increasing painless swelling in the perineum which stiffens and becomes more prominent with erection of penis as well as on vigorous physical activity. On examination there was a firm, non tender, non pulsatile, irreducible, non compressible mass in the anterior perineal triangle on the left of the raphe. CEMRI revealed a T1 hypointense and markedly T2 hyperintense lesion (4.6 ×2.5 ×5 cm) almost in midline in relation to corpus spongiosum with ill defined fat planes with bulbospongiosus and ischiocavernosus suggestive of hemangioma or sarcoma. To differentiate between the two he underwent CEUS, which revealed solid tumour with no internal vascularity. A provisional diagnosis of neurofibroma was made. In view of diagnostic dilemma he underwent USG guided FNA which was suggestive of nerve sheath tumour. Patient underwent excision of the mass through midline perineal incision. Results: A well-encapsulated mass lying deep to left bulbospongiosus muscle with adhesion to corpora. Mass was completely excised. HPE of the resected specimen revealed angiomyxoma of the anterior perineal triangle positive for desmin, smooth muscle actin, muscle-specific actin and vimentin. At 3 months follow up patient is asymptomatic with no signs of reccurence. Conclusion: perineal angiomyxoma is a benign tumour where surgical excision is curative. In case of perineal swelling a differential diagnosis of angiomyxoma should be kept in mind.

   UMP 46: A by chance association of urinary bladder stone with adenocarcinoma of urinary bladder Top

Arshad Hasan, Praveen Kumar Yadav, Amiya Shankar Paul, Anunay Singh, Faizul Haque, Sabyasachi Panda, Gyan Prakash Singh

SCB Medical College and Hospital, Cuttack, Odisha, India

Introduction: Association of urinary tract stones and development of malignancy is well established. Bladder stones which are more common in males than females and are mainly made of calcium oxalate usually develops due to bladder outlet obstruction. Long standing and neglected bladder stones may cause bladder carcinoma by irritation or as a source of infection. Adeno carcinoma of the bladder is one of the rare neoplasm arisen from the urothelium of the bladder with pure glandular phenotype have several risk factors like exstrophy of bladder, schistosomiasis endemic area, chronic irritation, obstruction, cystocele and endometriosis. Methods: We present a case of 46 years male who admitted with intermittent gross hematuria. Investigation revealed cause of hematuria is bladder stone with big size bladder mass. Biopsy of mass shows high grade carcinoma. Radical cystectomy and ileal conduit was done as primary treatment modality. Histopathology report showed adeno carcinoma of bladder. Conclusion: This is unusual by chance association of a rare malignancy with stones but possibility should have been kept in mind.

   UMP 47: Matrix stones, a rare entity endengering renal health Top

C. S. Shah, P. J. Shah, P. D. Dholaria, S. M. Moteria, J. C. Amlani, V. D. Joshi

BT Savani Kidney Hospital, Rajkot, Gujarat, India

Introduction: Renal stones are composed of matrix protein which forms basic infrastructure over which stone form by calcification. In some individuals this protein structure fails to calcify due to unknown reasons leading to stones that have 65% matrix protein component rather than standard 2.5%. Matrix stones are amorphous and soft that take shape of pelvi-calyceal system. They are radiolucent but may have calcified center or peripheral rim. Materials and Methods: we report a series of five patients operated at our institute and found to have matrix stones. Three patients presented to us with obstructive uropathy and two with recurrent flank pain. On initial evaluation all were found to have radiolucent stone. Initial diversion included DJ stenting in one case, percutaneous nephrostomy in one case and DJ stent with perinephric drain (for perinephric collection) in one case. As defenative treatment all cases required PCNL during which soft amorphous material was retrieved from PCS in all cases. Material was sent for fungal culture and histopathology. All cases had sterile fungal culture and showed matrix like material on histopathology. All cases have been followed for 2 years. All are asymptomatic and no patient has recurrence. Conclusion: Matrix stones are rare variety of stones. They are radiolucent and difficult to diagnose preoperatively. High index of suspicion is required. Amorphous material should be differentiated from fungal bezoar. Treatment is stone removal followed by close follow-up.

   UMP 48: Priapism due to homocystenemia: Rare causation also needs evaluation Top

Sanjay Parashar, Saurabh Chipde, Vinayak Vajpayee, Jaisukh Kalathia, Udit Mishra, Anurag Tyagi, Shweta Arora

SAIMS, Indore, Madhya Pradesh, India

Introduction: Priapism is a urological emergency, factors responsible are idiopathic (46%), alcohol and drug abuse, trauma to perineum and spinal cord, sickle cell anaemia and hemoglobinopathies and pelvic malignancy. Purpose of this case study is emphasis on thorough evaluation of priapism including infrequent etiology like hyperhomocysteinemia. Materials and Methods: Case 1: A 31 year old patient visited to our department with sustained penile erection since last 6 days wth no history of sexual stimuli or trauma. Immediate distal shunt (Al-ghorab) was unsuccessful, proximal shunt (Quackels) achieved satisfactory detumescence. On thorough evaluation for the cause of priapism, only homocysteine level was found to be significantly raised (40.46 μmol /L). The patient was discharged on oral medicine (Vitamin B 12 and folic acid supplements) in follow up patient develops erectile dysfunction for that he was advised penile implant. Case 2: A 24 year old patient came to us with sustained penile erection since 12 hr. The penile Doppler was s/o reduced coronal flow, patient achieved detumescence with therapeutic corporal aspiration followed by local injection of phenylepherine. Patient developed 2 episodes of priapism within next 2 weeks and detumescence achieved by same measure. Patient investigations revealed raised homocysteine level (18.24 μmol/L). Patient kept on vitamin B 12 and folic acid supplements. Further follow-up was uneventful. Conclusion: Priapism being a emergent condition should be thoroughly evaluated even for the rare causes and should be timely intervened to avoid the unavoidable consequences of permanent erectile dysfunction.

   UMP 49: TCC of lower ureter with squamoid diffrentiation- unususal presentation Top

Gopal Rathi, Subodh Shivde, J. Date, P. Patwardhan, N. Akshay, Akhil Mane

Deenanath Mangeshkar Hospital, Pune, Maharashtra, India

Most of the tumors involving the upper urinary tract (renal pelvis and ureter) are urothelial tumors. These tumors are uncommon, representing only about 5% of urothelial tumors. Squamous cell carcinomas of the upper urinary tract are even less common, constituting 1-1.6% of all urothelial tumors. The overall survival of patients with this type of malignancy appears to be less than with transitional cell carcinoma. However, when corrected for lymph node status, patient survival appears to be comparable between the two conditions. We present a case of 65 yrs male presented with backache and found to have multiple lympahdenopathy involving cervical, retroperitoneal lymph nodes. Cervical lymph node biopsy showed metastatic squamous cell carcinoma. Investigated thoroughly to find primary but couldnt find site. So 6 cycles of chemotherpay given. On subsequent follow up, found to have right moderate hydronephrosis with hydroureter suspected due to lymph node obstruction. Ureteroscopy and rgp done and surprisingly found to have large lower ureteric vascular tumor having ball valve type obstruction in lower ureter. Subsequent patient undergone right nephreureterectomy with bladder cuff. Patient had high grade TCC with squamoid diffrentiation. patient was on subsequent follow up. This was very unusual presentation of this rare type of tumour of ureteric malignancy.

   UMP 50: Case report of a supranumerary kidney with double ureter presenting as urinary incontinence: A rare presentation Top

A. Kriplani, A. Chawla

KMC, Manipal, Karnataka, India

Introduction and Objectives: Supernumerary kidney with double ureter is one of the rarest entities of the urinary tract. Here we present a case of supernumerary kidney presenting as total incontinence of urine due to ectopic opening of the anomalous ureter. Case Report: 18 year female, presenting with continuous urinary leak since birth with no previous surgical history. On examination, urethral meatus was normal with an additional opening in between the urethral meatus and vaginal opening. On ultrasound examination both kidneys were normal size and echotexture. A 3x3 cm mass with a hypoechoic center was seen attached to the upper pole of the left kidney. CECT verified it as an additional kidney measuring 3 x 2.5 cm with a separate collecting system and blood supply, abutting the upper pole of left kidney. The separate, complete ureter of the supernumerary kidney was seen draining at a level distal to bladder. These findings were confirmed on MRI. Anomalous findings were confirmed on exploration. Antegrade methylene blue dye injection through the incised ureter of the supernumerary kidney confirmed the ectopic distal opening in the introitus. Patient underwent ureteroureterostomy with anastomoses of supranumerary ureter to the intact orthotopic ureter. A 4.5 F/26 cm DJ stent was inserted in orthotopic ureter which was removed after 6 weeks. Postoperatively patient was relieved of the urinary leak. Conclusions: A rare clinical presentation of supranumerary kidney as urinary leak through ectopic ureteric opening was evaluated thoroughly and managed meticulously leading to postoperative satisfaction.

   UMP 51: Ileal ureter substitution: A contemporary series Top

Raja Sekhar Guddeti, Arun Chawla

KMC, Manipal, Karnataka, India

Ileal substitution of the ureter is a complex procedure, considered a surgery of the last resort in ureteral repair and is useful in the presence of an extensive ureteral stricture. It is indicated in cases of long or multiple ureteral stenosis. There are few large studies in the literature reporting the outcome of this procedure. We present a case series of 14 patients who underwent ileal ureter substitution. Indications for ileal ureter were iatrogenic 6 patients (stricture -2, avulsion -3, failed Baori -1), genitourinary tuberculosis 4 patients, retroperitoneal fibrosis 3 patients and solitary kidney with ureteric TCC 1 patient. Patients were evaluated with IVU in 6 cases, CECT in 5 cases and with nephrostogram in 3 cases. Right ureter substitution done in 9 and left side substitution in 8. Ileal anastomosis done in isoperistaltic fashion in all patients. End to end ileoureteral anastomosis done in 11 and end to side in 3 patients. Cuff of bladder was removed and ileal-bladder anastomosis done in end to end fashion. All cases DJ stent was placed, 3 cases nephrostomy inserted. Post op was uneventful in 13 patients. Repeat surgery was done in 1 patient for proximal leak. Mean elevation of serum creatinine after the procedure of 0.6 mg/dl was noted. Progressive renal failure noted in 1 patient. 3 patients developed metabolic acidosis. In conclusion, ileal substitution is a reasonable option for long-term reconstruction with preserved renal function.

   UMP 52: Retroperitoneal ganglioneuroma mimicking right adrenal mass Top

A. S. Karthikeyan, R. Govindarajan, G. Sivasankar, P. Periasamy, A. Senthilvel, R. Jayaganesh

Kilpauk Medical College Hospital and Government Royapettah Hospital, Chennai, Tamil Nadu, India

Case Report: 21 yrs old Male admitted with c/o Upper abdominal pain – dull aching, non –radiating for 2 months. Physical examination did not reveal any signs. Patient then underwent CECT ABDOMEN and was found to have right adrenal mass lesion. MRI KUB revealed right adrenal mass engulfing anterior aspect of IVC. Patient was planned for right adrenalectomy and proceeded. Intraoperative Findings: Large multiloculated, solid mass occupying retrocaval and encasing ivc. densely adherent with ivc, posteriorly extending extending upto vertebra, mass encasing and lifting up ivc. Rt adrenal gland was normal. Their management involves total surgical excision when feasible however, in some instances; it can be challenging and demanding because of their tendency to engage neighboring vital anatomical structures. The prognosis is excellent for ganglioneuromas after surgical removal. After being completely excised, they do not usually recur. Conclusion: Surgical strategy including meticulous operative dissection guided by the quality principles of surgical oncology although challenging and demanding can result to a safe and complete tumor excision, which is directly correlated with an improved patient's postoperative outcome and excellent prognosis.



Print this article  Email this article


    Similar in PUBMED
    Article in PDF (656 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

    Brij Kishore Pat...
    BKP 01: Urogynec...
    BKP 02: Implemen...
    BKP 03: Exstroph...
    BKP 04: Intermit...
    BKP 05: Fluorosc...
    Chandigarh Best ...
    CBVP 01: Ambulat...
    CBVP 02: Stepwis...
    CBVP 03: Robotic...
    CBVP 04: Simulta...
    CBVP 05: Robot a...
    CBVP 06: Sapheno...
    CKP Menon Best P...
    CKP 01: Predicto...
    CKP 02: Associat...
    CKP 03: Urinary ...
    CKP 04: Is urofl...
    CKP 05: Study on...
    CKP 06: Obstruct...
    CKP 08: Role of ...
    CKP 09: Human pa...
    SS Bapat Prize P...
    INT 01: Tissue e...
    INT 02: Nephrosc...
    INT 03: Effect o...
    INT 04: Construc...
    INT 05: Pedicled...
    INT 06: Construc...
    Vijayawada Best ...
    VPP 01: A random...
    VPP 02: Will ret...
    VPP 03: Percutan...
    VPP 04: Individu...
    VPP 05: Future o...
    VPP 06: A warnin...
    VPP 07: Ureteric...
    VPP 08: Prostati...
    VPP 09: Novel te...
    VPP 10: Supraves...
    VPP 11: Diagnost...
    VPP 12: Patholog...
    VPP 13: Nerve sp...
    VPP 14: Are we j...
    VPP 15: Incidenc...
    VPP 16: Creatini...
    VPP 17: Renal al...
    VPP 18: Manageme...
    Podium Session 1...
    POD 01-01: The s...
    POD 01-02: Minip...
    POD 01-03: Asses...
    POD 01-04: Posit...
    POD 01-05: Does ...
    POD 01-06: Clini...
    Podium Session 2...
    POD 02-01: Urete...
    POD 02-02: Evalu...
    POD 02-03: Mini-...
    POD 02-04: Compa...
    POD 02-05: Dilem...
    POD 02-06: Percu...
    Podium Session 3...
    POD 03-01: The t...
    POD 03-02: Prosp...
    POD 03-03: Evalu...
    POD 03-04: Outco...
    POD 03-05: Hepar...
    Podium Session 4...
    POD 04-01: Dorsa...
    POD 04-02: Risk ...
    POD 04-03: Role ...
    POD 04-04: Use o...
    POD 04-05: Intra...
    POD 04-06: Techn...
    Podium Session 5...
    POD 05-01: Gata3...
    POD 05-02: Signi...
    POD 05-03: Signi...
    POD 05-04: Oncos...
    POD 05-05: Liqui...
    POD 05-06: Role ...
    Podium Session 6...
    POD 06-01: A com...
    POD 06-02: Signi...
    POD 06-03: A pro...
    POD 06-04: Non t...
    POD 06-05: Bioch...
    POD 06-06: Long-...
    Podium Session 7...
    POD 07-01: Chall...
    POD 07-02: Vesic...
    POD 07-03: Trans...
    Podium Session 8...
    POD 08-01: Sacra...
    POD 08-02: Exten...
    POD 08-03: Compa...
    POD 08-04: A lon...
    Podium Session 9...
    POD 09-01: Robot...
    POD 09-02: Skele...
    POD 09-03: Pedia...
    POD 09-04: Prosp...
    POD 09-05: Compa...
    Podium Session 1...
    POD 10-01: Prema...
    POD 10-02: Does ...
    POD 10-03: Folat...
    POD 10-04: Assoc...
    POD 10-05: Compa...
    POD 10-06: To st...
    Moderated Video ...
    MV 01-01: Techni...
    MV 01-02: Asopas...
    MV 01-03: Laparo...
    MV 01-04: Absent...
    MV 01-05: Laparo...
    MV 01-06: Laparo...
    Moderated Video ...
    MV 02-01: Robot ...
    MV 02-02: Laparo...
    MV 02-03: Roboti...
    MV 02-04: Laparo...
    MV 02-05: Use of...
    MV 02-06: Avoidi...
    Moderated Poster...
    MP 01-01: Evalua...
    MP 01-02: A dile...
    MP 01-03: An unu...
    MP 01-04: Is pro...
    MP 01-05: Our ex...
    MP 01-06: Metach...
    MP 01-07: Role o...
    MP 01-08: Role o...
    MP 01-09: Succes...
    MP 01-10: Ureter...
    MP 01-11: Staged...
    MP 01-12: Chylur...
    Moderated Poster...
    MP 02-01: Transp...
    MP 02-02: The pr...
    MP 02-03: Leydig...
    MP 02-04: Prospe...
    MP 02-05: Manage...
    MP 02-06: Renal ...
    MP 02-07: A rare...
    MP 02-08: Metast...
    MP 02-09: Lip me...
    MP 02-10: Perine...
    MP 02-11: Primar...
    MP 02-12: Outcom...
    Moderated Poster...
    MP 03-01: Use of...
    MP 03-02: Effect...
    MP 03-03: A rare...
    MP 03-04: Unusua...
    MP 03-05: A stud...
    MP 03-06: Prospe...
    MP 03-07: Compar...
    MP 03-08: Detrus...
    MP 03-09: Role o...
    MP 03-10: 46, XX...
    MP 03-11: Revisi...
    Moderated Poster...
    MP 04-01: Manage...
    MP 04-02: Transi...
    MP 04-03: Migrat...
    MP 04-04: A rare...
    MP 04-05: Recurr...
    MP 04-06: Role o...
    MP 04-07: An int...
    MP 04-08: Synovi...
    MP 04-09: Contin...
    MP 04-10: Roboti...
    MP 04-11: Primar...
    MP 04-12: Additi...
    Moderated Poster...
    MP 05-01: Extend...
    MP 05-02: Manage...
    MP 05-03: Recurr...
    MP 05-04: Record...
    MP 05-05: Modifi...
    MP 05-06: Paraur...
    MP 05-07: A case...
    MP 05-08: Muller...
    MP 05-09: Qualit...
    MP 05-10: Study ...
    MP 05-11: Combin...
    MP 05-12: Placen...
    Unmoderated Vide...
    UMV 01: Laparosc...
    UMV 02: Ueterosc...
    UMV 03: Isolated...
    UMV 04: Retroper...
    UMV 05: Safety a...
    UMV 06: Use of r...
    UMV 07: Robotic ...
    UMV 08: Robotic ...
    Unmoderated Post...
    UMP 01: Ureterec...
    UMP 02: Genitour...
    UMP 03: Postoper...
    UMP 04: Forgotte...
    UMP 05: Corellat...
    UMP 06: Conserva...
    UMP 07: Intraope...
    UMP 08: Micropap...
    UMP 09: Urotheli...
    UMP 10: Recurren...
    UMP 11: Unusual ...
    UMP 12: Nephron ...
    UMP 13: Advanced...
    UMP 14: Penile f...
    UMP 15: Kidney p...
    UMP 16: Manageme...
    UMP 17: Risk fac...
    UMP 18: Effect o...
    UMP 19: Dissemin...
    UMP 20: Prostati...
    UMP 21: Bilatera...
    UMP 22: Results ...
    UMP 23: Cystitit...
    UMP 24: A simple...
    UMP 25: PSMA upt...
    UMP 26: Personal...
    UMP 27: Uncommon...
    UMP 28: Iatrogen...
    UMP 29: RIRS in ...
    UMP 30: Adenocar...
    UMP 31: Massive ...
    UMP 32: Penile g...
    UMP 33: Penile h...
    UMP 34: Holmium ...
    UMP 35: Human ur...
    UMP 36: Emphysem...
    UMP 37: Characte...
    UMP 38: Sporadic...
    UMP 39: Mucinous...
    UMP 40: Unusual ...
    UMP 41: IS CT sc...
    UMP 42: Role of ...
    UMP 43: A case o...
    UMP 44: Milky Ur...
    UMP 45: Perineal...
    UMP 46: A by cha...
    UMP 47: Matrix s...
    UMP 48: Priapism...
    UMP 49: TCC of l...
    UMP 50: Case rep...
    UMP 51: Ileal ur...
    UMP 52: Retroper...

 Article Access Statistics
    PDF Downloaded62    
    Comments [Add]    

Recommend this journal