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Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 1-56

Abstracts - USICON 2020

Date of Web Publication23-Jan-2020

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How to cite this article:
. Abstracts - USICON 2020. Indian J Urol 2020;36, Suppl S1:1-56

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. Abstracts - USICON 2020. Indian J Urol [serial online] 2020 [cited 2020 Jun 1];36, Suppl S1:1-56. Available from:

   Brij Kishore Patna Prize Paper Session Top

   Pyeloplasty for pelviureteric junction obstruction in anomalous kidneys: An experience at tertiary care center Top

Kumar Lalit, Nayyar Rishi, Nayak Brusabhanu, Singh Prabhjot, Kumar Rajeev, Seth Amlesh

AIIMS, Delhi, India

Introduction: Pyeloplasty is gold standard method of surgical treatment for pelviureteric junction (PUJ) junction obstruction with good outcome. The presence of PUJ obstruction with other anatomical anomalies of the kidney is uncommon. The presence of difficult, unfamiliar and anomalous anatomy makes pyeloplasty challenging in these conditions. Materials and Methods: We conducted a retrospective review of pyeloplasty in patients with congenital anomalous kidneys at our national tertiary referral center. Sixteen patients who were planned for surgery for PUJ obstruction from December 2013 to June 2018 were included. Results: Sixteen cases were having anomalous kidneys consisting of horseshoe kidneys(HSK) in 9 patients, ectopic non-fused kidneys in 4 patients and ectopic fused pancake kidney, duplex kidney and malrotated kidney each in 1 patient. Mean follow up duration was 30 months (5-60months). Robotic approach was most commonly used in 8 patients followed by laparoscopic and open approach in 5 and 3 patients respectively. There were no intraoperative complication. Operative duration in open, laparoscopic and robotic approaches was 96mins, 97mins and 137mins while hospital stay was 5.33 days, 3.60 days and 4.37 days respectively. Clinical success was 100% in each group while radiological success were 100% in laparoscopic and robotic approach while 66.67% in open group. Conclusion: Pyeloplasty is feasible, effective and safe procedure even in complex cases of renal anatomic anomalies with pelviureteric junction obstruction. With increasing experience, minimal invasive techniques though technically demanding provides equivalent success rate with better cosmetic outcome and faster convalescence.

   Acellular tissue engineered pericardial patch urethroplasty: A new horizon of substitution urethroplasty Top

Choudhury Sunirmal, Roy Pinaki, Pal Dilip Kumar

SSKM and IPGMER Hospital, Kolkata, West Bengal, India

Introduction and Objectives: Substituion urethroplasty using buccal mucosal graft (BMG)is now considered as the treatment of choice for long segment anterior urethral stricture. Buccal mucosal graft harvesting causes considerable morbidity to patients and quality of buccal mucosa is also found to be poor in betel nut chewing males. Acellular tissue engineered pericardial patch (ATEPP) urethroplasty can provide a new option in this regard and such our objective is to use acellular tissue engineered pericardial patch (ATEPP) in patients undergoing substitution urethroplasty and to find the results in terms of success with follow-up. Materials and Methods: All patients of long segment anterior urethral stricture planned for substitution urethroplasty who are willing to give consent are included in the study. Sample size was ten patients. After ensuring sterile urine culture all patients had undergone ATEPP urethroplasty in lithotomy position in perineal approach. Urethral foley’s catheter was removed on 21stpost operative day. Results: Out of 10 patients, 8 (80%) have got successful outcome. Post operative maximal flow on uroflowmetry (Qmax) ranged from 15ml/sec to 22 ml/sec. Two patients have got failure due to wound infections. Conclusion: Our pilot study proved that a product of tissue engineering, already being used in the cardiovascular surgery domain, can be used in stricture urethra with satisfactory results using standard approach. This can be specially useful in betel nut chewing population with unhealthy gum and will appear as a new horizon of substitution urethroplasty.

   Role of restage transurethral resection of bladder tumour in high risk non muscle invasive bladder carcinoma Top

D. Desai, U. Sharma, H. Goel, S. Gehlawat, R. Sood

PGIMER and Dr. RMLH, New Delhi, India

Introduction: 75% of patients with bladder cancer present with non-muscle-invasive disease. Re-TURBT within 6 weeks of primary TURBT has been recommended for patients with high grade/T1 disease in guidelines quoting high incidences of tumour upstaging to T2 disease. However until now, no study in our country has investigated usefulness of a second TURBT. Materials and Methods: We conducted a prospective study between Sept-17 and June-19, including 250 consecutive patients undergoing re-TURBT for biopsy proven high risk NMIBC after complete TURBT. Histological upstaging of disease on re-TURBT were noted and correlated with preoperative factors. Results: Of 250 patients, 212 had deep muscle in primary specimen. Thirteen patients had upstaging of tumour to T2 disease on re-TURBT (5.2%). On re-TURBT 45 patients had a grossly visible recurrent growth. 9 out of the total of 13 upstaged cases belonged to the group who had “visible recurrent tumour†on repeat scopy (20%), whereas the remaining 4 recurrences were in patients who had no visible growth (only a 1.9% risk of upstaging). Maximum risk of upstaging (30%) was in the group which had no deep muscle included in original specimen, and who had a gross recurrent disease at re-TURBT. However, there was no correlation between other preoperative factors such as age, sex, duration of haematuria, smoking status, occupation etc with the risk of tumour upstage on re-TURBT. Conclusion: With more research we may be able to limit use of re-TURBT to carefully selected subgroups, thus avoiding another procedure under anaesthesia, reducing costs, hospital admissions and morbidity.

   Use of affordable 3D printed models in surgical planning, resident training and patient education in laparaoscopic partial nephrectomy cases: A new realm in developing countries Top

Anil Mani, Sanjay Kumar Sureka

Moulana Hospital, Perinthalmanna, Kerala, India

Introduction: To investigate the impact of three-dimensional printing on the surgical planning, potential of training and patients' comprehension of minimally invasive surgery for renal tumors. Materials and Methods: 3 patients with T1N0M0 single renal tumors and indicated for laparoscopic partial nephrectomies were selected. CT data was retrieved and was processed with open source online software to create 3D printable files after processing. 3 different models of each case were constructed with a 3D printer (costing <50 rupees per model) to delineate various anatomical relations. The models were presented to operating surgeons, residents and patient. The usefulness of the models was assessed by a scoring system. The scores were given in a range from 1 to 10. The size of resected tumors was also compared with that on the models. Results: Effectiveness in surgical planning and intraoperative correlation as scored by the operating surgeons and the assisting residents were 7.89 ± 0.19 and 8.83 ± 0.62 respectively. Patient and attendants were fascinated to precisely know about the details of the disease and the procedure and excited to get a tactile sensation of the disease while giving a score of 9.67 ± 0.58. Conclusions: Generating 3d models of kidneys is feasible and affordable. Anatomical relationship to the pelvicalyceal system and renal vessels can be well identified and the surgeons can preoperatively assess extent of the endophytic component. The tactile feeling of the disease can be exciting for the patients and may help better comprehend the disease and the nature of the procedure.

   Laparoscopic donor nephrectomy in vascular anamolies - How far can we go ? Is it feasible and safe? Top

Alagappan Chockalingam

Apollo Speciality Hospital, Tiruchirappalli, Tamil Nadu, India

Introduction and Objectives: Complex vasculature can be present in many of the potential donors, a finding that may preclude a candidate from donation in practice Also, the suitability of Laparoscopy for donors with vascular anomalies is still a matter of discussion and at times debate. We report our experience with Laparoscopic Donor Nephrectomy (LDN) in the setting of complex renal vasculature. Materials and Methods: Between Dec 2017 to Nov 2018, 25 LDN were performed in our Hospital. All donors were evaluated with preop three dimensional CT- angiography. 40% had Complex vasculature. All underwent LDN by Transperitoneal approach. Standard 4 port technique was used in left and 5 ports used in right side. Results and Observations: All cases done by Laparoscopy without any conversion to open. Meanoperative time was 130+/-20 mts. Mean blood loss - 50 ml. no patient required blood transfusion. Mean WIT - 235 s+/- 30 sec. kidney was retrived in low lying left iliac fossa incision. Donor was discharged on day3-4.Mean creatinine of at time of discharge was 1.3+/- 0.4. Only one had DGF. The mean operative time was increased in LDN with vascular (arterial) anomaly, compared to those with normal anatomy. WIT increased by 30s in multiple arteries, but unchanged in venous anomaly. Conclusions: LDN is effective and safe in Vascular anomalies. The advent of CT angiography has increased the preop awareness, preparedness and precise intra-operative dissection of the renal vasculature, resulting in good outcome. LDN with vascular anomalies is safe for both Donor as well as recipient with outcome similar to those with normal vasculature.

   Role of sentinel lymphnode biopsy in clinically node negative carcinoma penis - A prospective validation study Top

R. M. Sharma, A. Giridhar, T. S. Rao

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

Introduction: Lymph node metastasis is a strong prognostic indicator in Carcinoma-Penis with 25% difference in 5-year cancer-specific survival among node-negative and node-positive patients. Occult nodal metastasis is seen in 20-25%. Nearly 80% of the patients who are clinically node negative are over treated with prophylactic groin dissection. Objectives: 1. Sensitivity, specificity, false negative rates, positive predictive value, negative predictive value of Sentinel Lymphnode Biopsy (SLNB) 2. Occult-nodal metastasis prevalence 3. Sensitivity, specificity, false-negative rates, positive predictive value (PPV), negative predictive value (NPV) of FNAC, Ultrasonography, Frozen section. 4. Estimate complications in terms of penile-edema, bleeding, flap necrosis, infection. Methods: This prospective study was conducted between June-2016-December-2017. All patients with impalpable inguinal nodes are subjected to USG and FNAC of suspicious nodes. Only those with non-suspicious USG/negative FNAC were included. Dual-dye technique was used to identify Sentinel node. Superficial inguinal dissection was done in all cases and both specimens were subject to Frozen section. If >2 nodes were involved on Frozen section, ilioinguinal dissection was done. Results: Most patients were >50 years, had pT2 tumors. SLNB had Sensitivity, specificity, PPV, NPV, Accuracy of 100% respectively. Identification Rate: 96.7%. USG had Sensitivity, specificity, NPV, Accuracy was 33.33%, 50.85 %, 93.75 %, 50.00% respectively. Of the 33 FNACs, one false-negative and 32 True-negative cases. Median pain score- 3.Flap necrosis - 1; ALT reconstruction done. 3 had skin edge necrosis, 2 had infection which was controlled by antibiotics and one needed drainage of infected fluid. 2 had seroma drained by clip removal Conclusions: Ultrasonography alone is unreliable, USG-FNAC improves the reliability to some extent. SLNB with frozen-section study when done in properly selected cases-in high volume centres by experienced professionals is very reliable tool in establishing the nodal-status, thereby facilitating need directed treatment and prevent either over/under treatment.

   C K P Menon Best Paper Prize Session Top

   Single use versus reusable ureterorenoscopes in management of lower polar calculus: Single center prospective study Top

Sanjoy Lakshminarayan Paul

Dispur Hospital, Guwahati, Assam, India

Introduction: Lower-pole stones (LPS), defined as stones lying within a lower (inferior) pole calyx, are the most common renal stones. LPS are more likely to require treatment because they are less likely to pass spontaneously. We have performed comparative study between Single use & reusable uretero-renoscopes in management of LPS. Methods: Total of 48 cases were studied, 24 patients in each arm. All patients having LPS of size less than or equal to 2 cm were included in the study. Allocation of treatment options to different patients was done by using randomization. In this method the treatment options were marked as Treatment group A (reusable scope) & Treatment group B (disposable scope). Both the groups were compared in terms of stone characteristic,physical and optical properties, Stone free rates,complications,cost effectiveness. Results: Between April 2018 to April 2019 , 24 procedures were performed in each treatment group. Both the groups were comparable in terms of stone characteristic, duration of surgery /fluoroscopy with no significant difference. A double-J stent was deployed in all the cases post-operatively. On analysis comparing results between SFR was compared. SFR for TGA was 79.16 % & TGB was 75% after day 1. SFR after 1 month was 95.83% and 91.6 % in TGA and TGB respectively, Global SFR was 93.44%. Complications were recorded and managed accordingly. Conclusions: Both the scopes are comparable in terms of efficacy and safety. Disposable scope has advantage of easy manoeuvring ,light weight to use with no maintaninence. Reusable scopes are more cost effective.

   Efficacy of one versus three days of intravenous amikacin as prophylaxis for patients undergoing transurethral resection of prostate - A prospective randomized trial Top

E. Selvin Theodore Jayanth

Christian Medical College, Vellore, Tamil Nadu, India

Background: Single dose antibiotic prophylaxis prior to transurethral resection of prostate is recommended. Poor adherence to this policy and the use of longer duration is not uncommon. This study evaluated the efficacy of single versus 3 days of intravenous Amikacin. Methods: This is a prospective, randomized control trial. Patients with sterile preoperative urine culture were randomized to receive either one day (Group A) or 3 days (Group B) of intravenous Amikacin. All the patients had catheter removal on the 3rd day and midstream urine culture on the 4th day. Follow up 1 week postoperatively was done by a hospital visit and at one month by telephonic interview. The primary outcome was bacteriuria rate at postoperative day 4. The secondary outcomes were, symptomatic UTI, its risk factors and other complications at one month. Results: Of the 338 patients randomized, 314 patients were evaluable until day 7 and 307 until one month. Bacteriuria rate at day 4 [Group A: 8.8% (95% CI:4.2-13.2); Group B: 4.4% (95% CI:1.2-7.7%), p=0.124, fisher exact test] was similar in both the groups. At One month the rate of symptomatic UTI's were similar in both groups [3.5% (95% CI:0.8-6.9) vs 1.7% (95% CI:0.2-4.2) p=0.344, fisher exact test]. Bacteriuria (CFU>10,000/ml) at day 4 was a significant risk factor for development of symptomatic UTI (p=0.006). The development of antibiotic resistance was higher in group B(p=0.002). Conclusion: A single day was non inferior to three days of intravenous Amikacin as a prophylaxis with respect to bacteriuria and symptomatic UTI.

   'Pee' BuSt Trial-A single centre prospective randomised study comparing functional and anatomic outcomes after substitution urethroplasty with 'buccal mucosa graft versus inner preputial skin graft' for anterior urethral stricture disease Top

Shantanu Tyagi, Arup Kumar Mandal, Shrawan Kumar Singh, Sudheer Devana, Kalpesh Parmar, Aditya Prakash Sharma

PGIMER, Chandigarh, India

Introduction and Objective: The optimal choice of graft for Substitution Urethroplasty (SU) remains debated at present. This can be attributed to the paucity of well-conducted prospective randomized trials on comparative outcomes after the usage of various graft materials for SU. The objective of our study was to prospectively assess the results of SU performed with either Inner Preputial Graft (IPG) or Buccal Mucosa Graft (BMG) so as to identify the 'best substitution material' based on Functional and Anatomic success. Methods: From January 2018 to July 2019, 64 patients with anterior urethral stricture disease, complying with strict inclusion and exclusion criteria, were prospectively randomized to undergo SU with either IPG or BMG. Anatomic Variables(Uroflowmetry, Retrograde and Voiding cystourethrography) and Functional variables (LUTS, Sexual function) were assessed pre-operatively and post-operatively at predefined intervals. Success was defined by 'Both' Functional outcomes and Anatomic outcomes. Results: Mean follow-up was 12 months (3-19). The overall success rate was 83% (84% in the BMG and 81% in the IPG arm). At 18 months, Mean Qmax was comparable between two arms (22ml/s in BMG and 19ml/s in IPG arm), Mean IPSS (2.4 v/s 2.6) and Mean IIEF (21.60 v/s 21) were also comparable between BMG v/s IPG arm respectively. Intraoperative blood loss (35 v/s 53ml) and Hospital stay (3.37 v/s 4.50 days) were significantly less in IPG arm. Orgasmic Domain of IIEF was surprisingly better in IPG arm at 6 months. Conclusion: Our study is among the first such attempt to determine the non-inferior and comparable success rates after SU with IPG v/s BMG through a prospective randomized methodology.

   Comparison of conventional therapy and pelvic floor relaxation techniques using biofeedback in patients with chronic prostatitis/chronic pelvic pain syndrome Top

S. Dias, V. Patidar, M. Pandey, S. Prakash, R. Namdev, S. Trivedi, U. S. Dwivedi

Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Introduction: CP/CPPS is characterized by pelvic pain and voiding symptoms, management of which is challenging. Pelvic floor tension myalgia may contribute to the symptoms of CP/CPPS. Measures that diminish pelvic floor muscle spasm may improve these symptoms. The present study is designed to assess the efficacy of biofeedback and pelvic floor relaxation treatment for CP/CPPS. Materials and Methods: 84 patients diagnosed with CP/CPPS were randomly allotted into two groups, Group A (conventional therapy) and Group B (Pelvic floor muscle relaxation and biofeedback group). The Biofeedback and Electrical Stimulation apparatus (UROSTYM, LABORIE) was used for pelvic floor muscles electrical stimulation and relaxation with biofeedback. National Institutes of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) scores were evaluated at start of therapy, after 3 months of treatment and at 6 months (after 3 months of last treatment received). Results: At 3 months, patients in both groups had significant decrease (improvement in symptoms) in NIH-CPSI scoring. However, at 6 months, only 19(47.5%) patients in group A maintained fall in NIH-CPSI score >6 compared to 37(94.8%) patients in group B(p<0.05). At 6 months, there was significant decrease of NIH-CPSI score in group B whereas, in group A score had increased (worsening of symptoms). Conclusion: Pelvic floor muscle relaxation and biofeedback training is safe and effective treatment for CP/CPPS with sustained efficacy even after cessation of therapy.

   SGR-IRS model of training laproscopic donor nephrectomy to urology residents: Effective way of learning with minimal complications Top

T. M. Mistry, V. Tyagi, M. Pahwa, P. Laddha, S. Chadha, H. Jauhari

Sir Ganga Ram Hospital, New Delhi, India

Introduction and Objective: Laproscopic approach to donor nephrectomy is increasingly becoming standard of care for the general advantages of laparoscopy & comparable outcomes with respect to transplant success. Laproscopic donor nephrectomy (LDN) is an advanced laproscopic procedure & it is associated with a steep learning curve. Training of urology residents in laproscopic donor nephrectomy is a resourceful task. In the present study we evaluated our institute protocol of training residents for laproscopic donor nephrectomy. Materials and Methods: Three residents underwent training as per the SGR-IRS protocol for total 6 months divided into two phases of 3 months each. Residents received hands-on training on 258 LDN. Data was collected regarding age, sex, any comorbidity, radiologic anatomy of donors & any complication occurred. We evaluated residents' performance & complications occurred during the two phases. Confidence of the residents was measured using a 10-point Likert scale, pre- and post training. Statistical analysis was done. Results: The mean difference in complications observed in each resident with respect to phase 1 & 2 was statistically significant (P = 0.0270, P = 0.0206 & P = 0.0153 respectively). The mean improvement in confidence scores of all residents at the end of training was also found to be statistically significant (P = 0.0004). There was no incidence of bowel injury or emergency exploration. Conclusion: SGR-IRS training protocol is a safe & effective approach to train laproscopic donor nephrectomy to urology residents. However, large multi-institutional studies would be required for its generalised application.

   Comparison of standard 12-core systematic transrectal ultrasound guided biopsy and magnetic resonance-transrectal ultrasonographic fusion biopsy in the detection of prostate cancer - A prospective randomized study Top

P. Sridhar, A. Seth, R. Kumar, P. Singh, B. Nayak, C. J. Das, S. Kaushal

All India Institute of Medical Sciences, New Delhi, India

Introduction: The MRI/TRUS fusion biopsy is an alternative to standard 12-core TRUS guided biopsy for prostate cancer (Pca) detection. However, comparative studies are lacking. Methods: Men with elevated serum PSA of 4-11 ng/ml and/or suspected stage T2 on DRE were randomized into Fusion-group or TRUS-group. Men in the fusion-group underwent mpMRI and suspicious lesions were further classified (PIRADS-V2). Region-of-interest (ROI) marked with the ProFuse-software. Using Eigen MRI/TRUS fusion device, targeted biopsy (TB) along with systematic 12-core biopsy (SB) was performed. The primary outcomes were detection of any Pca and clinically significant Pca (csPca). Secondary outcomes included VAS pain scores, probe-indwelling time and complications. Results: A total of 124 men underwent randomization (Fusion-group:61 patients; TRUS-group:63 patients). The overall Pca detection rate was comparable between the two groups (15(24.59%) vs 16(25.40%), p=0.92). Although not statistically significant, Fusion-group had 6% higher csPca detection compared to TRUS-group (11(18.03%) vs 8(12.70%), p=0.41). The probe-indwelling time (19.49(±3.21) vs 9.47(±1.79), p=0.001) and mean VAS score [4.02(±1.55) vs 3.47(±1.21), p=0.03) were significantly higher in the Fusion-group. Complication rates were comparable between the two groups. Subgroup analysis of Fusion-group showed 2 of 11 men (18.2%) had csPca exclusively detected on SB alone while another 2 of 11 men (18.2%) had csPca detection exclusively on TB alone. Four patients [4/15 (26.6%)) had Gleason's score up-gradation in TB as compared to SB. Conclusion: In biopsy-naïve men with clinical suspicion of Pca, fusion-group had 6% increased detection of csPca, but with significantly higher probe-indwelling time and VAS score compared to TRUS-group.

   Development of a novel Indian nomogram for predicting extracapsular extension in prostate cancer Top

K. Ravi Chandran, Appu thomas, K. V. Sanjeevan, K. P. Ginil

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Objectives: To compare accuracy of Magnetic resonance imaging (MRI) with the Partin nomogram (PN) for predicting extracapsular extension (ECE) in prostate cancer (PCa) in a Indian cohort undergoing radical prostatectomy (RP). To develop a novel Indian nomogram for clinicians to estimate pathologic ECE risk. Methods: We analysed 273 patients who underwent MRI of prostate and RP. Univariate and multivariate logistic regression analyses were performed to identify predictors of ECE. Forward stepwise method was used for variable selection in binary logistic regression, and we constructed new Indian nomogram by adding MRI ECE risk score to variables used in PN. AUC calculated and compared between PN and Indian nomogram. Calibration curves assessed the agreement between the actual ECE risk and the predicted probability of the new Indian nomogram. Results: A total of 123 of patients (45.1%) had ECE on MRI whereas 136 patients (49.8%) had ECE on final pathology. Sensitivity, specificity, positive predictive value, and negative predictive value MRI for ECE were 76.6%, 66.9%, 70.0%, 73.9% and 71.7 % (95% CI) respectively. Based on multivariate logistic regression analyses, cT stage, Gleason score (GS), and ECE risk score remained significant. The highest and lowest values of the AUC for single variables were 0.748 (ECE risk score) and 0.636 (cT stage). AUC for PN in predicting ECE was 0.64, it increased to 0.826 with new nomogram. Novel Indian nomogram had higher predictive accuracy and superior calibration. Conclusion: MRI adds incremental value to PN. Novel Indian nomogram can help in decision making process of nerve sparing radical prostatectomy.

   Unilateral versus bilateral vaso-epididymal anastomosis for idiopathic obstructive azoospermia: A randomized trial Top

Nishant Gurnani, Manoj Kumar, Rajeev Kumar

All India Institute of Medical Sciences, New Delhi, India

Introduction: Vaso-epididymal anastomosis (VEA) for idiopathic obstructive azoospermia (iOA) has low success rates and patients often need subsequent ART. We perform VEA unilaterally as bilateral VEA makes percutaneous sperm retrieval for ART difficult, and has added morbidity. However, a subset analysis of our previously published data showed higher success with bilateral VEA when compared with unilateral surgery. We, therefore, conducted a prospective, randomized trial to compare outcomes between unilateral and bilateral VEA. Methods: The trial was registered on the Clinical Trials Registry of India and approved by the institution ethics committee. Men with iOA, scheduled for VEA, were randomized to undergo unilateral or bilateral surgery. Randomized group allocation using opaque envelopes and a random numbers box was done after completion of unilateral VEA to avoid surgeon bias. Success was defined as appearance of sperms in the semen analysis performed after 6 weeks and every 3 months thereafter in a blinded laboratory. Results: Of the 60 patients recruited, 40 were randomized, 2 were lost to follow-up, and 38 were analyzed for this report. Twenty one patients underwent unilateral and 17 underwent bilateral VEA. Patency was achieved in 15 subjects (39.4%); 10 in the bilateral group (59%) and 5 in unilateral group (24%), p=0.031. Bilateral VEA was associated with significantly greater operative time (79 min vs 43 min; p = 0.035) and more complications (11 versus 5; p =0.016). Conclusions: Bilateral VEA has significantly higher success rates when compared with unilateral surgery for idiopathic obstructive azoospermia but is associated with higher operative time and complications.

   Robot assisted radical prostatectomy with extended template lymph node dissection - Is it curative in itself for a subgroup of node positive prostate cancer patients? Outcome analysis of 100 node positive prostate cancer patients over last seven years Top

Ashwin Sunil Tamhankar, Gagan Gautam

Max Institute of Cancer Care, New Delhi, India

Introduction: Radical prostatectomy with extended lymphadenectomy (ELND) may itself be a curative modality of treatment for a subset node positive of prostate cancer patients. Methods: 100 lymph node (LN) positive patients undergoing robot assisted radical prostatectomy (RARP) over seven years were analysed for biochemical recurrence (BCR) and other survival parameters using Kaplan Meier analysis. Patients were offered adjuvant therapy at the time of BCR avoiding immediate adjuvant therapy. Based on positivity, patients were divided in 1LN (45), 2 LN (22), >2 LN (33) positive groups. Results: At a median follow up of 21 months (1-70), for BCR, biopsy Gleason score, LN positivity group (1, 2, >2), seminal vesicle invasion (SVI), preoperative prostate specific antigen levels (PSA), tumor volume (TV) and lymph node density (LND) were significant. However, on multivariate analysis only the number of positive nodes was significant factor. Patients with only one (HR 0.331) or two positive LN (HR 0.466) were significantly less likely to have BCR than >2 nodes. One or two LN groups were sub-stratified based on cut-offs of PSA 31.1 ng/ml, LND of 11.2% and TV of 33.94% in low, intermediate and high risk. 1, 3, 5 year BCR free rates were (71.4%, 63.5%, -) for low risk, (50%, 27.8%, 27.8%) for intermediate risk and (16.1%, 8.1%, -) for high risk group. None of the other preoperative or post operative pathological parameters were significant for cancer specific survival, overall survival, local or distant recurrence free survival. Conclusions: RARP with ELND may be curative for nearly 1/4th of one or two node positive patients till 5 years of follow up and it would delay the BCR by a median of 40 months and 12 months respectively in low and intermediate risk patients with either one or two positive nodes. Deferred adjuvant therapy would be the most suitable strategy in these two subsets of node positive prostate cancer patients for avoiding or delaying potentially toxic systemic androgen deprivation therapy when they have a fair chance of cure by the virtue of RARP with ELND.

   Chandigarh Best Video Prize Session Top

   Novel robotic assisted approach for left radical nephrectomy with inferior venecaval thrombectomy in supine position Top

T. A. Kishore, R. Vishnu, Sunil Bhat, S. Himanshu, Gregory Pathrose, S. Kiran

ASTER Medcity, Kochi, Kerala, India

Aim: To demonstrate novel Robotic approach for left Radical nephrectomy with Inferior venecaval (IVC) thrombectomy in Supine position. Materials and Methods: 44 year old presented a 9cm left renal mass and thrombus extending into the IVC. The patient was placed in supine lithotomy with steep Trendlenburg's position. The Da Vinci Si robot was docked from the cranial end. Six ports were placed which included three robotic arms, camera and two assistant ports. The dissection commenced with incision of the mesentry, thereby reflecting the bowel contents upwards. The peritoneal edges were suspended on the anterior abdominal wall preventing bowel interference. The left renal vein was lifted up and left renal arteries were ligated. The IVC, right renal vein and right renal artery was dissected. The left renal vein bearing the thrombus was divided using a vascular stapler. The bull dog clamps were applied sequentially, IVC thrombectomy was performed and cavotomy closed. The patient was given a 20 degree tilt and robot docked from the shoulder side. The nephrectomy was completed and specimen extracted through a Pfannensteil incision. Results: Operative time was 315 minutes, Console time was 225 minutes, IVC clamp time was 13 minutes, hospital stay was 4 days. The pathology showed T3N0M0 Grade III tumour. Conclusion: This novel approach is of great utility in patient with left side tumors with IVC thrombus. It gives a good exposure to interaortocaval area and allows early ligation of renal arteries. There is no requirement of repositioning of the patient.

   The Technique of double faced dorsal onlay and ventral inlay graft penile urethroplasty in complex pan-urethral strictures Top

Ashish Pardeshi, Vijay Raghoji, Narendra Wankhede, Rajesh Rajendran, Pratikshit Mahajan, Navnath Fulari

Kidney and Urology Super-Speciality Clinic, Pune, Maharashtra, India

Introduction and Objective: Severe Lichen Sclerosus (LS) is associated with meatal stenosis and pan-urethral strictures. Dorsal onlay buccal mucosa urethroplasty has become a standard of care for the treatment of such strictures. However severe narrowing of penile urethra can pose challenges for the long-term durability of the repair due to significant disparity in the urethral plate and the BMG. We studied the technique of Combined Ventral inlay and dorsal onlay BMG penile urethroplasty for complex pan urethral strictures and its long-term results. Methods: 37 patients in the age group of 23 to 54 years (Mean age 34.56) with severe LS who had severe meatal stenosis and very narrow penile urethra were operated by this technique from June 2014 to May 2018. Patients with diseased buccal mucosa, poor mouth opening, previous urethroplasty and active LS were excluded. Bilateral buccal mucosa grafts were harvested under general anesthesia. Results: Maximum follow-up was for 37 months. 32 out of 37 patients (86.48%) had no issues and had an average maximum flow of 18ml/sec.3 patients developed recurrent meatal stenosis which required ventral meatotomy. 2 patients developed penile edema after surgery, which was managed conservatively. 8 patients had mild degree of erectile dysfunction which recovered with medications. Conclusion: The combined BMG urethroplasty offers better and more durable results in case of very narrow penile urethra in patients with pan-urethral strictures due to LS.

   Robot assisted right radical nephrectomy with level ii inferior vena cava tumor thrombectomy: The video demonstration Top

Preetham Dev, T. B. Yuvaraja, Santosh Waigankar

Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India

Objective: The video demonstration of robotic radical nephrectomy with inferior vena caval (IVC) thrombectomy and retroperitoneal lymph-node dissection for right-sided renal cell carcinoma with level II IVC thrombus. Methods: 79 year old man presented with 11.2 cm right renal mass completely replacing the kidney along with renal vein thrombus extending into IVC. Patient underwent angio-embolisation on day of surgery. Procedure was done with Da Vinci Xi robot, standard 6 port transperitoneal approach in left lateral position. Steps followed are 1) entering retroperitoneum 2) hilar dissection and exposure of IVC 3) control of IVC and left renal vein 4) IVC cavotomy, thrombectomy, reconstruction 5) control of renal vessels 6)nephrectomy and lymph node dissection. Intraoperative and immediate post-operative outcomes are noted. Results: Robotic right nephrectomy and level II IVC thrombectomy were successfully completed without any complications. Total console time of 2 hours 45 minutes with IVC clamp time of 20 minutes. Estimated blood loss was 200cc; there were no intraoperative or major perioperative complications. The patient was discharged on postoperative day 5. Present approach reduces the post-operative morbidity with early recovery, adequate IVC control and reconstruction. Conclusion: We demonstrate the detailed video description of right sided level 2 IVC thrombectomy and radical nephrectomy completed with robot assisted technique. This versatile approach adds to the armamentarium for minimally invasive surgical management of renal cell carcinoma with IVC thrombus and avoiding a large muscle-cutting abdominal or thoracoabdominal incision to achieve the necessary surgical access for vascular control and thrombectomy.

   Enterourethroplasty for long gaps after failed pelvic fracture urethral distraction defects Top

Pankaj M. Joshi, Shrikant Ankolikar, Ayman Mousa, Shrikant Jai, Shreyas Bhadranawar, Sanjay B. Kulkarni

Kulkarni Reconstructive Urology Center, Pune, Maharashtra, India

Introduction: Pelvic fracture urethral injury merits anastomotic Urethroplasty. Patients who undergo multiple failed urethroplasty may develop long gap and bulbar urethra necrosis. These patients merit substitution urethroplasty. We describe management of such patients using Enterourethroplasty. Materials and Methods: We are a tertiary referral center for Urethral Reconstruction. We have operated on more than 1307 cases of pelvic fracture in last 2 decades. Out of this we have experience of 117 patients who had bulbar urethral necrosis. Our first choice of procedure for such patients is the pedicled preputial of penile skin tube. We had 4 patients in whom the prepuce was not available and had short penis leading to paucity of penile skin to be tubularized based on dartos. We have performed enterourethroplasty in these patients based on the sigmoid colon. This involves perineal surgery, dissection of anterior and posterior urethra. Abdomino perineal approach is used. Sigmoid colon is mobilized on its mesentery. Distal part of sigmoid colon is excised. Proximal part is tubularized based on the pedicle. This neourethra is anastomosed to native urethra. Catheter is kept for 6 weeks. Results: 4 patients underwent enterourethroplasty. Follow up ranged from 4 -17 months. 1 patient developed Colo-cutaneous fistula which was self-limiting and healed on its own. All 4 patients have normal voiding and have not required any intervention. All 4 have post micturition dribble. Conclusion: Management of long gaps and bulbar necrosis is challenging. Enterourethroplasty as described by Mundy et al is a option for such patients. This involves abdomino perineal approach. This option of substitution urethroplasty has good results over long term.

   Robotic assisted management of renal hilar tumors Top

Syed Mohammed Ghouse, C. Mallikarjuna, K. P. C. Reddy, B. Taif, D. Ragoori, B. Enganti

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

Nephron-sparing surgery, especially through a minimally invasive approach, is increasingly being performed for incidentally detected renal masses with excellent outcomes owing to improvements in axial imaging, intraoperative ultrasound with doppler, and overall in- creasing expertise. Inspite of the advances tumors in central location remain a technically surgical challenge during nephron-sparing surgery. Addition of robotic armamentarium has made even this possible. The challenges encountered during partial nephrectomy in central hilar tumours is secondary to the proximity of these tumours to the vessels and collecting system. These challenges are encountered not only while resection of the tumour but also during renorraphy. We discuss the robotic management of central tumors, which include tumors that are both anterior and posterior to the renal vasculature and endophytic central tumors, with a focus on surgical technique. Video also highlights the various maneuvers like transhilar approach, selective clipping of segmental/ interlobar vessels, individual ligation if vessels and infundibulae of calyces, management of dead space and proper cortical approximation. In anteriorly placed tumours non clamping of the renal vein and avoiding mass ligature in the tumour bed with careful renorrhapy with perinephric fat interposition to obliterate the dead space are few techniques followed. In posteriorly placed tumours selective clipping of the posterior segmental artery with dissection in the plane between the tumour and the renal pelvis is demonstrated. In central hilar tumours incising a cap of renal parenchyma over the tumour with enucleoresection of the tumor and renorraphy are demonstarted.

   The tale of two robotic IVC thrombectomies: Good and the bad Top

Ginil Kumar Pooleri, B. Shivraj, Abhishek Laddha

Amria Institute of Medical Sciences, Kochi, Kerala, India

Introduction and Objective: Robot assisted RNIT (RA -RNIT) can be considered in selected cases of renal tumour with IVC thrombus and is a very challenging surgery. We are presenting two cases of RA-RNIT, a good case without any per/post operative issues and a complicated case with an infra renal bland thrombus incidentally detected on table. Materials and Methods: The video of the surgeries were recorded, edited and presented for comparison between the cases to understand the peroperative difficulties that can happen in RA-RNIT. Both cases had infra hepatic IVC thrombus (Level 2) on MRI. One of the case had severe desmoplastic reaction and on unclamping IVC, there was no back bleeding .Suspecting infra renal thrombus, thrombectomy was attempted with fogarty caheter followed by therapeutic dose of anticoagulation post operatively. On post operative MRI he was found to have bland thrombus which was probably overlooked in pre op MRI. Results: Desmoplastic reaction can be very severe in some cases of IVC thrombus. Bland thrombus may be missed in pre operative imaging. Both can cause per operative difficulty. Thrombectomy using fogarty catheter can be attempted through robotic port. Post operatively such cases require prolonged anticoagulation. Hence proper hemostasis should be ensured. Conclusion: RA RNIT should be attempted only by a well-experienced surgeon and proper pre operative evaluation regarding extent of thrombus and exclusion of infra renal bland thrombus is required.

   SS Bapat Prize Paper Session on New Innovations and Technology Top

   Burjwal, kamat and jambu impactometer: An ingenious device to measure the impact of pneumatic lithotrite Top

Nagesh Kamat, Saurabh Jambu, Burjwal

Kamat Kidney and Eye Hospital, Vadodara, Gujarat, India

Introduction: The pneumatic lithotrite is an instrument which uses pneumatic energy to propel the 'bullet', thus fragmenting the stone. We have devised an instrument to measure the impact delivered by the handpiece, thus measuring the integrity of the pneumatic device. We constructed a prototype of this impactometer. Materials and Methods: This device has been constructed with a meter and a contact point. The pneumatic probe which is to be assessed, is placed in the contact point and the pneumatic is activated. The impactometer measures the force with which the probe hits the contact. We have measured the impact of two different manufacturers, with different probe diameters. Results: The device could reliably measure the impact of the probes. This device was conceived with the idea of identifying a faulty pneumatic probe, before using it. In a hard calculus, it is difficult to identify whether the stone is not fragmenting due to the stone hardness or due to a faulty probe. This impactometer helps in identifying a defective probe. The impact values varied from 0.320 kg/cms2 (for the 7 F probe) to 0.090 kg cms2 ( for the 3 F probe). The instrument made serves as a prototype and will need calibration and comparison with standard measurement devices. Conclusion: We have devised an pneumatic impactometer which is a device to measure the impact delivered by a pneumatic instrument . We are presenting the first prototype of this device.

   Development of an innovative disposable uroflowmeter with urine test Top

Ashish Rawandale Patil

Institute of Urology, Dhule, Maharashtra, India

Introduction and Objectives: Uroflowmetry, Urine macro and microscopy, Urine culture, three part urine tests are routinely required for urological diagnosis. Conventionally uroflowmetry is done in the hospital setup. Drawbacks include financial overheads of infrastructure, equipment investment, maintenance, cleanliness, technician. Patient related drawbacks include voiding in an unaccustomed setup and having to pass urine multiple times for multiple tests causing long hospital wait times. We started this project with an aim to create a portable, affordable kit that can do uroflowmetry and other tests in a single void. Methods: The kit was conceptualised, CAD designed, patented and printed using SLS 3D printing. An algorithm was formulated to calculate the uroflow parameters depending on how the urine flowed in the kit. Bench analysis using a fixed and variable flow input was done. A mobile app was developed to allow distant reporting. Results: The Peak flow, Average flow, Total voided volume, Voiding graph were measured using a conventional uroflowmeter and our disposable uroflowmeter and compared. Parameters were comparable with no statistically significant differences. Conclusions: Our indigenous disposable uroflowmeter is first of its kind. Uroflowmetry, Urine macro and microscopy, culture, three part test, can be done in a single void. It is hygienic, allows home based natural void test. Is portable, affordable, eco-friendly, needs no electricity, follows a go green concept. It allows distant reporting and hence can be used for screening patients in inaccessible areas of our country. It saves hospital space, equipment investment, hospital and patient time and technician cost.

   Initial human experience with a novel stone aspiration device used during ureteroscopic lithotripsy for renal stones Top

Shashank Agrawal, A. Singh, B. Eisner, G. Preminger, A. Ganpule, R. B. Sabnis, M. R. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Introduction and Objectives: Basket extraction of stone fragments after ureteroscopic lithotripsy is time-consuming and may result in poorer-than-expected stone free rates. Here in we report the first-in-human experience using a novel stone aspiration device designed to more efficiently and effectively remove stone fragments after ureteroscopy. Methods: Patients with renal stones 5-15mm were randomized, into two groups; Group 1 - Fragment extraction via basket retrieval after laser lithotripsy was performed until surgeon felt stone free status, Group 2 - after laser lithotripsy ureteroscope was replaced by novel device (K-VAC; Kalera Medical, San Diego, CA) which passed systematically through all calyces using fluoroscopic guidance, and stone fragments were aspirated for approximately 2 minutes in each area where stones were located. 12/14 Fr ureteral access sheath was used. NCCT KUB was performed post-operative day 1 and 30. Stone free was defined as no stone fragments. Results: Eight and nine subjects were randomized to Group 1 and Group2 respectively. No differences in demographics or pre-operative stone volume (mean basket group = 436 mm3, K-VAC group = 559 mm3, p = 0.59). Mean % stone volume removed was significantly higher in the K-VAC group (85.2% versus 58.7%, p=0.025). No difference in the mean total fluoroscopy (318 seconds versus 295 seconds, p=0.78). At 1 month follow up, 100% of subjects in the K-VAC group were stone free compared to 75% of subjects in the basket group. Conclusions: Use of novel stone aspiration device, K-VAC, demonstrated superior stone free rates compared to conventional basketing during ureteroscopy with lithotripsy.

   Cold en bloc excision of bladder tumor less than 2 cm using a novel zed scissors: A new technique for treating bladder tumors Top

B. M. Zeeshan Hameed, Joseph Thomas, Arun Chawla, Milap Shah

Kasturba Medical College Hospital, Manipal, Karnataka, India

Background: The presence of detrusor muscle(DM) is essential for the completeness of bladder tumor resection. En bloc resection is the standard of care, the advantages being: presence of detrusor muscle, less tumor seeding and reimplantation. The disadvantages of electrocautery are obturator jerk, perforation and charring of specimen. We intend to check the safety and feasibility of a modified endo-scissors to excise bladder tumors. Materials and Methods: Patients with bladder tumor were enrolled for Cold En Bloc Excision(CEBE). The inclusion criteria: size2cm, number>3, upper tract tumors and CIS. We used a modified endoscissors ‘Zed Scissors’ with slender shaft, semi-curved blades and can be connected to electrocautery. The excision was done using the scissors through the working channel of a 20.8F Nephroscope. The tumor with DM was excised under cold cut and sent for histopathological examination. Follow up was at 1&3months with cystoscopy. Results: N=5 patients underwent CEBE. The mean size was 1.4cm (1.2cm-1.8cm) The mean excision time was 4 min 26sec. None of them had obturator jerk or bladder perforation. There was no drop in hemoglobin. Patients were discharged after 48hrs of procedure. The histopathology were low grade T1(N=4) and Ta(N=1), all had presence of DM in the specimen. Follow up on 1st and 3rd month with cystoscopy did not show any recurrence. Conclusion: Cold En Bloc excision is a promising technique to treat bladder tumors less than 2 cm with consistent presence of deep muscle layer in specimen and negligible complications.

   Smart scope: Role of mobile as endocamera in urology Top

D. Karthikeyan, P. Periyasamy, G. Sivasankar, Senthilvel, Jayaganesh, Aysha Shaheen

Kilpauk Medical College, Chennai, tamil Nadu, India

Introduction: Recent advances and the widespread availability of Smartphone have ushered in a new wave of innovations in healthcare. We present our initial experience with SMART SCOPE - IPHONE SCOPE, a new docking system that optimizes the coupling of the iPhone with modern endoscopes. Materials and Methods: We used mobile holders with adapters used for binoculars, which could fit telescopes with eyepiece diameter of 26.4-46.4mm. Iphone was initially attached to mobile holder and then telescope was fitted into adapter and adjusted. Light source was connected to telescope and after the focus of iphone was locked, Image in iphone was zoomed 3X magnification. Relay lens can also be used for better magnification. We compare our smartscope-iphone with the smart scope from KARL STORZ in terms of price, portability and performance. Results: Smartscope was initially used in beetle endotrainer and as the images were satisfactory it was used for DJ Stent removal in 10 cases. When the cystoscopic images acquired with smartscope were compared with those of HD camera, they were of identical color resolution and could be mirrored to smart TV. Conclusion: Smartscope demonstrated feasibility of coupling endoscopes to a smartphone. The lighter and inexpensive smartscope acquired images of the same resolution and acceptable color resolution. Smartscope can be effectively used for DJ stent removal as it is easy to carry around.

   A novel bladder tube for traumatic bladder neck contracture in females Top

Rishi Nayyar, Siddarth Jain, Kulbhushan Sharma, Sahil Pethe

AIIMS, New Delhi, India

Introduction: Bladder neck contracture with urethral loss is a challenging clinical scenario with not many surgical options. Although Tanagho's bladder tube provides one option in these cases, good results are limited to short tubes. In longer tubes, limitations include poor continence, higher placed bladder neck with incomplete voiding, formation of a dependent recess at trigone, a rotational tug on the anastomosis and posteriorly directed suture line. We describe a novel bladder tube in such difficult cases with the aim of overcoming limitations of Tanagho's reconstruction. Materials and Methods: 2 young females with post traumatic complete bladder neck obliteration and associated urethral loss were included. Both cases had bilateral normal pelvic muscle strength (oxford scale 5). A novel bladder neck based 'inverted U anterior wall flap' was used and tubularized to reconstruct bladder neck and urethra. The anatomical principle behind continence with Tanagho's tube ie using the native bladder neck tissue to reconstruct is better preserved with our novel technique. No additional anticontinence procedure was added. An omental wrap and a peritoneal flap were used in one case each to cover the anastomosis. Results: Blood loss was less than 100 ml in both and perioperative period was uneventful. The catheter was removed at 3 weeks. Both patients are fully continent and voiding well with low post-void residue at follow up of 12 and 4 months respectively. Follow up urodynamic showed a stable, well compliant bladder with normal void. The urethral length of 5 and 4 cm was achieved in the two patients with demonstrable sphincter-like contraction in the mid-urethral zone on cystoscopy. Conclusions: Our novel bladder tube technique for reconstruction of female urethra provided excellent results in the short term.

   Vijayawada Poster Prize Session Top

   Efficacy and safety of mirabegron for the treatment of low compliant acontractile/underactive detrusor due to conus/cauda/peripheral nerve lesions: A prospective study Top

Vishnu Prasad, Siddharth Yadav, Pawan Vasudeva, Kumar Saurav, Y. M. Prashanth, Vijay Tyagi

VMMC and Safdarjung Hospital, New Delhi, India

Introduction and Objectives: The normal function of the lower urinary tract is disturbed after spinal cord injury (SCI), and a life-long control and therapy is required. Overactive bladder (OAB) is characterized by reduced bladder capacity, elevated detrusor pressure during the storage phase and/or reduced compliance. The aim of the study was to evaluate the safety and efficacy of Mirabegron in suprasacral spinal cord injury patients with overactive bladder. Materials and Methods: It was a prospective study. Patients who had a stable spinal cord lesion with bladder involvement, on CIC were included. They were to make a 3-day CIC diary and subsequently underwent UDS study. Tab Mirabegron 50 mg was given to all the patients and followed up after 2 weeks and at 6 weeks where UDS was repeated. The clinical and UDS parameters where compared pre and post Mirabegron and analysed. Results: A total of 30 patients were included. After 6 weeks of mirabegron therapy, the number of patients having leakage in between CIC reduced from 28 to 20, the end filling pressures (EFP) reduced from 38.2 to 15.5cmH2O (p=0.003), compliance increased from 12.5 to 101.5ml/cmH2O (p=0.000) and the number of patients where the storage pressure crossed >40cmH2O reduced from 8 to 2. However, the cystometric bladder capacity did not change significantly. Mirabegron was well tolerated, none discontinued therapy or reported major side effects. Conclusion: Mirabegron reduces EFP, improves compliance and is safe in patients with spinal cord injury and overactive bladder.

   Testis sparing surgery in small tumours - Is it safe? Top

K. Ravi Chandran, Appu Thomas, K. P. Ginil, K. V. Sanjeevan

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Introduction and Objective: Detection rates of small testicular tumours, mostly benign, have increased in our contemporary practice. These are often misdiagnosed and treated with immediate orchidectomy. In this study, we aimed to evaluate the surgical and oncological outcomes of testis sparing surgery (TSS) in tumours less than 3 cm. Methods and Results: Between November 2016 and May 2019, 32 orchidectomy were done for testicular tumours, 7 consecutive patients with testicular tumours < 3 cm underwent TSS with frozen section examination (FSE). Mean patient age was 35.57±12.8 years. The mean volume of benign tumours was significantly less than that of malignant tumours (1.75 cc vs 8 cc). At a cutoff of 2.6 cc tumour volume, it was a predictor of malignancy with 92% sensitivity and 94% specificity (95% CI, p 0.03). Clinical presentations varied: a testicular lump was palpable in 4 patients, 1 had testicular pain and 2 with incidental testicular lesions during infertility evaluation. Tumour markers were normal in all. Mean warm ischemia time was 29 minutes (21-39 minutes). Intraoperative FSE revealed benign lesions in all. Histopathology was benign in all, except one, including Leydig cell tumour (n=2), Adenomatoid (n=3), Yolk sac tumour (n=1), and Sex cord stromal tumour unclassifiable (n=1). IHC plays a pivotal role in diagnosis. The mean follow-up was 8 months with no local recurrence. Conclusion: Its safe to perform TSS in patients with small testicular masses (< 3cm) and non-elevated tumor markers. FSE is a potential tool in determining benign testicular lesions.

   Double blind, randomized, placebo controlled study of tadalafil with dutasteride versus tadalafil with placebo for lower urinary tract symptoms secondary to benigh prostatic hyperplasia: A single centre study Top

G. R. Tak, A. G. Singh, A. P. Ganpule, R. B. Sabnis, M. R. Desai

MPUH, Nadiad, Gujarat, India

Introduction: An important reason for lower urinary tract symptoms (LUTS) in elderly men is Benign Prostatic Hyperplasia (BPH). Erectile dysfunction (ED) also has a negative effect on the quality of life (QoL) also a major problem at this age. Dutasteride decreases the size of the prostate but has sexual problems, impotence as an adverse effect. These may be nullified with Tadalafil which used in the treatment of impotence and erectile dysfunction. It also has a proven beneficial effect in BPH. Objectives: To assess the efficacy and safety of Tadalafil with Dutasteride and Tadalafil with placebo for LUTS secondary to BPH. Methods: Study design: A prospective, double-blind, randomized, placebo-controlled study (n=30) patients enrolled in each group Period of study: February 2016 to December 2016 Dose and duration of study drugs Tadalafil 5mg, Dutasteride 0.5mg, duration 6 months. Results: Dutasteride + Tadalafil arm (D+T) and Tadalafil+ placebo arm (P+T), for only two parameters (IPSS-24 and Uroflow at 24 weeks UFR-24), (D+T) group showed statistically significant improvement over the (P+T) group (p30 g. In addition, men with coexisting ED will benefit from a PDE5 inhibition

   Early warning parameters for the development of chronic kidney disease in children with posterior urethral valves Top

Banthia Ravi, Yadav Priyank, Sayal Sarita, Srivastava Aneesh, Singh Udai Pratap, M. S. Ansari

SGPGI, Lucknow, Uttar Pradesh, India

Objective: Serum creatinine levels and the presence of dysplasia have been traditionally used as prognostic markers for the progression of Chronic Kidney Disease(CKD) in children with Posterior Urethral Valve(PUV). We evaluated the role of urinary indices as prognostic factors to predict the progression to CKD3 and above in children undergoing Trans Urethral Valve Fulguration(TUVF) for PUV. Methods: We conducted a prospective study from January 2014 to June 2018. The baseline demographics, laboratory and imaging parameters were observed. Children with eGFR<60ml/min at presentation were excluded. We evaluated 24-hour urine protein, creatinine and volume (24P, 24C and 24V), urine protein creatinine ratio (P:C), urine microalbumin, urine pH and osmolality on post op day 2(POD2) following TUVF. On follow up, the children were grouped into CKD grades 3 and above (group A) and CKD1-2 (group B) on the basis of their nadir creatinine and eGFR in the first year after TUVF. Results: A total of 92 children were included. Median follow up was 22.4 months. Median age was 30 months(2-140). On follow up the number of patients in group A was 67 and group B was 25. Median 24P was 0.379 g/day, 24C was 0.135g/day and P:C was 2.64. On logistic regression, 24P (β-0.412,95%CI-0.263 – 0.56) and P:C ratio (β-0.044,95% CI 0.024- 0.064) were found to significantly predict the progression to CKD3 and above in these children. ROC curve for 24P and P:C was drawn and area under curve was 0.7719. A cut off of 1.73 for P:C yielded a specificity of 82% and sensitivity of 80.5%. Additionally predictors, which were statistically significant, were serum creatinine at presentation and age at TUVF. Conclusion: POD2 24 hour urine protein and protein creatinine ratio (cut-off 1.73) can be used to predict the development of CKD3 and above in children with Posterior Urethral Valves undergoing Trans Urethral Valve Fulguration.

   Correlation of renal volume in patients without any renal disease on computed tomography scan with it's age and renal function Top

Haresh Thummar, Pokhraj Suthar, D. Chirag, H. Vithlani, Gupta

Aim: To evaluate the relationship of renal volume, measured using semi-automated Computed Tomography software with eGFR (estimated GFR), measured by the MDRD equation (Modification of diet in renal diseases study group) and age in individuals with no known history of renal disease. Materials and Methods: 200 patients, aged between 20 and 80 years (95 women and 105 men), with normal renal function, who had undergone contrast enhanced CT of the abdomen at our institution between July 2017 and August 2018 for various indications, were retrospectively included in the study. Their renal volumes were calculated using semi-automated CT software. Details of age and serum creatinine for each patient were collected and the eGFR was calculated using the MDRD equation. Renal volumes thus obtained were then correlated with age and renal function (serum creatinine and eGFR). Statistical analysis was done using Pearsons correlation coefficient. Results: The mean renal volume was 236.52 ml. The mean renal volume of men was approximately 18 ml more than in women (242 vs 224). Renal volume correlated significantly with the eGF (r = 0.3012, p<0.01). There was moderate negative correlation of renal volume with age and serum creatinine. (r = -0.1996, p<0.05 and r = -0.1865, p<0.05 respectively.). Conclusion: This study demonstrated that renal volume has a moderate inverse relationship with age and serum creatinine but a strongly direct correlation with eGFR. Thus, unlike serum creatinine, which is subject to frequent fluctuations, renal volume may serve as a long-term marker of renal function. However, study with large number of patients with longterm follow up is required.

   What's correct way to assess kidney stone density on CT KUB? Top

Haresh Thummar, Pokhraj Suthar, D. Chirag, H. Vithlani, S. Gupta

Introduction and Objective: Hounsfield unit (HU) have been used to predict the stone density and hardness, which is one of the factor to choose surgical modality for further management. However, stone is not uniform in density. We could not find much literature about this. But stone density is not equal in all areas of stone. This study is conducted to evaluate stone density (HU) at different area of stone by three techniques and compared with each other. Materials and Methods: 69 patients presented with renal or ureteric calculi of size > 1 cm on CT scan, were measured density at three area of stone.(1) Freehand HU - average HU at margin of calculi (2) Circle Centre HU - average HU of circle of >4 mm in diameter from center of calculi (3) Single Point HU - HU at center of calculi. Results: All 69 patients with CT reports showing density taken at random points by radiologists is less than single point HU at centre. P value of Freehand HU to circle center HU is < 0.001. P value of circle centre HU to single point HU is < 0.05.P value of Freehand HU to single point HU is < 0.001. Conclusion: This study demonstrated that stone density at single point in the center of stone is higher than other areas of stone. Larger circle to assess stone density may be more preferred technique which may be helpful to decide further plan of surgical treatment and increase stone free survival rate.

   Study on impact of patient and hospital related factors affecting catheter associated urinary tract infections in a tertiary care hospital Top

Shalabh Agarwal, Baid Anand Ravindra, G. G. Laxman Prabhu, Shetty Ranjit, K. N. Sanman, P. Ravinder Prajwal

KMC Hospital, Mangaluru, Karnataka, India

Introduction and Objectives: Urinary tract infections (UTIs) account for 15% to 30% of all hospital-acquired infections (HAI). Inappropriate use of urinary catheters puts patients at increased risk for both infectious and noninfectious complications. Objective of the study are to assess various patient/hospital related factors associated with CAUTI and to Assess the spectrum of causative organisms and antimicrobial sensitivity pattern. Materials and Methods: A prospective observational study on 250 patients, who underwent catheterization during the study period included. Patients and hospital-related factors having an impact on CAUTI were studied. Urine culture was sent at time of catheterization. Patient data, culture reports, and symptoms were recorded and tabulated. Statistical analysis was done. Results and Observations: Overall incidence of CAUTI was 10.8%. Maximum incidence found in age group 61-70 years (33.3%) with incidence among males and females were 55.6% and 44.4% respectively. Incidence increases as the duration of catheterization increases, with incidence being 77.7% when the duration of catheterization was 4 or more. Incidence was more in patients catheterized in casualty (74.1%) and catheterized by nursing staff (66.7%) than by resident doctors (33.3%). Incidence among patient who received prophylactic antibiotics after catheterization was 33.33% compared to 66.67% among patients, who did not receive antibiotics. E coli was the commonest organism isolated (63%). Conclusions: Our study showed age, duration and place of catheterization, absence of prophylactic antibiotic use, catheterizing personnel and diabetes as important and independent risk factors for CAUTI. Physicians should be sensitized to need for carefully evaluating each patient and establishing a real requirement for catheterization before proceeding.

   Role of videourodynamic study in diagnosing female primary bladder neck obstruction and outcomes of bladder neck resection Top

B. Sri Harsha, Sidhartha Kalra, L. N. Dorairajan, R. Manikandan, K. S. Sreerag, Manjunath Metri

JIPMER, Puducherry, India

Introduction: Bladder outlet obstruction (BOO) in females is characterised on anatomical and video urodynamic study (VUDS) findings. Primary bladder neck obstruction (PBNO) in females is infrequently diagnosed and management can be challenging. Objectives: 1. Identifying clinical and VUDS characteristics of female PBNO 2. Correlation of surgical outcomes with clinical and VUDS characteristics. Methods: 9 Patients of PBNO were identified on clinical and VUDS characteristics over the last one year. Patients not satisfied with conservative treatment or had complications due to obstruction were offered surgical intervention- Bladder neck incision/resection (BNI /BNR). Results: Out of 9 patients, 5 presented with voiding symptoms with high post void residue (PVR), 4 had urinary retention. Mean Q max and Q average preoperatively were 4.5ml/sec and 3 ml/sec respectively, mean PVR- 295 ml, mean Pdet@qmax- 59 cm H20 and mean serum Creatinine- 4.5 mg/dl. VUDS showed poor funnelling of bladder neck during voiding. 6 out of 9 patients underwent bladder neck resection. Mean Q max and Q average post operatively were 25.2 ml/sec and 18 ml/sec respectively, PVR was insignificant with resolution of renal failure. Patients with lower pdet@Qmax (n=2, mean 21.5cm H20) did equally well as compared to those with higher value (n=4, mean 52.5 cm H20). None of the patients had incontinence or any other complication on follow up. Conclusions: Clinical assessment with VUDS correlation holds a key in identifying patients with PBNO. BNR is a safe and effective treatment in PBNO in females who fail or are not candidates for conservative management.

   Expression of syndecan-1 in urothelial bladder cancer: A novel marker for prognosis and targeted therapy Top

K. Saurav, U. Agrawal, P. Vasudeva, Y. M. Prashanth, V. Prasad, V. Tyagi

VMMC and Safdarjung Hospital, New Delhi, India

Introduction and Objective: Syndecan-1 ( SDC 1, CD 138) is a cell surface adhesion molecule essential for normal cell morphology and interaction with the surrounding microenvironment. Deregulation of SDC1 contributes to cancer progression by promoting cell proliferation, metastasis, invasion and angiogenesis. Methods: This prospective study evaluated 60 consecutive patients with urothelial bladder tumor. Urothelial cancers were confirmed for grade by histopathology. IHC for syndecan-1 was performed using ABC secondary kit and DAB as chromogen. Results: A total of 60 patients were included, of which 1 had PUNLMP, 35 had low grade tumor and 24 had high grade tumor. Syndecan-1 was found to be localised to cell membrane. Syndecan-1 expression was seen in 56 patients ( 93.3 %). Patients with high grade tumor showed higher intensity expression of syndecan -1 (21/24; 87.5 %). Conclusion: SDC 1 expression profile varies with cancer grade. High SDC 1 protein expression is seen in high grade carcinomas as well as carcinoma in situ, but not in low grade and non-invasive phenotypes. The expression signature of Syndecan-1 in tumor cells may have synergistic value for patient selection and prediction of clinical outcome. SDC1 is also an attractive molecular target for therapeutic strategies. Research is ongoing on various molecules targeting SDC1.

   Safety and efficacy of endoscopic combined intrarenal surgery - A retrospective analysis Top

Karthickeyan Naganathan, Vikram Sridharan, Maheswaran Shanmugam, Govindarajan Ramalingam, K. S. Devanathan

Jayam Multispeciality Hospital, Tiruchirappalli, Tamil Nadu, India

Introduction and Objectives: Endoscopic combined Intrarenal Surgery (ECIRS),the simultaneous performance of PCNL and flexible ureteroscopy for upper tract stones has many advantages.This study is aimed at analysing the safety and efficacy of ECIRS in the Galdakao-modified supine Valdivia position. Methods: We retrospectively analysed the data of 31 patients who underwent ECIRS between August 2015 to October 2018.Patients with large stone burden involving multiple calyces, complex calyceal anatomy, combined renal and upper ureteric stones were included. Mean operative time, stone free rate, need for transfusion, number of tracts avoided were analysed. Results: Out of the 31 patients,18 had stones in pelvis and multiple calyces (58%), 4 had stones in lower and middle calyx (13%).Three had stones in lower and upper calyces (10%),6 patients had stones both in upper ureter and pelvicalyceal system (19%). Single lower calyceal tract was utilised in 28 patients and 2 patients had single tract through middle calyx. Mean operative time was around 168+/- 23 minutes. Average drop in hemoglobin was around 1.6 g +/- 1.1g.Twenty seven patients (87%) were stone free at the end of first procedure.Three patients were stone free at the end of second procedure (10%) and one was left with residual stones due to infundibular stenosis (3%).All patients tolerated the procedure under regional anaesthesia and none required blood transfusion. Conclusion: ECIRS is safe in terms of anaesthesia and surgical technique where expertise and infrastructure are available. ECIRS is as efficient as standard PCNL in terms of stone free rate with the added advantage of minimal nephron loss.

   The preoperative predictors of extraprostatic extension of carcinoma prostate (PT3) - An Indian perspective Top

Rohan Sharma, Abhijit Patil, Abhishek Singh, Arvind Ganpule, Ravidra Sabnis

MPUH, Nadiad, Gujarat, India

Introduction and Objectives: There is need for developing nomogram predicting extraprostatic extension (EPE) from Indian cohort. We present our experience of preoperative factors predicting extraprostatic extension (pT3) in clinically localized prostate cancer(cT2). Methods: We analyzed 336 cT2 patients who underwent robotic radical prostatectomy at our centre. Post hoc analysis done of prospectively maintained data. Variables with significant association in univariate analysis were analyzed with multivariate binary regression. ROC curves were plotted for independent predictors of EPE. Results: Palpable nodule present in 81.1% pT3 and 44.4% pT2 patients. Mean PSA was 12.0±8.9ng/ml in pT2 and 20.5±18.3 ng/ml in pT3. There were 32.4% patients with biopsy Gleason ≥4+3. The mean maximum cancer in a core was 75.9±29.4% in EPE group and 53.5±30.3% in non-EPE group. The mean core positivity was 63.0±28.1% in EPE group and 40.3±24.7% in non-EPE group. Palpable nodule (p=003), T2c stage (p=0.005), Gleason ≥4+3(p= 0.02), maximum cancer in a core (p=0.01), core positivity(p=0.05) were predictors of EPE independent of PSA. ROC analysis for maximum cancer in a core, core positivity, Gleason ≥4+3, palpable nodule and T2c stage had an area under curve(AUC) of 0.695, 0.679, 0.664, 0.664 and 0.425 respectively. Conclusion: Palpable nodule, clinical T2c stage, biopsy Gleason grade ≥4+3, maximum cancer in a core, core positivity were predictors of EPE independent of PSA.

   Impact of intervention in renal functions in patients of chronic kidney disease with urolithiasis Top

N. Jain, S. Patwardhan, B. Patil, N. Jibhakate

Seth GS Medical College, Mumbai, Maharashtra, India

Introduction: We studied the impact of percutaneous nephrolithotomy in patients of chronic kidney disease with urolithiasis by estimating the GFR values. Materials and Methods: In patients of chronic kidney disease with urolithiasis who underwent percutaneous Nephrolithotomy we estimated the Glomerular filtration rate by using CKD- EPI creatinine equation. In all the patients a radionuclide scan was performed prior and 3 months after the procedure. Results: A total of 100 patients underwent PCNL for urolithiasis in the study period with a mean age of 46.27 ± 10.49 years. 22 % were female and rest were male. 11 out of 100 (11%) patients had staghorn calculi. Perioperative and postoperative blood transfusion was needed in 6% of patients. 23% had positive urine culture with pseudomonas as the most common organism. At follow-up after 3 months average improvement in renal function is 1.11 (1.63 to 0.59). renal function in 57 % of patients had improved and 43 % had remained same or deteriorated. All stages of CKD were associated with significant improvement in renal function. 13 out of 100 patients had diabetes. The difference between GFR improvement between non diabetic and diabetic patient is significant (p=0.017). No significant difference in outcome in patients with infected or uninfected urine. There was no significant difference between various stone composition in GFR improvement. Conclusions: At short-term follow-up renal function showed statistical improvement in patients with chronic kidney disease more so if the disease is secondary to calculus. But the difference in marginal and appears clinically non-significant.

   Is active surveillance a valid treatment option in low risk prostate cancer in India? Top

Shanky Singh, Saurabh Patil, Puneet Ahluwalia, Gagan Gautam

Max Hospital Saket, New Delhi, India

Introduction and Objectives: Prostate cancer represents a substantial public health burden and it is generally considered more aggressive and deadlier for developing country men like India. So is it safe to consider active surveillance for these “higher” risk patients? And if not, should upfront radical prostatectomy be preferred in low risk carcinoma prostate in such men? In the following study, we present the available—albeit limited—evidence aimed to address these important questions. Materials and Methods: Data of pre and post robot assisted radical prostatectomy specimens was analysed in 46 cases of low risk prostate cancer patients according to NCCN guidelines with a pre-op Gleason score of 3+3. Gleason scoring was done on both specimens. Two cases were excluded as malignancy wasn't found post-operatively. T stage and Gleason scores were compared pre and post-op. The Gleason scores were correlated with the age, PSA and number of needle biopsy cores. Results: Of 46 cases, data was analysed for 44 cases (among 2 cases malignancy wasn't found post-operatively). Clinically, out of 44 cases 6 patients had T2a stage and 38 patients had T1c stage. The mean age and PSA were 61.07 (SD 6.84) years and 6.89 (SD 2.06) ng/ml, respectively. The average Gleason score significantly increased by 0.59 (p<0.001) post-operatively. The primary grade increased in 4 (9.09%) cases, secondary grade increased in 22 (50%) cases. Overall, 25 (56.82%) cases had an increase in Gleason score. Upstaging occurred in 40 cases of which 70.45% (31) cases upstaged to T2. Upstaging occurred to T3 in 20.45% (9) cases of which 5 cases upstaged to T3a and 4 cases upstaged to T3b. Change in Gleason score was significantly associate with PSA and number of needle biopsy cores. Conclusions: There is a significant upgrading of Gleason score and upstaging of prostate cancer on radical prostatectomy specimens in low risk patients from India who would otherwise meet criteria for active surveillance. So upfront radical prostatectomy could be a valid treatment option compared to active surveillance in such patients.

   Prospective comparison of transperitoneal and retroperitoneal laparoscopic nephrectomy for giant hydronephrotic kidney Top

D. Desai, S. Gehlawat, U. Sharma, H. Goel, D. Sharma, M. Chaure, R. Sood

PGIMER and Dr. RML Hospital, New Delhi, India

Introduction: Giant hydronephrosis (GH) is a rare entity and its etiologies are varied. Laparoscopic nephrectomy is a reasonable option for GH and significantly reduces the morbidity of surgery. It can be performed via a transperitoneal or retroperitoneal approach. Each approach has its advantages and disadvantages. These approaches are never compared in a prospective design for GH kidneys. Objective: To compare the efficiency and safety oftransperitoneal approach with retroperitoneal approach in laparoscopic nephrectomy for GH kidneys. Methods: In this study between November 2014 and June 2019, 26 patients underwent transperitoneal laparoscopic nephrectomy and 22 retroperitoneoscopic nephrectomy. Two groups were compared for duration of surgery, estimated blood loss(EBL), overall complication rate, open conversion rate, visual pain score on the first and second postoperative days and length of hospital stay. Results: Retroperitoneal nephrectomy took significantly longer mean operative time (137.0 ± 37.4) in comparison totransperitoneal nephrectomy (112.7 ± 26.5)[P value <0.0003]. EBL was slightly more in retro-peritoneal group (154.5 ± 194.5ml vs 148.5 ± 143.7ml), but was statistically insignificant. Difference in visual pain score (5.2 vs 3.2 on day 1; 3.4 vs 1.3 on day 2) and analgesic requirements were significantly more intransperitoneal group. Difference in duration of hospital stay was statistically insignificant, but was more in trans-peritoneal group (2.0 ± 0.8days vs 1.77 ± 0.9days).There were no significant differences between two approaches in other outcomes of interest. Conclusion: Although retroperitoneal laparoscopic nephrectomy for GH kidneystook significantly more operative time in comparison to transperitoneal approach, retroperitoneal laparoscopic nephrectomy is associated with significantly less pain and less analgesic requirement leading to shorter hospital stay and short convalescence.

   Effect of transurethral resection of prostate on urodynamic parameters in patients of benign prostatic hyperplasia with upper tract changes Top

Parmar Kalpesh, Sahu Subranshu, Kumar Santosh, Dewana Sudheer, Khanna Ashish, Tyagi Shantanu

PGIMER, Chandigarh, India

Introduction and Objective: Benign prostatic hyperplasia (BPH) leads to upper tract changes due to poor compliance and long standing obstruction. Trans urethral resection of prostate relieves outlet obstruction and improvement in bladder dynamics. We aim to evaluate the Urodynamic parameters in pre and post-operative cases of BPH with upper tract changes following TURP. Methods: A prospective observational study was done from July 2017 to Dec 2018 and 21 patients were enrolled during the study period. Patients were catheterised on initial evaluation. Urodynamic study(UDS) was performed prior to surgery and again 3 months after TURP. Filling phase and voiding phase parameters were compared. Results: The mean age was 64.2 ± 9.07 years. The mean baseline creatinine value was 4.47 ± 2.95 mg/dl which came down to 1.61±0.67 mg/dl after catheterization. During filling phase of UDS, detrusor pressure at end filling phase (Pdet) was as high as 37 cm H2O preoperatively and 6 cm H2O after surgery. Mean cytometric capacity and bladder compliance improved after surgery. During voiding phase of UDS, detrusor pressure at peak flow (Pdet Qmax) showed no changes in post op period. Flow rate was improved and post void residual decreased significantly after surgery. Detrusor contractility index and bladder outlet obstruction index markedly improved after surgery. Conclusion: Bladder dynamic and resolution of upper tract change following TURP is reflected in the changes in urodynamic parameters in filling and voiding phase. A large sample size study will provide more robust evidence to this unique study.

   Living renal transplantation: A prospective randomized study comparing SHKP solution and Custodiol® HTK solution Top

Shashank Agrawal, P. Sonwane, V. Kumar Mohan, A. Ganpule, A. Singh, R. B. Sabnis, M. R. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Introduction and Objectives: Preservative solutions maintain organ in optimal condition from retrieval time until transplantation. In view of ever-increasing medical expenses, use of simple preservation fluid in live renal allograft transplantation without reducing outcome results is potential area of cost saving. Here we compare the results of live renal allograft transplant using SHKP solution prepared in our institute and Custodiol® HTK solution. Methods: 30 patients undergoing transplant were prospectively randomized into two groups. Group1 : fifteen harvested kidney preserved in SHKP solution , group2 : HTK used as preservative solution. SHKP solution consists of 500ml Normal Saline , 5000U Heparin , 20ml KCl and 120mg papaverine. Kidneys were immediately placed into an iced saline bath and flushed with cold (4°C) SHPK solution or HTK solution until the effluent was clear. Results: Both groups were comparable to donor characteristics, recipient characteristics such as age, sex, warm, cold ischemia time. Renal function was comparable in both groups at POD 1, one month, 6 and 12 months. Delayed graft function was similar in both arms (p=NS). Mean Nadir creatinine was comparable in both groups. Day 1 urine output was more in group 1 but statistically insignificant (p=0.06). One year graft-survival rate was 93.33 % in each group (p=NS). Conclusion: In live renal allograft surgery cold SHKP solution when used as flushing and preservative fluid is as efficient as HTK solution with additional cost benefit for patient.

   High risk non-muscle invasive bladder cancer - Can we avoid the RE transurethral resection of bladder tumor? Top

Mahendra Pal, Ganesh K. Bakshi, Gagan Prakash, Deep Jain, Rajesh Adapala

Tata Memorial Hospital, Mumbai, Maharashtra, India

Introduction: In non-muscle invasive bladder cancer (NMIBC), indications of restage transurethral resection of bladder tumor (R-TURBT) are T1, high grade (HG) especially when detrusor muscle (DM) in not included in specimen. However, there are few studies questioning the utility of R-TURBT, if complete resection is accomplished during first TURBT. Hence we prospectively analyzed immediate oncological utility of R-TURBT where primary TURBT was done in high volume center (HVC) of uro oncology. Objective: To assess the utility of R-TURBT where primary TURBT was done in HVC. Methodology: Study period was 3 years and included patients having HG, T1 tumors and absent DM at first TURBT, over a. Comparison was done with patients who underwent first TURBT at a tertiary center. Other variables recorded were presence of DM and residual disease post first TURBT. Results: Total of 109 patients fitted the selection criteria. 21 patients underwent first TURBT at TMH and 88 patients outside. In patients treated outside HVC, DM was not detected in 53% versus 0 in HVC (p< 0.001). Conclusion: Patients undergoing first TURBT at centers outside HVC were found to have absent DM and residual disease in high risk NMIBC patients. The difference in DM detection and residual disease is statistically significant though. It suggests the need to rethink the role of re TURBT, if the prior R-TURBT is done at institutions with high volume of these surgeries.

   Posterior urethral stricture management in children - A difficult task! Top

Yashpal Thakur, S. Jain, P. Yadav, R. Kapoor, A. Shrivastava, M. S. Ansari

SGPGIMS, Lucknow, Uttar Pradesh, India

Introduction and Objective: Posterior urethral stricture management in pediatric patients remains a challenging task and has functional implications in a growing child.We are sharing our institute's 16 year experience of its management . Methods: We retrospectively reviewed 71 boys with posterior urethral strictures managed at our institute between 1992-2017 with minimum follow up of 1 year.The etiology, extent of injury, radiologic findings, treatment and complications were evaluated.Preoperative evaluation included history, examination, radiological evaluation with RGU-MCU. Success was defined as presence of initiation, flow, and completion of voiding with radiological evidence of reestablishment of urethral continuity. Results: Total patients was 71 and mean age was 12.43 ± 5.17 year (Range 1-18).Blunt trauma was the underlying etiology in 70 cases and in one following TUVF (n=1). Mean length of distraction defect before surgery was 3.41 cm (range 2-6cm). Reconstruction route was perineal (n=63,88.7 %), Transpubic (n=7,9.8% %). Short strictures was treated by excision and end-to-end anastomotic urethroplasty in 39 boys. Long strictures was managed by combined inferior pubectomy in 27, transpubic urethroplasty in 7.Primary surgery was successful in 21 (n=21,29.5%), and redo in first instance in (n=17.39,24.5%) and at second in (n=35.5,50%). Late complications included recurrence (n=12,16.9%) and incontinence (n=4, 5.6%).Redo progressive perineal urethroplasty required in ( n=21 ,29.5%), DVIU (n=10,7.1%) and dilatation (n=28,19.8%) following first procedure. Conclusion: Most post traumatic posterior urethral strictures in children can be managed through the perineal route. The transpubic approach should be reserved for more complex strictures.Proper preoperative evaluation is needed to choose the best individualized surgical technique.


   Prospective study of role of mri in post traumatic posterior urethral distraction defects Top

C. Prasad, G. Sivasankar, Periyasamy, Senthilvel, R. Jayaganesh, Aysha Saheen

Government Kilpauk Medical College Hospital and Government Royapettah Hospital, Kolkata, West Bengal, India

Introduction and Objectives: Pelvic fracture urethral injuries are typically partial and more often complete disruptions of the most proximal bulbar and distal membranous urethra. MRI has been found to be accurate in demonstrating the distraction defect length and displacement & dislocation of the prostate apex The standard of care is delayed urethral reconstruction with excision and primary anastomosis. The purpose of our study to evaluate the role of MR urethrography in the management of posterior urethral distraction defects. Materials and Methods: 19 Patients (mean age 24 years; range, 16-42 years) from December 2016 through February 2019, with posttraumatic posterior urethral stricture underwent MR imaging before planned definitive surgery. 19 of these patients were evaluated by using conventional RGU combined with VCUG prior to MR imaging. All patients had a urethral injury due to pelvic trauma. The interval between the original trauma and the MR imaging, varied from 3 to 8 months (mean, 4.7 months). Results and Observations: On the basis of the MR findings, when the stricture length (1-2.5 cm), primary anastomotic urethroplasty was performed with a perineal approach. The patients who had a long stricture (>2.5 cm) on MR images underwent progressive perineal anastomotic urethroplasty. In two cases the stricture length was more than 3.5cms, we have performed through transpubic approach. Conclusions: MR urethrography could accurately measure the stricture length in T2 sagittal, coronal views of reconstruction. It also judges the extent of spongiofibrosis, prostatic apex dislocation, which will aid the surgeon to perform appropriate surgical procedure.

   Experience of anastomotic urethroplasty for pelvic fracture urethral distraction defects at a single center: Risk factors for surgical complexity and post operative outcomes Top

Priyank Kothari, Hemant Pathak, Mukund Andankar, Amit Sharma, Tarun Jain

Topiwala National Medical College, Mumbai, Maharashtra, India

Objective: PFUDD are debilitating injuries of the posterior urethra affecting 10% of patients with pelvic fractures. 42 patients of anastomotic urethroplasty were followed for PFUDD to determine risk factors for surgical complexity while accessing post operative complications and outcomes. Methods: 42 patients underwent anastomotic urethroplasty for PFUDD between 2014 - 2018 with 2-5 yrs follow up. Patient age (mean 26 yrs), mechanism of injury , time to delayed repair, nature of pelvic fracture and EF (IIEF-5 Score) were recorded . Urethrogram and cystogram were used to assess gap length( could be measured in 66.67%), G/U index and status of bladder neck . Immediate post operative complications and delayed outcomes in terms of uroflowmetry , continence and EF were recorded. Results: 37 patients needed perineal approach (88%)while 5 required abdominoperineal approach .( avg gap length 2.15 cm vs 2.77 cm) . Average time to urethroplasty post SPC was 6 months . Ancillary maneuverers were required in 10 patients(23.8%). Open bladder neck was identified in 7 patients(16.66%), only 2 (4.76%)of which had incontinence post urethroplasty.16 patients(38%) had varying degrees of ED post injury(graded by IIEF-5 questionaire) while 18 had ED post urethroplasty . 9 patients(21.42%) had recurrence , 6 of which required redo-urethroplasty and 3 endoscopic intervention. 3 patients each had wound site hematoma and SSI managed conservatively. Conclusion: Anastomotic urethroplasty has excellent success rates(78.58%) for PFUDD. Greater G/U index and gap length are associated with surgical complexity. ED and incontinence affect quality of life requiring subjective assessment.

   The new gold-standard in short-segment bulbar-urethral stricture? Top

Pawan Katti, P. K. Sharma, G. R. Choudhary, R. K. Saran, M. K. Chhabra

SNMC, Jodhpur, Rajasthan, India

Introduction and Objective: Urethral-stricture is common disease entity intriguing urologists since long. Wide variety of surgical options have been tried, each helping us add new insights. The refinements in treatment have continued unabated till-date, which tells a story, that we as urologists have not been successful in conquering this highly morbid pathology conclusively. Challenging the currently most popular modality for short-segment (<3cm) bulbar-urethral stricture- Excision with End to End anastomosis is an alternative: Dorsal-Onlay BMG-Urethroplasty (one-sided approach). Is it capable enough to be the gold standard? We have tried to address this question here. Methods: Patients diagnosed with short-segment (<3 cm) bulbar-urethral stricture were enrolled into our study (N=50). Patients alternatively assigned to Excision with End-End anastomosis (A-arm, N1=25) and to BMG urethroplasty (B-arm, N2=25). Postoperative RGU/MCU, uroflowmetry compared to preoperative ones. Subjective symptoms and complications recorded and analyzed. Results: 9(36%) patients in A-arm developed post-void dribbling vs 1(4%) in B-arm. Sexual dysfunction was found in 5(20%) patients in A-arm vs none in B-arm. 50% reduced incidence of stricture recurrence with B-arm 2(8%) vs A-arm 4(16%). Conclusion: From the results obtained we like to propose BMG-urethroplasty (one-sided approach) as a better treatment modality over Excision followed by End-End anastomosis for short-segment bulbar-urethral stricture disease. Among all the parameters measured the results were superior in BMG-Urethroplasty arm. As it has already established itself for long-segment stricture disease, its utility and merit needs to firmly extend to short-segment stricture disease also.

   Evaluation of risk factor for recurrence after buccal mucosal graft urethroplasty for anterior inflammatory strictures Top

Vivek Vassudeo, M. C. Arya, A. S. Jadaon, A. Singhal, A. Gandhi, Yogendra

Sardar Patel Medical College, Bikaner, Rajasthan, India

Urethral reconstruction using a buccal mucosal graft (BMG) urethroplasty has become a wellestablished modality in the management of anterior urethral strictures. Regardless of the surgical technique, BMG urethroplasty may fail over time with development of recurrent strictures. Recurrent strictures are either short segment fibrous ring strictures at the proximal or distal anastomotic sites or graft failure with extensive fibrosis involving the entire grafted area. The aim of the study is to define risk factors for recurrence after buccal mucosal graft urethroplasty. The study was a retrospective analytical study. Data of patients of male urethral strictures treated with buccal mucosal graft urethroplasty at the institution from 2013 to 2018 who developed recurrence were reviewed. Various factors were statistically analysed for their correlation with recurrence like age, etiology of stricture, length of stricture, previous endoscopic management with and without performance of clean intermittent catheterisation. Mean age of the recurrent stricture cohort was 45.6 years. Mean time to develop recurrent stricture was 19 months. On univariate analysis, factors found to be significantly associated with recurrence of stricture were lichen sclerosus related strictures, length of stricture and more numbers of DVIUs and patients who were on CIC pre operatively (P<0.05). Buccal mucosal graft urethroplasty is an established and gold standard treatment option for inflammatory stricture of anterior urethra. Though direct visual internal urethrotomy or endoscopy is most commonly performed intervention for male urethral stricture. Use of clean intermittent catheterisation/callibration after endoscopic management is supposed to improve results but increased stricture rate in patients who are on CIC after DVIU may be due to improper performance of CIC.

   Onlay preputial flap urethroplasty for children with mid or proximal penile hypospadias with chordee Top

V. Patel Priyeshkumar, R. B. Nerli, Deole Sushant

JN Medical College, Belgaum, Karnataka, India

Introduction: Onlay preputial flaps are single-stage alternatives to TIP (Tubularized incised plate) urethroplasty. The repair of mid and proximal penile hypospadias with a ventral curvature of greater than 20° after releasing the ventral penile skin continues to challenge surgeons, and there is no agreement as to the best technique for its correction. We report our results of preputial flap onlay urethroplasty for the one-stage repair of mid- and proximal penile hypospadias with chordee. Materials and Methods: We retrospectively reviewed the hospital data base for children undergone onlay flap urethroplasty and hypospadias repair for mid or proximal penile hypospadias with chordee. Results: During the study period Jan 2000 till Dec 2017, 21 children underwent onlay preputial flap urethroplasty. The procedure was successful in 15 (71.42%) children with no need to undergo further procedures or operations. There were five urethrocutaneous fistulas and dehiscence of glans in one. Conclusions: An onlay urethroplasty using the preputial flap, yields results comparable to those of staged techniques and results in fewer procedures under anesthesia in children.

   Revisiting scrotal dropback for long segment urethral strictures Top

Pankajkumar Zanwar, S. K. Patwardhan, G. Gopalakrishnana

Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India

Introduction: Scrotal dropback was used to be done in past for long segment urethral strictures, however over the period of time, its use became less and less frequent with the advent of newer techniques like augmented anastomotic urethroplasties and local flaps. However scrotal dropback still remains a favourable option in patients with complex and multiple failed interventions especially patients with long segment ischemic bulbar necrosis. Materials and Methods: We have performed scrotal dropback in 3 patients with long segment bulbar strictures. Of these, 1 patient had bulbar necrosis and 2 had previously operated failed urethroplasties for PFUI. Through the perineal incision, proximal urethra was mobilized, Scrotal skin mobilized, invaginated and incision taken on scrotal skin where it reaches proximal urethra and urethral margins sutured to scrotal skin. Catheter removal done at 2 weeks. Results: 1/3 patient underwent retubulerisation, and 2 are awaiting. One who underwent retubulerisation, is voiding with flow rate of 18ml/sec at 6 months post operatively with urethral caliber of 20fr. Other 2 patients are operated 3 months back are having no stomal stenosis, have flow rate >20ml/sec and no peristomal skin changes., these are awaiting retubulerisation. Conclusion: Though the use of scrotal dropback has become historic, it still holds importance in management of complex urethral strictures, posterior urethral disruptions and long segment bulbar necrosis. Though technically difficult, it is an effective alternative to complex tubulerised flaps and in segments inadequate for buccal mucosa urethroplasty. Hence it is imperative for young urologists to know about this technique.


   Evaluation of biochemical-recurrence and urinary continence after robotic-assisted radical prostatectomy: A single center experience Top

Mahendra Singh, Ajay Sharma, Sachin Kathuria, Vikram Shah Batra, Himanshu Pandey, Gautam Ram Choudhary, Prateek Gupta

Sir Ganga Ram Hospital, New Delhi, India

Introduction and Objectives: Robotic-assisted radical prostatectomy (RARP) is an established treatment modality for prostate cancer and done frequently at various centers in western countries. In comparison to western countries, RARP is done in very few centers in India due to limited availability of this new and costly modality. There are very few studies evaluating RARP in Indian set-up. We evaluated biochemical recurrence rate (BCR) and urinary continence status after RARP in our institute. Materials and Methods: Total 90 patients with carcinoma prostate who underwent RARP were included in study. Various demographic and pathological data were recorded. The BCR and urinary continence status were assessed at regular interval as per protocol. Results: In our study, we had observed that total 29 patients (32.2%) BCR during 3 year follow-up. The mean time for BCR to occur was 21.41±9.88 months and median time was 24 months. The continence rate in our study at 6th week, 3rd month, 6th month, 9th month and 12th month were 41.1%, 72.2%, 84.4%, 90% and 92%, respectively. The median time to achieve continence status was 3 months. Conclusion: In our study, BCR was higher in comparison to RARP series from Western countries, as a significant proportion of cases belonged to high risk category. Our results are similar to previously published data on RARP series in high risk prostate cancer. The continence data in our study are equivalent to contemporary literature supporting the reliability and reproducibility of RARP across the globe.

   Retzius sparing versus non retzius sparing prostatectomy - A randomised control trial Top

Sunil Kumar Bhat, Himanshu Sharma, P. Gregory, R. Vishnu, T. A. Kishore

Aster Medcity, Kochi, Kerala, India

Introduction and Objective: Urinary continence, erectile function and oncologic outcome comprises the trifecta in radical prostatectomy. In order to improve the continence, efforts have been directed towards maximal preservation of peri-prostatic anatomy. Our objective was to compare the outcomes of Retzius sparing robotic radical prostatectomy (RSRP) and the conventional robotic radical prostatectomy (RARP). Methods: Patient with organ confined prostate cancer who were candidates for robotic assisted prostatectomy were included in the study. Patients with T3 disease as reported in MRI, previous TURP and prostate size more the 90 grams were excluded from study. Patients were assigned to either group by computer generated random allocation. Surgery was performed by a single surgeon who is fellowship trained and has performed over 400 RARP. They were followed up at 1, 3, 6, 9, 12 months after surgery with serum PSA , assessment of their continence and erectile function. Results: Of the total 120 patients, data analysed, mean age, body mass index of the patients(BMI) were comparable in both the groups. There was no significant difference in operative time, blood loss, margin positivity and biochemical recurrence. The analysis of incontinence rates at one month,3 months and 6 months showed a significant difference favouring RSRP. (12/60 vs 46/60 at 1month, 4/60 vs 34/60 at 3 months and 2/60 vs 8 /60 at 6 months). Conclusions: Retzius sparing approach has better early continence rates compared to the conventional approach. It is feasible to perform the procedure in case of high risk prostate cancer in low volume settings with acceptable morbidity.

   Pentafecta outcome in initial 30 cases of robot assisted partial nephrectomy - Our experience Top

P. Lavanya Raghu Sarath, Altaf Khan, Mujeeburahiman, Nischith D'Souza, Jeevan Kumar

Yenepoya Medical College Hospital, Deralakatte, Karnataka, India

Objectives: To study the Pentafecta outcome of initial 50 cases of robot- assisted partial nephrectomy (RAPN) at our institute. Materials and Methods: A total of 30 patients underwent robot assisted partial nephrectomy between January 2016 and June 2018. We prospectively analysed the pentafecta outcome defined as a warm ischemia time (WIT) of <25 min, negative surgical margins, no complications intraoperatively or within 3 months of RAPN, GFR Post surgery 1 yr, ckd status at end of 1yr. Results: All patients successfully underwent robot assisted partial nephrectomy. Median warm ischemia time was 14.5 minutes. One patient with complex tumour had positive surgical margin. There were no Clavien- Dindo Grade IV and V complications. Grade I-III complications were seen in 18% of patients. Conclusion: RAPN is feasible and safe. It is equivalent to open Partial Nephrectomy even in terms of pentafecta outcome.

   Histopathological correlation of robotic assisted radical prostatectomy specimen with simultaneous Ga 68 PSMA PET/MRI (multiparametric) in cases of adenocarcinoma prostate Top

Sharwan Kumar, Rajesh Taneja, Vaibhav Sood, Azhar Azaz Khan, Vikas Kumar Bansal, Venkatesh

Indraprasth Apollo Hospitals, New Delhi, India

Objective: To correlate the histopathological extent and characteristics of malignancy in the RARP specimen, with the preoperative simultaneous PSMA PET /MRI imaging characteristics. Methodology: Thirty eight men with biopsy proven carcinoma prostate who underwent RARP, who also underwent preoperative simultaneous PSMA PET/MRI were included in the study . PET, mpMRI, and combined 68Ga-PSMA PET/MRI were independently evaluated using PIRADS V2. The whole specimen of prostate gland was divided into 12 sectors and histology compared with corresponding sectors of 68 Ga-PSMA PET, mp-MRI individually and simultaneous 68Ga-PSMA PET/ mp-MRI. Results and Limitations: Of the 38 patients, mp-MRI,PSMA PET and simultaneous PSMA PET/MRI detected cancer in 86.84% (33 out of 38), 94.73% (36 out of 38) and 97.36% (37 out of 38) patients respectively. Overall, 308 of 456 sectors (67.5%) contained cancer at pathologic examination. Simultaneous PSMA PET/MRI statistically outperformed mp-MRI and PET imaging for localization of carcinoma prostate. On sector wise correlation of excised whole mount RARP specimen with imaging, the sensitivity of mp MRI, 68Ga PSMA PET and 68Ga PSMA PET/MRI to detect malignancy was found to be 60.06% (95% CI 54.36%-65.58%), 78.25% (95% CI 73.22%-82.73%) and 81.48% (95% CI- 76.70%-85.67%) respectively. It also showed correlation between SUV max of 68Ga PSMA PET with rising Gleason Score ( p value < 0.001).

   Outcomes of robotic assisted IVC thrombectomy (R-IVT) in level I–III renal vein thrombus single tertiary care experience Top

Gregory Pathrose, Sunil Bhat, Himanshu Sharma, Vishnu Raveendran, Kiran Nair, T. A. Kishore

Aster Medcity, Kochi, Kerala, India

Introduction: Inferior vena cava thrombectomy (IVC-T) poses a formidable challenge for the surgical and anesthesia team. The high complication rate associated with open IVC-T (OIVC-T) has been cited as the rationale for development of RIVC-T. (Robot assisted Inferior vena cava thrombectomy) Methods: Retrospective analysis of patients operated our institute with level I to III thrombus was done to assess feasibility of Robotic assisted IVC thrombectomy in treating renal tumors and to assess their outcomes. We analyzed complete demographic profile, total operative duration with console time, length of hospital stay, preoperative and postoperative creatinine and intraoperative blood loss. Results: Out of ten patients (N=10), the tumor levels were 3, 4 and 3 for levels I, II and III respectively. Nine patients had right sided tumor while one patient has left sided tumor. The mean age of patients was 61.9 years (+/-13) years The total operative time of 362.5(+/-124.8) mins which included of console time of 186.5(+/-59 ) mins. The average blood loss was of 628(+/- 230) ml. The average Inferior vena cava clamp time was 28.7 (+/- 10.19) mins. The average length of hospital stay was 7.8(+/-3.27) days. Two patients needed conversion to open while rest all the tumor and thrombus was extracted via Pfnansteil incision The mean preoperative and post-operative creatinine was 1.5(+/-0.5) gm% and 2.23(+/-1.5) respectively Conclusion: With careful case selection, appropriate imaging and adequate surgeon experience is key to success allowing Robotic IVT as alternative to open thrombectomy which provides equivalent oncological outcomes when compared with open surgery with the added advantage of being minimally invasive.

   Laparoscopic radical prostatectomy for oligometastatic prostate carcinoma is it a right choice Top

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

BJMC and Civil Hospital, Ahmedabad, Gujarat, India

Introduction: Men with Metastatic prostate cancer (mPCa) at diagnosis have 5-year survival of only 28%. Androgen deprivation, salvage radiotherapy and chemotherapy represents standard treatment for mPCa but it offer a limited improvement in patient survival. Recently, local treatment of primary disease by surgery has been shown to exert clinical benefit. Objective: To investigate the results of performing Laparoscopic Radical Prostatectomy (LRP) in patients with in oligometastatic prostate cancer. Methods: Of a total of 246 patients having LRP at our center,34 (13.1%) had oligometastatic; patients were staged by preoperative MRI and bone scanning. The median patient age was 68 years; PSA level- 67.64 ng/mL and biopsy Gleason 7 . Results: Total 34 patients underwent LRP. Mean age was 68 years. Mean prostate was 41.47 gms. Mean pre operative PSA was 67.46ng/ml. Mean operative time was 197.8 min with mean hospital stay was 5 days. Continence rate was 65.71% at 6 months. Blood transfusions were given to 8 (23.52%) patients.Mean gleason score was 7. Gleason up gradation was seen in 44.1% of patients.3 years survival and 5 year survival rate was 64% and 55% respectively. Margin positivity was 50%. Conclusion: LRP for men with metastatic prostate cancer appears safe in expert hands for selected patients. Our findings support the safety of surgery in this setting.


   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

Government Medical College, Thiruvananthapuram, Kerala, India

Introduction: Symptomatic ureteric stones cause surrounding inflammation and edema promoting obstruction. C-reactive protein (CRP), white blood cell count (WC) 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 the success of MET. Objective: To assess the association of C - reactive protein (CRP), White blood cell (WBC) count and neutrophil count in predicting stone passage after medical expulsive therapy (alpha blocker) for distal ureteric calculi. Methods: Patients with distal ureteric calculus of size 5-10mm 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 and Discussion: 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. Conclusion: Decision making regarding when and whom to intervene with invasive procedures during the course of MET to avoid complications is still confusing. We conclude that low value at diagnosis and a serial decrease in these markers during the course of MET implies that the stone is likely to pass.

   Mini percutaneous nephrolithotomy challenging the feasibility of pushback percutaneous nephrolithotomy in large proximal ureteric stones!!! Top

J. Sanjay Prakash, T. Mathisekaran, Nitesh Jain

Apollo Main Hospitals, Chennai, Tamil Nadu, India

Background: To evaluate the efficacy and safety of Mini-Percutaneous Nephrolithotomy (PCNL) in the treatment of large proximal ureteral stones (2cm or less from the lower pole of kidney). This was a prospective observational study from January 2018 to June 2019 conducted in Department of Urology. A total of 77 patients were included in this study, 63 unilateral and 15 bilateral cases. Methods: 63 patients underwent standard prone mini PCNL with 15Fr amplatz using fluoroscopy. 12 cases USG guided access was obtained and in 3 cases of tortuous ureters, retrograde wire was passed via RGC and retrieved via amplatz to straighten the ureter. Calculi fragmented with laser. The ureteral stents were placed at the end of the procedure and removed after 6 weeks. Results: The mean stone size was 17.6mm. All the patients were having hydronephrotic kidneys, however, all the renal units were functional. Mini-PCNL was performed successfully in all patients. Mean operation time (OT) was 52 min. 88% patients were discharged as day care and rest admitted for 24 hours for logistic purposes. X-ray KUB done was done on POD1 to ensure stone clearance. All cases were followed up for 6weeks and underwent successful DJ stent removal. No complications were encountered. The stone-free rate in all patients was 100%. Observations and Conclusions: Mini-PCNL is both safe and effective therapy for large proximal ureteral stones with complete stone clearance rate, saves time, prevents unnecessary manoeuvres and comparable complication rates challenging the necessity of pushback PCNL in the current era.

   A comparative study between pneumatic lithotripsy, holmium laser and shock pulse in terms of efficacy and safety in surgical management of impacted lower ureteric calculus: A prospective randomised study Top

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

Gauhati Medical College and Hospital, Guwahati, Assam, India

Introduction and Objective: When the ureter is not otherwise obstructed there is 71% chance of spontaneous passage of stone from lower ureter. Ureteroscopic lithotripsy(URSL) is one of the mainstays of treatment for lower ureteral calculus.The common energy sources for URSL are pneumatic lithotripter, holmium laser, shock pulse (combined ultrasonic and pneumatic) lithotripter. This study was performed to compare the efficacy and safety of pneumatic lithotripter, holmium laser and shock pulse in surgical management of lower ureteric stone. Methods: Total 150 patients of impacted lower ureteric calculus randomised to three groups of stone disintegration methods by random number generator in this prospective study. Patients who required auxiliary procedure for stone clearance regarded as failure. Results: Patients in three groups didn't vary in terms of age, sex, laterality of stone, mean fragmented stone area (FSA). Stone clearance in pneumatic (89%) significantly low (p<0.05)than laser(98.2%) and shock pulse (98.7%) which are comparable. Retropulsion rate in pneumatic (17%) is significantly higher than the laser(2.5%) and shock pulse(2%). Stone disintegration rate [fragmented stone area (mm2 )/minute] significantly varied between groups(p<0.001), highest in shock pulse(33.32 ) and lowest in laser (16.91), intermediate in pneumatic (24.74). Irrigation fluid requirement (litre/mm2) significantly higher in shock pulse(0.070)(p<0.001) than laser (0.045) and pneumatic (0.035). Post operative urinary tract infection rate comparable between the groups. Conclusion: Current energy sources available vary in terms of stone clearance rate, stone disintegration rate, irrigation fluid requirement and retropulsion rate. The choice of energy sources are individualised to obtain optimum result.

   A prospective study comparing S.T.O.N.E. Score versus Guy's stone score versus clinical research office of the endourological society score to find which scoring system is more accurate to predict post-percutaneous nephrolithotomy stone-free status Top

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

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Introduction: Percutaneous Nephrolithotomy (PCNL) is a standard method of renal stone removal practiced worldwide. Guy's Score, S.T.O.N.E. Nephrolithometry score, CROES Nephrolithometry nomogram are validated scoring systems predicting success of post-PCNL stone-free status. We tried to find out which scoring system is better predictor of stone-free status. Materials and Methods: We have prospectively included all patients in a continuous basis at our hospital, from July 2017 to January 2019, who underwent standard PCNL (tract size >/= 24 Fr). All demographic and perioperative data were collected including calculation of Guy's Score, S.T.O.N.E. score and CORES Nomogram Score based on preoperative computed tomography. Comparison of the 'stone-free' group and 'residual-stone' group were done for various parameters using standard statistical tools. Results: Total 252 patients were enrolled. The mean Guy's Score, S.T.O.N.E. score and CORES Score in the 'stone-free' group were 1.60, 6.98 & 212.27 and in the 'residual-stone' group were 2.93, 8.98 & 129.89 respectively (p < 0.001 in all). ROC curves showed; all three scores had comparable predictive accuracy for post-PCNL stone-free status with S.T.O.N.E. Score having highest AUC value (0.852). Guy's Score had significant association with operative time (OT), estimated blood loss (EBL) and length of stay (LOS) (p < 0.001 in all). S.T.O.N.E. score and CORES Nomogram were also significantly associated with EBL (p = 0.029 and 0.001 respectively). Conclusion: All three scoring systems are equally predictive of post-PCNL stone free status. EBL is significantly associated with all scoring systems. Guy's score is also significantly associated with OT and LOS.

   A study to review the incidence and factors associated with acute kidney injury in patients diagnosed with ureteric calculi Top

Sheshang Kamath, Sujata Patwardhan

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

Aims and Objectives: The study aims to evaluate the incidence and factors associated with acute kidney injury (AKI) among patients presenting with ureteric calculi. We also intend to study the impact of time delay since first symptom to presentation to our hospital among patients with ureteric calculi and its influence on AKI. Materials and Methods: The study is a prospective observational study and included all symptomatic ureteric calculi patients. AKI was defined as per the KDIGO guidelines. All the patients diagnosed with ureteric calculi were grouped into those having an episode of AKI and those without an episode on AKI. Results: The incidence of AKI in our study was 14.63% (18 patients) among 123 patients of ureteric calculi. Average time delay from time of diagnosis to presentation among patients with AKI was 31.7±6.2 days (mean ± S.D) as compared to 19.5±5.7 (mean ± S.D) days among all cases. Factors which were significantly associated with AKI in patients with ureteric calculi include time delay, diabetes mellitus, bilateral ureteric calculi, stone size greater than 10 mm, solitary functioning kidney and urine culture showing gram negative growth. Fifty percent of the AKI group eventual required nephrectomy of one renal unit. Conclusion: This study will help us streamline our resources predominantly towards those patients who present with factors associated with increased risk of AKI. As the time delay to presentation in patients with AKI with ureteric calculi is significantly higher, it is imperative to counsel patients with stone disease.

   Effect of different energy and frequency settings on stone retropulsion and operative duration in laser lithotripsy for upper uretric stone Top

Ravindra Purohit, Pradeep Kumar Sharma, M. K. Chhabra, R. K. Saran, Gordhan Chaudhary

Dr. SN Medical College, Jodhpur, Rajasthan, India

Introduction: Stone retropulsion , though less with laser lithotripsy, still stands as a challenge while dealing with uretric calculus. Through this study an attempt has been made to find the effect of different frequency and energy settings on stone retropulsion and operative duration in laser lithotripsy for upper uretric calculus. Methods: 60 patient who were admitted with upper uretric calculus sized between 0.5 to 1.5 cm, planned for laser lithotripsy at urology department were alternatively assigned into three groups A, B and C. Laser settings in group A was kept 0.6J/5Hz, in group B was kept 0.2J/15Hz and in group C was kept 0.2J/50Hz. Note is made about the operating time and stone retropulsion rate in all three groups. Results: In group A mean operation time was 31 minutes, as compared to 44 minutes in group B and 39 minutes in group C. The stone retropulsion was seen in 4patients (20%) in group A, 1 (5%) in group B, and 2 (10%) in group C. Conclusion: High energy settings (0.6J) increases fragmentation rate thereby reduces operating time but significantly increases stone retropulsion risk. Low energy significantly reduces stone retropulsion rate with acceptable increase in operating time. Frequency (15 Hz and 50 Hz) did not significantly affect stone retropulsion rate at low energy settings. Low energy and moderate frequency are best to minimize stone retropulsion and maximize efficiency.


   Study of factors influencing the encrustation of indwelling catheters: Prospective case series Top

Sanket Kalpande, K. Sarvanan

Institute of Urology, MMC, Chennai, Tamil Nadu, India

Introduction and Objectives: Long term catheterisation is frequently necessary for patients with retention of urine or intractable incontinence who are unfit for definitive treatment or being evaluated for definitive treatment. In this study the important factors influencing the encrustation of indwelling catheters are analysed. Methods: 52 patients on catheter drainage for a period ranging from 1 month to 1 year were taken in the study. Patients reported either for problems like catheter block or routinue changing of catheter. The catheters were removed and encrustation was subjected to chemical analysis. Urine was examined for pH, specific gravity, culture sensitivity and appearance. Blood samples were taken for estimation of calcium, phosphorus and uric acid. Results: Out of 52 patients, 28 with urea splitting and 10 with non-urea splitting had positive urine culture (38 out of 52). Amongst 28, 27 (96%) had encrustation compared to 5 (50%) out of 10 with non-urea splitting organisms (P value< 0.05). Amongst 24 patients having pH>7, 22 (92%) had encrustation (P value< 0.001). Conclusion: This study showed definitive influence of following factors in encrustation formation- infection with urea splitting organism, alkaline pH, physical activity of patient, duration of keeping a particular catheter.

   Penile gangrene post TURP Top

Abhiyutthan Singh Jadaon, Mukesh C. Arya, Jai Prakash Swami, Vivek Vasudeo, Ankur Singhal, Ajay Gandhi

Sardar Patel Medical College, Bikaner, Rajasthan, India

Introduction: We are presenting a case of penile gangrene and urethrocutaneous fistula following TURP in a BPE. This is the second case in literature to our knowledge. CASE REPORT A 66 years male presented with Fournier gangrene involving whole of penis. He had undergone TURP 3 weeks back. He underwent debridement which included total penectomy and suprapupic catheterization. On follow up, micturating urethrogram (MCU) showed closed urinary bladder neck. Perineal urethrostomy (PU) was planned, antegrade scopy was done for passage of guide wire from SPC site. The bladder neck area was stenosed and guide wire could not be passed.Then the urinary bladder was opened via the spc site scar. Bougie was introduced under vision and pushed upto bulbar urethra and after raising of perineal urethrostomy skin flap. The necrotic tissue over the bougie was excised. Perineal urethrostomy was done. Patient voided comfortably post catheter removal of PU. DISCUSSION Gangrene of penis following TURP has been described only twice in literature. We explain the whole sequence of events on following basis: the causes can be diathermy injury, urinary extravasation, infection, prolonged urethral catherisation, compromised vascularity of penis.Our patient did well following debridement, SPC and finally perineal urethrostomy. Conclusion: Disaster of penile gangrene though very rare but can occur following TURP. We recommend that insulation in working element be checked at regular interval to avoid diathermy injury. Also a timely follow up visit might help us to treat infection at an early stage.

   Efficacy of tadalafil versus tamsulosin as monotherapy for lower urinary tract symptoms secondary to benign prostatic hyperplasia: A randomized single centre study Top

Sai Vijay Boya, A. V. Shanmughadas, A. T. Rajeevan, K. M. Dineshan, A. V. Venugopalan, Felix Cardoza

Government Medical College, Kozhikode, Kerala, India

Objective: To assess efficacy of Tadalafil in comparison to Tamsulosin in controlling lower urinary tract symptoms secondary to benign prostatic hyperplasia. Study design & period: Randomized, non-blinded, open label, active controlled 12 week study on men ≥45 yr of age with BPH-LUTS for >6months at screening with a total International Prostate Symptom Score (IPSS) greater than or equal to 13. Materials and Methods: Patients with significant post void residue (>100ml) and patients who were on nitrates along with renal failure were excluded from the study. Tadalafil 5mg (n=60) and Tamsulosin 0.4mg (n=60) were administered once daily to both the patient groups which were randomized by block randomization method using winpepi software. Scheduled visits were conducted every two weeks and at the end of 12 weeks and improvement in IPSS score as primary outcome and post void residual volume at the end of the study as secondary outcome measure were analyzed. Observation and Results: Tadalafil significantly improved IPSS results, from baseline, compared to Tamsulosin (p=0.004). Significant improvement in IPSS score was noted from 2 weeks of treatment. There was also significant improvement in BPH Impact Index(BII). Most common side effects noted were headache (7%) and dizziness. Conclusion: Tadalafil at the dose of 5 mg once daily for 12 weeks resulted in clinically significant symptomatic improvement with the onset of significant improvement as early as 2 weeks.

   Life with a long term urinary catheter: Perspective in Indian patients Top

Saini Sashank, M. Nazar, John Tony Thomas, Misra Nishant

Government TD Medical College, Alappuzha, Kerala, India

Introduction and Objectives: This is an ongoing prospective study assessing the quality of life in ambulatory patients with long term urinary catheters (LTC). Most previous studies in the west on long term catheters have been done on bed ridden patients in nursing homes. Methodology: We studied 35 patients, over a period of 3 months. LTC was defined as catherization more than 3 months. We used ICIQ-LTCqol (International Consultation on Incontinence Long-Term Indwelling Catheter Users), a validated questionnaire. This questionnaire consists of 19 questions related to catheter function and lifestyle impact. Questionnaire was filled by the patient, family member or treating physician. Results: Patients ranged in age from 52 to 95 years. Of the 35 patients, 26 had urethral catheter and 9 had suprapubic catheter(SPC). Median duration of catherization was 12 months. 14 patients (40%) were on LTC as they were unfit for surgery, 6 patients (17%) had extensive stricture urethra and 8 patients(23%) had neurogenic bladder. The factors studied included blockage, leaking, smell and urinary infection. Patient's age and duration of catheter moderately correlated with the quality of life which was calculated using Pearson coefficient. Embarrassment and adaptability to the catheter were the two factors causing the most bother to the patients. Conclusion: Quality of life in ambulatory patients on LTC is negatively affected and the bother and concern decreases with increasing age and duration of catherization, signifying adaptation to a life with catheter. Quality of life was better in patients on SPC than those with urethral catheter.

   Evaluation of the causes of immediate post-operative significant hematuria after holmium laser enucleation of the prostate Top

Pankaj N. Maheshwari

Fortis Hospital Mulund, Mumbai, Maharashtra, India

Introduction and Objectives: Holmium laser enucleation of prostate (HoLEP) is a commonly performed procedure for bothersome lower urinary tract symptoms related to benign enlargement of the prostate (BEP). HoLEP is usually a blood-less procedure which can be performed even in patients who are anti-platelet agents like ecosprin or clopidogril. In most patients there is no need for postoperative Foley catheter traction or bladder irrigation. In this retrospective analysis, we tried to look at causes of significant bleeding that needed cystoscopy for hemostasis or clot evacuation within first 24-hours after HoLEP. Methods: From May 2014 till May 2018, 312 patients underwent HoLEP for BEP. Patients with associated urethral stricture, history of TURP in past, associated cancer prostate, bladder tumor or prostatic abscess were excluded from the study. After these exclusions, 252 patient were included in this analysis. These patients were divided in three groups. Group A needed repeat cystoscopy for significant hematuria within 24 hours; Group B had hematuria but got controlled conservatively and Group C had clear urine in post-op period. These patient were compared for size of the gland, associated hypertension or diabetes, associated use of antiplatelet agents like ecosprin or clopidogril, intraoperative capsular perforations and morcellation injury. Results: The groups were comparable for age, size of the prostate and the incidence of hypertension or diabetes in the study population. Our protocol is to continue Ecosprin peri-operatively and try and stop clopidogril for seven days if medically feasible. Bleeding and need for cystoscopy did not correlate with the use of these drugs. Small capsular perforations are not uncommon during HoLEP. Even they did not predict significant bleeding in immediate post-operative period. Morcellator injury strongly correlated with risk of bleeding. All patients who had immediate post-op bleeding needing cystoscopy had bleeding from bladder mucosa injury that happened during morcellation and got missed at the time of the procedure. None of these patients had any prostatic fossa bleeding. Conclusions: Bleeding after HoLEP is very rare. Significant post-operative bleeding is almost always related to the morcellation injury and is never from the enucleated prostatic fossa.

   Predicting outcome of trial of voiding without catheter in acute urinary retention secondary to benign enlargement of prostate Top

Rony Jacob, Ranjit Shetty, G. G. Laxman Prabhu, Prajwal Ravinder, K. N. Sanman

KMC Hospital, Mangalore, Karnataka, India

Introduction and Objectives: Acute Urinary Retention (AUR) is an important feature of progression of Benign Prostatic Hyperplasia (BPH). The management of AUR is immediate urethral catheterisation. The TWOC is becoming current standard practice worldwide because it is advantageous to the patient when it is successful. Aim: To evaluate the factors predicting outcome of TWOC in patients with AUR due to BPH. Methods: Study period was 2 years at KMC Hospital Mangalore, constituting 62 patients. Subjects included all patients presenting to urology department with first episode of spontaneous AUR with clinical diagnosis of BEP. Patients were assessed with USG after catheterization, for prostate size, intravesical prostatic protrusion[IPP] and Detrusor wall thickness [DWT]. Patients were started on alpha blocker[silodosin-8mg]. After 72 hours, TWOC was given. Success of TWOC was voiding within 6 hours after catheter removal,voiding >150ml of urine, PVR < 100ml, Qmax on uroflowmetry > 10ml/sec. IPP was graded as grade I<5mm, grade II- 5-10mm and grade III->10mm. DWT was divided into </> 2mm. Prostate size was divided into </> 40gms. Logistic regression analysis was performed to identify predictors. Results: IPP of grade III, DWT of >2 mm and Duration of LUTS & >6 months were statistically significant predictors for failure of TWOC. Conclusion: There was significant correlation between Grade III IPP, DWT >2mm and Duration of prior LUTS > 6 months in predicting failure of TWOC in patients with first episode of spontaneous AUR with a clinical diagnosis of BEP.


   Kidney transplant in patients with severely low ejection fraction (15%–20%) - Our experience Top

Aditya Pradhan, Yajvender Pratap Singh Rana, Sunny Goel, Harish K. Sinha, Devpriya Mitra

BLK Superspeciality Hospital, New Delhi, India

Introduction: A significant percentage of ESRD patients on hemodialysis have concomitant heart failure of varying severity. Because of concern about perioperative cardiovascular events and mortality, delayed or nonfunctional grafts the decision of transplant in this subgroup of patients is not straightforward. We present our experience of 10 such patients with EF 15-20%. Materials and Methods: We analyzed the records of total 150 transplants done between July 2017 - July 2019. 10 patients had severe systolic dysfunction - EF 15-20 % with features of CHF having NYHA class - I/II. All patients were assessed and evaluated by cardiologist and cardiac anaesthetist for better peri-operative optimisation and received rigorous hemodialysis for 2-3 weeks. In only 2/10 patients, coronary angiography was done which did not reveal significant disease. All patients were monitored intensively with Flo trac monitoring system for 24 hrs. Results: Mean age of patients was 52.6 + 4.1 years. 7/10 patients were male. Mean EF 15-20 %. All patients had good diuresis after transplantation. 3 patients were electively ventilated for 24 hrs. Post operatively, fall of creatinine was satisfactory. Mean nadir creatinine was 1.2 + 0.3 at time of discharge. There was no rejection/graft dysfunction at 6 months followup. All patients had improvement in the cardiac function post-operatively Conclusion: In these subgroup of patients, improvement in LV systolic function is significant provided the perioperative issues are tackled diligently along with the cardiologist and cardiac anaesthetist. These patients should not be denied a renal transplant solely on account of poor cardiac function.

   Outcome of live related kidney transplants with multiple renal arteries Top

Muzzain Iqbal, M. S. Wani, Hamid Arif, Rather Jan Mohd, Khawaja Rouf, Ahmad Yasir, Malik Sajad

SKIMS, Srinagar, Jammu and Kashmir, India

Introduction: The use of grafts with multiple renal arteries has been considered a relative contraindication because of the increased incidence of vascular and urological complications. The aim of the study is to determine whether the kidney grafts with multiple arteries have an adverse effect on the post transplant graft function and survival. Methods: A total of 107 kidney transplants done in our centre between 2015 to 2018 were reviewed and divided in two groups; group A- kidney grafts with single renal artery. Group B- kidney grafts with multiple renal arteries.89 grafts had single renal artery and 18 had grafts with multiple renal arteries, hence required multiple vascular anastomoses. Anastomoses time, average blood loss, warm ischemia time (WIT), cold ischemia time (CIT), serum creatinine at 3,6 and 12 months, delayed graft function (DGF), renal artery stenosis (RAS), urological complications, graft survival at one year were studied in each group. Results: No significant differences were seen in the two groups regarding serum creatinine (p value of 0.224, 0.248, 0.458 at 3, 6 and 12 months respectively), DGF (7:2, p value 0.645), RAS (2:1, p value of 0.428), urological complications (10:3, p value of 0.645). Significant differences are seen in anastomoses time (29.83: 44.72 mints, p value <0.001), WIT (17.1 : 18.4 sec, p value of <0.001), CIT (50.9: 77.5 min, p value <0.001), blood loss (157:219 ml, p value of <0.001) and lymphocele formation (4:4, p value of 0.026). However this did not seem to have any effect in the graft survival at one year. The difference in graft survival between the two groups was insignificant (8:2, p value of 0.674). Conclusions: kidney transplantation using grafts with multiple renal arteries may be associated with higher rates of lymphocele formation along with increased blood loss, CIT, WIT and anastomoses time. However it is equally safe as using grafts with single renal artery regarding vascular, urological complications as well as the graft survival.

   Our experience in 100 cases of robotic assisted kidney transplantation Top

Himanshu Sharma, Sunil Bhat, P. Gregory, R. Vishnu, T. A. Kishore

Aster Medcity, Kochi, Kerala, India

Introduction and Objective: Kidney transplantation has been the standard of care for patients with end stage renal disease. While open surgery has been traditionally done, minimally invasive surgery has recently been introduced for the recipient undergoing kidney transplantation. Our objective was to study the surgical outcomes of robotic assisted kidney transplant (RAKT) and graft survival at 6 months. Methods: This was a retrospective study of 100 patients who underwent RAKT in a quaternary private hospital setting. The surgery was performed using our novel peritoneal flap technique allowing complete extraperitonealization of the kidney after transplantation. Results: The mean age of the recipients was 42±12.24 years, out of which 77 were males and 23 females. 96 patients received living donor allograft while 4 patients underwent deceased donor renal transplant. 22 patients had a double vessel renal allograft while 78 received a single vessel renal allograft. The mean blood loss 178.58±62.64 mL, mean anastomotic time was 25.58 ± 4.23 min, mean total operative time was 195±45.40 min, mean hospital stay was 6.69 ± 1.89 days, time to nadir creatinine was 6.84±1.40 days and the mean creatinine level at the end of 3 months was 1.24 mg/dL.Two patients required open conversion while two were re-explored. One patient had a urinary leak and required ureteric re-implantation and one surgical site infection was observed. Conclusions: Total extraperitonealization of the renal allograft reproduces closely the technique of open kidney transplant with good graft function. Robotic assisted kidney transplant is a safe and feasible option for patients undergoing kidney transplantation.

   Extension of the graft renal vein using gonadal vein during right sided retroperitoneoscopic donor nephrectomy Top

S. J. Rizvi, S. Khemchandani, R. Machiraju, U. Kumar, R. Jain

Institute of Kidney Diseases and Research Centre, Ahmedabad, Gujarat, India

Introduction and Objectives: Laparoscopic donor nephrectomy is considered the standard of care for living kidney donation. The Achilles heel of the procedure remains obtaining an adequate length of right renal vein. We report on out experience of using the donor's right gonadal vein to extend the length of the right renal vein of the allograft. Materials and Methods: from Dec 2018 to May 2019 we performed 8 right sided laparoscopic donor nephrectomies by the retroperitoneoscopic route. In six cases the donor's right renal vein was procured at the same time. In five cases the gonadal vein graft was slit open and fashioned into a cylinder corresponding to the circumference of the renal vein and used to lengthen the renal vein. Results: additional operative time for vein graft retrieval was 7 minutes. Time taken on bench to reconstruct the renal vein was 42 minutes. A mean extension of 9 mm was achieved. In all cases the augmented vein was successfully anastomosed with the right external iliac vein and all grafts had prompt function. All grafts functioned primarily and there were no hemorrhagic complications. At a median follow up of 5 months all recipients had normal serum creatinine. No evidence of venous thrombosis was seen on follow-up graft doppler studies. Conclusions: The donor's ipsilateral gonadal vein may be safely used to extend the right renal vein. Additional length and thickness of tissue used for anastomosis makes recipient surgery easier and reduces the discrepancy between arterial and venous length.

   Renal transplant in abnormal bladders Top

Rishabh Handa, M. Raghuveer, S. J. Rizvi, P. Modi

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

Introduction and Objective: Renal transplant is the treatment of choice in end stage renal disease patients and patients with abnormal bladder are no exception. A normal bladder stores urine at a low pressure, does not leak, and empties nearly completely by natural voiding. On the other hand, an abnormal bladder has small capacity, high storage pressure, poor compliance and incontinence. We describe our experience with renal transplant in patients with abnormal bladder. Materials and Methods: Retrospective data of patients with abnormal bladder undergoing renal transplant from January 2012 till January 2018 was collected and outcomes were studied. Results: Total 16 cases with abnormal bladder underwent renal transplant in the above mentioned period of which 5 patients had an augmented bladder, 1 had an ileal conduit and 10 were on clean intermittent self catheterization (CISC). Graft survival at 2 years was 82%. Patient survival was 91%. Mean serum Creatinine was 1.5mg/dl. Conclusion: Renal transplant can be safely done in patients with abnormal urinary bladder. The outcome of renal transplant in abnormal bladder is not negatively affected with proper preoperative evaluation, intraoperative technical modifications, appropriate post operative care and commitment and coordination amongst patients and treating clinicians.

   Retrospective study on triple and quadruple arterial anastomosis in renal transplant over period of 10 years Top

Kuppurajan Narayanasamy, Balasundaram, Tanmay Shete

KMCH, Coimbatore, Tamil Nadu, India

Aim: Does multiple arterial anastomosis has any detrimental effect on long term renal function. Materials and Methods: All renal transplants with triple or quadruple arterial anastomosis, between 2009 to 2019 were included in the study. Over 10 years we performed around 2000 renal transplants. Out of which 228 were double arterial anastomosis. In this study we have analysed 14 transplants with triple and 2 with quadruple arterial anastomosis. It is retrospective analytical study.Analysis includes donor imaging,intraoperative findings, immediate postoperative and delayed graft function,renal doppler. Results: 14 cases were with triple and 2 with quadruple arterial anastomosis.13 were live related and 3 were cadaveric renal transplants. Out of 14 transplants, 7cases preoperatively known to have three arteries,in 4 cases intaoperatively found to have 3rd artery which was missed on preoperative CT Angiogram. In 3 Cases due to early branching two arteries harvested being anastamosed as three arteries. For four arteries one patient known to have 4 and other had 3 on preoperative imaging, intraoperative found to have four arteries. The minimum diameter of artery anastamosed was 1.5mm Average anastomosis time was 46.6 minutes. Average cold ischaemia time was 112 minutes. All cases immediate renal perfusion was good. In three cases immediate urine output was good in remaining it was slow to start with.Followup creatinine is normal in 43% cases and derranged in 57%. Followup renal Doppler was normal in 15 cases.In all cases with raised creatinine there was no vascular cause related to graft dysfunction. Conclusion: In our limited retrospective study with triple and quadruple arterial anastomosis ,no patient has vascular complication and vascular related renal dysfunction.It can be done if no other suitable donor is available.But further prospective study with large number of cases and longterm followup is required.


   The role of controlling nutritional status score as a novel predictive marker for pathological stage and grade in bladder cancers and prostate cancer at initial presentation Top

Likhiteswer, Himanshu Pandey, Mahendra Singh, Gautam Ram Choudhary, Vijay Kumar Sarma, Suresh Goyal, Prateek Gupta

AIIMS, Jodhpur, Rajasthan, India

Introduction: Recently the CONUT score has received focus as a predictive biomarker of survival in patients with several cancers. Objective of the present study is to investigate CONUT score in bladder cancer (BC) and prostate cancer (PC) patients and its correlation with tumour stage and grade of the disease. Materials and Methods: We prospectively reviewed 54 patients of BC and 41 PC patients. CONUT score was calculated based on serum Albumin concentration, lymphocyte count and total cholesterol concentration with high CONUT score representing poor nutritional status. The pathological features - pathologic stage and tumour differentiation (grade for BC and Gleason score (GS) for PC) were analysed. Results: For CONUT score, the AUC for predicting grade was 0.805 for BC and 0.673 for PC and the optimal cut off value was 2 based on ROC curve. High and low CONUT score were seen in 29 and 25 patients in BC , 6 and 35 patients in PC. High CONUT score was significantly associated with ≥T2 (p =.02), sensitivity of 87% and PPV of 87% of CONUT score in predicting high grade BC, whereas in PC low CONUT score has a sensitivity of 84% and PPV of 80% in predicting GS of ≥8, but it was not associated with high stage of disease (p = .16). Conclusion: Preoperative CONUT score in bladder and prostate carcinoma patients should be taken into consideration to predict oncological outcomes. Further studies are required to validate current findings.

   Role of BRCA1 and BRCA2 gene in arsenic associated urinary bladder carcinoma Top

Alankar Jaiswal, Dilp Kumar Pal, C. K. Panda

Institute of Postgraduate Medical Education and Reearch, Kolkata, West Bengal, India

Introduction and Objective: Urinary bladder cancer has a strong association with environmental exposures such as arsenic. Arsenic induced genomic instability through BRCA pathway has been shown to contribute to arsenic carcinogenic effects. The objective of this study was to find association between BRCA 1 and 2 genes and arsenic associated urothelial carcinoma of bladder. Methods: This study was performed in a tertiary hospital in eastern India from September 2017 to February 2019. All persons with bladder cancer who were operated were included in the study. The tumor tissue was analysed for arsenic content and further analysis for BRCA 1 and 2 genes were done by IHC. Results: Expression of BRCA1 and BRCA2 was analysed in 2 adjacent normal urothelium. Total 50 freshly operated primary bladder urinary carcinoma tissues had been used for analysis of arsenic content, BRCA1 and BRCA2 genes. The expression in the tumours was analyzed with respect to cumulative normal urothelium expression pattern. Total 31 samples were high in arsenic and 19 were arsenic negative. Out of Arsenic positive samples, 20 (64.5%) samples showed under expression of BRCA1 gene and 2 (6.4%) samples showed BRCA2 under expression. Out of arsenic negative samples, only 2 (10%) showed under expression of BRCA1 and 3 (15.7%) showed low expression of BRCA2. Under expression of the BRCA1 was comparatively much high in the arsenic-endemic samples. Conclusion: The conclusion:of this study is that there is a plausible role of arsenic-exposure to under expression of BRCA1 leading to urothelial carcinoma of bladder.

   Influence of inflammatory markers on the prognosis of rare kidney cancers with variant histology Top

A. Ghanghoria, S. K. Barua, T. P. Rajeev, S. J. Baruah, P. K. Bagchi, D. Sarma, M. Phukan

Gauhati Medical College and Hospital, Guwahati, Guwahati, India

Introduction and Objective: Although Clear cell renal cell carcinoma (RCC) is the most common histological variety of malignant renal tumor, histological variants are often encountered in clinical practice which behaves differently. Paucity of such tumors makes them a subject of interest worldwide. The objective of our study is to determine influence of inflammatory markers on the prognosis of rare kidney cancers. Methods: Data from cancer registry was retrieved and all rare kidney cancer patient's data analysed in terms of neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), systemic inflammatory immune index (SIII) and CRP to albumin ratio and their probable influence on cancer free survival (CFS), progression free survival (PFS) and overall survival (OS). Results: Datas of 33 cases of rare kidney cancers were included in this study. The follow up duration ranges from 6.8 months to 38.6 months . In the Univariate analysis, NLR had a significant influence on CFS, PFS and OS (cutoff value-3.2, 95% confidence interval [CI], CFS: p-< .001; PFS: p- 0.001; OS: p-< .001) whereas PLR and SIII had a significant impact on OS : PLR (cutoff value-67.5, 95% CI, p < .001), SIII (cutoff value-8.67, 95% CI, 11.10-19.57; p < .001). Conclusions: Inflammation markers such as NLR, PLR, SII Index and CRP/albumin ratio could be independent predictors of clinical outcome and prognostics factors in rare kidney cancers. However this needs to be validated by multicentre randomised studies.

   Assessment of primary solid renal mass using texture analysis of CT Images of kidney by active contour method: A novel method Top

Arora Anuj, S. Hariharasudhan, K. Sriram, S. Venkat Ramanan, K. Natarajan, Venkata Sai

Sri Rama Chandra Medical College and Research Institute, Chennai, Tamil Nadu, India

Introduction: In most instances the diagnosis in solid renal mass is confirmed after radical nephrectomy. In indeterminate cases, per-cutaneous biopsy is done to discriminate benign from malignant masses, but is more invasive. Grey Level Co-Occurrence Matrix (GLCM) is recognized as a representative radiological parameter to define the heterogeneity of solid renal masses. Aim: To identify certain radiological parameters that might help us to differentiate the benign from malignant renal masses, obviating the need for a biopsy. Materials and Methods: A prospective study was done from June 2017 to May 2019. About 188 patients were divided into two broad groups of 94 patients each: Group 1 was patients with renal mass, of which 67 were malignant and 27 were benign. The group 2 was the control group. We used the active contour method to delineate the renal mass and study the features in them. Data analysis for each feature was individually calculated with the help of Sigma Stats 4.0 software and one-way ANOVA analysis. Results: Six CT parameters namely, entropy, energy, sum average, sum variance, inertia and low gray level emphasis were found to be statistically significant which helps the clinician to differentiate the benign from the malignant renal masses. Conclusion: GLCM parameters are crucial tool for the determination of the solid mass composition of tumour. This obviates the need for an invasive procedure like Ultrasound or a CT guided biopsy of the mass. Further studies are needed to validate these parameters and make them useful for the clinicians.

   A cross-sectional study to evaluate increase in prostate cancer detection rate with MRI guided cognitive registration biopsy versus TRUS guided standard 12-core biopsy Top

Kinjal Banerjee, Y. Qadri, D. Bansal, R. Maheshwari, S. Chaturvedi, P. Panwar, A. Kumar

Max Superspeciality Hospital, Saket, New Delhi, India

Introduction and Objectives: TRUS guided 12-core prostate biopsy has a low diagnostic yield. MRI-TRUS fusion biopsy has higher accuracy but is expensive. MRI guided cognitive registration prostate biopsy is a cheaper alternative, however data on its efficacy is limited. Aim of this study is to evaluate the diagnostic yield of MRI guided cognitive registration biopsy (MRI-CRB) and MRI-TRUS fusion biopsy. Methods: Patients undergoing MRI-CRB between April 2017 – April 2019 at a single centre in India, were studied. Inclusion criteria was total serum Prostate Specific Antigen (S.PSA) between 4-20 ng/mL, PIRADS score 3 and above. Patients with palpable prostatic nodule were excluded. Apart from standard 12-cores, 1 extra core was taken from each suspicious lesion on MRI. Data was analysed using SPSS version 21.0 and Kruskal Wallis test and Chi Square test was employed. Results: 200 patients underwent MRI-CRB with mean age of 66.16 ± 8.48 years. Mean total S.PSA was 12.56 ± 4.32 ng/mL. Odds of detecting adenocarcinoma in extra cores was 2.27 times that of detection in standard cores and mean percentage of positive extra cores was significantly high in PIRADS 4 and 5 lesions(p value <0.0001 for both). Clinically significant prostate cancer was diagnosed in 58.5% of patients. Conclusion: MRI guided cognitive registration prostate biopsy has higher diagnostic yield than standard TRUS biopsy and similar accuracy as MRI-TRUS fusion biopsy.

   Enhanced recovery after surgery in radical cystectomy: Experiences of a tertiary health care institute in India Top

Neeraja Tillu, Sujata Patwardhan, Bhushan Patil, Sheshang Kamath

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

Early recovery after surgery concepts are used in majority of the surgical specialities. However, its application in urology has been limited. ERAS regime was compared to a more conservative regimen in patients undergoing radical cystectomy in bladder cancer in this study. Materials and Methods: We conducted a single institutional prospective study and the study group (ERAS) consisted of 31 patients undergoing radical cystectomy and urinary diversion from April 2016 to March 2018. The control group comprised 39 patients operated on from 2013 to 2016. Primary outcomes were 90 day complication rates and post discharge readmission rates. Secondary outcomes included comparisons based on adherence to ERAS protocol, intraoperative blood loss, blood transfusion rates, operative duration, length of stay. Postoperative comparisons were made on time to pass stools and reoperative rate. Results: Both groups were well matched for age, gender, ASA, BMI, type of diversion, preoperative T stage. There were no significant differences in operating time, perioperative bleeding, complications graded Clavien III or above (13%) and minor complications. There was a difference in the LOS between the two groups which was not significant-7 days in ERAS group versus 14 in the controls (p=0.06). There was a statistically significant difference in the frequency of readmission within 30 days: 1/31 (4%) in the ERAS group compared with 10/39 (28%) in controls (p = 0.034). Patients with ERAS had a reduced time to diet (7 d- 3 d). There was a statistically significant reduction in mean time to first passage of stool in (3.7 days versus 5.4 days). There was no 30-day mortality. Conclusions: Application of ERAS pathway in patients undergoing radical cystectomy with urinary diversion reduces length of stay, readmissions , bowel recovery time and minor complications as compared to conventional approach. It is a practical and safe approach.


   Uroflowmetry in healthy children: Development of flow rate - Voided volume nomograms Top

Kamalkant Harishankar Singh, V. Kumar, R. Upadhyay, K. Mahmood, A. Kumar, R. Sinha

IGIMS, Patna, Bihar, India

Introduction and Objectives: To measure urine flow parameters by uroflowmetry in healthy male children of age group 5 to 15 years and establish normal reference ranges of maximum and average flow rates and see influence of age and voided volume on flow rates and chart these values as nomograms. Methods: A total of 144 healthy male school children were enrolled. A single uroflow record from each child was evaluated.Of these 37 children with voided volume of less than 50 ml and/or a staccato/interrupted uroflow pattern were excluded, and 107 records analyzed. Data were evaluated using statistical formulas and goodness of fit determined. Linear regression analysis was used to generate nomograms. Results: Flow rates and voided volumes increased with increasing age. No significant difference was noted in uroflow rates from 5 to 10 years, but significant differences (p <0.001) started appearing at 11 to 15 years. Group A consisting of patients 5 to 10 years old and group B consisting of patients 11 to 15 years old were formed. There were 64 boys in group 1 and 43 boys in group 2. In group 1 the maximum and average + SD flow rates were 19.67 + 6.14 ml per second and 13.3 + 3.24 ml per second, respectively. In group 2 these rates were 26.41 + 9.98 ml per second and 17.7 + 6.37 ml per second, respectively. Conclusions: This study on uroflow parameters in healthy male child helps application of uroflowmetry testing in the pediatric population at different voided volume.

   Post natal management of prenatally diagnosed bilateral pelvi-ureteric junction obstruction Top

A. Suryawanshi, R. Babu, K. Natarajan

Sri Ramchandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Introduction and Objective: Bilateral pelvi-ureteric junction obstruction (PUJO) is rare and we report single Centre experience of managing this entity following prenatal diagnosis.We retrospectively audit our experience over past 15 years. Methods: Among patients who were treated for PUJO following antenatal diagnosis, only those with bilateral grade 3-4 PUJO were included. Presentation, evaluation and management are analyzed. Results: Between 2003-2018,1410 patients were evaluated following antenatal hydronephrosis (ANH) and 224 (15%) were diagnosed to have PUJO. 28 patients (M: F = 26:2) had bilateral PUJO (2%).Vesico ureteric reflux (VUR) was identified in 8/28 (28%). One patient warranting late ureteric reimplantation.Among 28 patients 6 had bilateral grade 4 hydronephrosis with palpable mass (group 1); 10 had bilateral grade 4 hydronephrosis without mass (group 2) and 12 had grade 3/grade 4 hydronephrosis (group 3). Patients in group 1 underwent neonatal intervention (4 bilateral pyeloplasty; 2 unilateral pyeloplasty with contra-lateral stenting). Patients in group 2 underwent unilateral pyeloplasty of worse side first followed by elective contra-lateral pyeloplasty after 2 months. Group 3 underwent unilateral pyeloplasty of worse side and were followed up with repeat renogram ; 3 /12 deteriorated on contra-lateral side warranting pyeloplasty. Conclusions: 1. Bilateral pyeloplasty is feasible and successful in infants; 2. Contra-lateral improvement is noted following unilateral pyeloplasty in bilateral PUJO patients. 3. Contra-lateral stenting/nephrostomy can be effective to prevent loss of function in those elected for unilateral pyeloplasty.

   Percutaneous nephrolithotomy in paediatric patients: A single centre experience Top

Mayank Gupta, M. Nagabhushan, R. Keshavamurthy

Institute of Nephro Urology, Bengaluru, Karnataka, India

Introduction and Objectives: In India, there is a high prevalence of Urolithiasis both in adults as well as in children. Percutaneous nephrolithotomy (PCNL) is an established technique used in children with renal calculi. We report our experience with PCNL in children. Materials and Methods: Clinical records of 120 children who underwent PCNL procedures for renal calculi from June 2007 to March 2019 were reviewed. Patients had pre-operative blood and urine analysis, USG KUB and X-ray IVU or CT KUB. Variables assessed included patient's age, sex and stone burden. PCNL technique, route, calyceal access and number of tracts were recorded. Operative time, Hb drop, stone clearance, complications, and treatment for residual stones were also reviewed. Results: The mean age was 12.8 years (2-18 years) with a M: F ratio of 2.3: 1. The mean stone diameter was 17mm. 108 cases required single puncture and twelve required multiple tracts. Access was most commonly through posterior inferior calyx. Overall, 24 staghorn stones, 39 multiple calyceal stones and 57 single stones were treated. 101 patients (84%) were completely stone free following initial PCNL. 3 patients had relook PCNL and 8 cases had ESWL for residual fragments. During the procedure mean Hb drop was 1.36±0.8 gm% while 10.6% patients required blood transfusion. Intra and post-operative complications included conversion to open surgery in 1.6%, pneumo/hydrothorax in 1.3% and uro-sepsis in 3.6%. Conclusion: Paediatric PCNL can be performed safely with minimal morbidity for large and complex stone burden, enabling rapid and complete stone clearance.

   Mini-PCNL versus extracorporeal shockwave lithotripsy in pediatric age group with borderline stones: An institutional study Top

Brijesh Tiwari, G. Vezhaventhan, Balasubramaniyam, Gopal Chengalvarayan, K. Saravanan

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

Introduction: The extracorporeal shockwave lithotripsy (ESWL) remains the most common first line of treatment for renal stones in the pediatric population. The purpose of this study is to evaluate and compare the outcomes of the ESWL and mini-percutaneous nephrolithotomy in treatment of stones size 1-2cm. Patients and Methods: A total of 54 patients younger than 12 years of age with 1-2 cm single renal stone (pelvic or calyceal) were randomized into two groups, each containing 24 patients. Patients in group 1 were subjected to mini-PCNL using 16 Fr percutaneous sheath while those in group 2 underwent ESWL. Results: The stone-free rate after first session was 81.4% (22 cases) and 66.6% (18 cases) for groups 1 and 2 (significant P < 0.005). Conclusions: mini-PCNL is a gives better stone cearence in single sitting in most of pediatric cases but comparable to ESWL after three session, However, the mini- PCNL has more radiation exposure, complications and requires a longer hospital stay.

   Mitrofanoff procedure in valve bladder syndrome: Our experience Top

Utsav Shah, S. Ramesh Babu, K. Natarajan

Sriramachandra Medical College, Chennai, Tamil Nadu, India

Introduction: In children with valve bladder syndrome, bladder management and night time drainage are crucial to prevent further damage to upper tract. Here we present our experience of open and laparoscopic Mitrofanoff appendicovesicostomy in such cases. Materials and Methods: A retrospective review of all the patients with valve bladder who underwent Mitrofanoff procedure between 2004 and 2019 was performed. The case records were analysed for complications and renal outcomes. Results and Observations: A total of 12 patients underwent Mitrofanoff procedure for Valve bladder. In 9 patients it was performed via open technique while in three it was performed laparoscopically. The median follow up was 8 years (1-15). All patients had umbilical stoma and were able to catheterise well. One patient had stomal stenosis warranting revision. Hydronephrosis and creatinine remained stable in 9 with the help of night time catheterisation. Urodynamic parameters showed no worsening in this group. One patient has undergone renal transplantation while two are on the waiting list. Conclusions: Mitrofanoff continent appendico-vesicostomy is an essential part of CIC and night time drainage in patients with valve bladder. With sensate urethra, urethral CIC is impossible in children with valve bladder and early Mitrofanoff with night time catheterisation postpones deterioration. Take Home Message: Mitrofanoff procedure is a useful adjunct in valve bladder for preventing damage to upper tracts.

   Bedwetting in girls staying at residential school Top

Shyam Mohan, R. B. Nerli

JNMC, Belgaum, Karnataka, India

Introduction: 12 % of children still wet the bed regularly at 7 to 9 years old. We report our study wherein girls staying in a residential school were assessed for bedwetting. Materials and Methods: A detailed history including diet, sleep, bowel movements & urinary voiding patterns. Physical examination included observation of gait, examination of spine and abdomen. The children were counselled regarding water intake, sleeping pattern, voiding before going to bed and use of alarms to wake up at night time to void and were advised to visit our hospital for further treatment if necessary. Results: A total of 342 girls belonging to class 6 - 10 (age 11 to 16 years) were examined for general fitness . A total of 37 (10.81%) girls had history of nocturnal enuresis. The median age of these girls was 12.5 Years. Fourteen (37.83%) of these girls had primary nocturnal enuresis , whereas 23(62.16%) had secondary enuresis. Eighteen (48.64%) girls had symptoms suggestive of attention deficit hyperactive disorder (ADHD). Similarly 12 (32.43%) girls were average performers in school. Conclusions: Often dismissed as something that children outgrow, bedwetting is a genuine medical problem that can be treated. Bedwetting can have a big impact on children's self-esteem. Giving them information about their bedwetting, gives them a psychological boost. This will help them to develop strategies to deal with their bedwetting, but also help them to realize that they're not alone.


   Robotic assisted laparoscopic repair of vesico vaginal fistula: Our experience at a tertiary care centre Top

Mohsin Quadri, Thirumalai Ganesan, Arun Kumar Balakrishnan, K. Ramesh, Deepak Raghavan, Ananthkrishnan Sivaraman, Nitesh Jain

Apollo Main Hospital, Chennai, Tamil Nadu, India

Introduction and Objectives: Vesico vaginal fistula (VVF) are rare,but when they are present they are devastating to women, causing distress due to persistant leakage of urine. Most VVF are the result of pelvic surgeries,where in 90% occur post hysterectomy. Our objective is to describe the surgical technique and outcomes with robot-assisted laparoscopic repair of VVF in 24 patients. Materials and Methods: From 2013 to 2018, a total of 24 patients with VVF underwent robot-assisted laparoscopic VVF repair. The principles of VVF repair were followed. The fistula tract was excised. The vaginal defect and the cystotomy were closed, omental interposition done between the bladder and vaginal suture lines. Perioperative patient characteristics, complications, operative data, and follow-up results were retrospectively reviewed. Results and Observations: All 24 patients of VVF, out of which 21 developed as a result of previous elective hysterectomies for benign indications, 2 patients underwent emergency hysterectomy for bleeding while LSCS and 1 patient developed as a result of LSCS. 5 were recurrent VVF's (Open-4,Lap-1). Mean operative time was 142 minutes (range, 123-160 minutes). Longer operative times were caused by concomitant surgeries (2 ureteric reimplantations). Median length of stay in hospital was 3 days (range 2.6-3.3 days). There were no intraoperative and significant postoperative complications. All patients were cured and were without VVF recurrence at a median follow-up of 26 months. Conclusions: Robot-assisted laparoscopic VVF repair is an effective approach to manage VVF even in complex fistulas and in recurrent cases. It is anticipated that an increasing number of VVF repairs will be undertaken with robotic assisted laparoscopic approach in offering more patients who need VVF repair at the advantage of minimally invasive surgery.

   Painful bladder syndrome: Myths and treatment outcomes Top

S. Prasanna, M. Kanagasabapathy, S. B. Viswaroop, M. Arul, G. Gopalakrishnan, S. V. Kandasami

Vedanayagam Hospital, Coimbatore, Tamil Nadu, India

Introduction and Objectives: The Bladder pain syndrome complex(BPS/IC ) presents with a baffling array of symptoms and always a diagnosis of exclusion. We intend to •Study the response time to treatment and time to relapse •Does intravesical agents alleviate symptoms and improve quality of life •Is Botox effective in BPS/IC? Methods: A total of 25 patients diagnosed and treated as BPS/IC (outpatient and inpatient) in the past three years are included. Past clinical and surgical history, comorbidities, cystoscopy findings were recorded. O'learySant Symptom and problem index, two day voiding diary was documented before and after treatment. Ultrasound/CT KUB was done to assess the upper tract. All had cystoscopy and hydrodistension followed by medical (Pentosanpolysulfate, anticholinergics, Gabapentin) treatment. In those who did not respond intravesical cocktail (2% xylocaine, 0.5% Bupivacaine, triamcinolone, 10000 U Heparin,10 ml Sodium Bicarbonate, Oxybutynin 5 mg, Pentosan Polysulfate Sodium 100 mg) therapy (daily for 2 weeks then weekly for 6 weeks). In refractory cases Botox injections and Surgery were offered.The minimum follow up was 6 months. Results: Median age is 55.5 (30-81)and (Male to female) M: F-17:8 . The mean BMI was 26.2, Charlson comorbidity index- 2.56.Hunners lesion cystititis(HLC) and Non HLC were 18 and 7 respectively. Of 25, 11 are on medical therapy with 10 showing stable response (Pain score <5) . 13 had Intravesical cocktail relapsed after few weeks of initial response. One had cystectomy with urinary diversion. The median follow up is 21 months. Conclusion: BPS is underdiagnosed. Relapses are common despite temporary respite from medical treatment including intravesical cocktail. Botox is ineffective. Surgery can be offered as a last resort.

   Ureterovaginal fistula; Is endoscopic management an optimal option? Our experience Top

Shashikant Vitthal Asabe, Vilas P. Sabale, Vikram Satav

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

Introduction: Ureterovaginal fistula is a known complication of pelvic surgeries, especially following gynecological and obs surgeries. Here, we report our experience with ureterovaginal fistulae and its management. Methods: Patients with ureterovaginal fistula treated in routine practice between 2008 and 2019 were included in this study. Medical records available in the hospital and with patients were used to collect the study-related data. Data were analyzed and reported using descriptive statistics. Results: A total of 25 patients of ureterovaginal fistula were included in the study. The mean age was 45.4 years and all the cases were secondary to gynecological and obs surgery. All patients presented with per vaginal leak, 10 (40%) patients presented with only leak, 13 (52%) patients had hypogastric pain, 2 (8%) patients had fever as symptoms. Blood and radiological investigations done accordingly. All patients underwent cystoscopy with gentle retrograde pyelography. Whenever even minimal contrast entered in proximal ureter besides the pelvic vaginal leak gentle attempt of dj stenting over terumo glidewire was attempted and successfully done in 17 patients initially . 8 cases after failed attempt of dj stenting underwent reimplant under same anesthesia. 2 patients out of 17 initial successful stenting had persistent leak warranting ureteric reimplant. Out of 25 patients 15 were successfully treated with only dj stenting. Conclusions: Results from this study show that majority of ureterovaginal fistulae can be treated successfully with endoscopic management reducing the morbidity significantly.

   Vaginal graft substitution urethroplasty for female urethral strictures: A good alternative to lingual/buccal micosal graft Top

Prashant Kumar Singh, Jigyasa Singh, P. B. Singh

PBS Urology, Varanasi, Uttar Pradesh, India

Introduction: Female urethral strictures are now managed by urethroplasty. We published LMG urethroplasty in 15 females with good outcome (BJU2009). In spite of good outcome, buccal or lingual graft were not a preferable choice in female either because of slight facial deformity or mild slurring of speech. We used vaginal graft for dorsal on lay substitution urethroplasty in 11 patients operated between Jan 2017 to Oct 2018 with satisfactory outcome. Materials and Methods: Eleven female patients between31 to 50 yrs. had obstructed flow requiring frequent dilatation. These patients were evaluated by uroflowmetry, ultrasound and MCU. All patient revealed distal narrow segment of urethra with length varying from 8mm to 16mm with dilated proximal urethra Urethra was dissected dorsally by a half circle incision as described in our first publication. Using sims speculum lateral wall of vaginal wall was exposed and graft was harvested taking precaution that length was more than required graft length at least by 1 to 1.5cm. Augmentation of urethra was done with mucosal side towards lumen of urethra. Catheter was maintained for 3 weeks. Results: All patients had uneventful recovery. Voiding trial was given after 3 weeks. All patients voided with good stream with average Qmax 22ml/sec. Follow-up is ranging from one to 8 month. All patients are voiding well without any need of dilatation Conclusion: Easy harvesting, minimum donor site morbidity and equally good result may make vaginal mucosa as first choice for substitution urethroplasty in female urethral stricture.

   Laparoscopic repair of recurrent vesico vaginal fistulas Top

Ujwal Kumar, R. Jain, S. J. Rizvi, P. R. Modi

Institute of Kidney Diseases and Research Centre, Ahmedabad, Gujarat, India

Introduction and Objectives: Vesico-vaginal fistula (VVF) has been a surgical challenge for surgeons for centuries. VVF following surgical trauma during hysterectomy is often seen now a days. Many surgical techniques, including open and laparoscopic repair, have been used to deal with this problem. Laparoscopic repair of VVF has been well reported but it has also been shown that success rate of VVF repair (open/laparoscopy) decreases progressively with failed previous procedures. Here we present our experience of laparoscopic repair of recurrent VVF. Methods: 10 cases of recurrent VVF were operated laparoscopically at our center between July 2013 to July 2019. We report our experience with laparoscopic surgery in management of recurrent VVF. Results: Out of the ten cases operated, eight had previously undergone one surgery for VVF repair and two had undergone two previous surgeries for the same. The mean operative time was 178 minutes and the mean blood loss was less than 100ml. The success rate of these surgeries was 100%. These surgeries adhere to the principles of abdominal repair, improve cosmesis, and shortened convalescence but definitely needed meticulous excision of dense fibrosis due to previous failed repairs. Conclusion: Laparoscopic VVF repair is a safe and effective way to deal with recurrent VVF cases. However, case selection is important and experience with VVF repair and laparoscopy is a prerequisite.


   Challenging ureters with large calculi-the role of laparoscopy Top

Yevale Ashish, Dube Siddharth, D. K. Jain

Bharati Vidyapeeth Medical College, Pune, Maharashtra, India

Introduction and Objectives: To study and compare prospectively the technique, outcome and complications of Laparoscopic ureterolithotomy (Lap-UL) in large upper ureteral calculi compared with ureteroscopic lithotripsy(URSL) and percutaneous nephrolithotripsy (PCNL). Methods: Prospective comparative study Inclusion Criteria: Patients with proximal ureteral calculus within 3cm of PUJ >15mm size on CTKUB Exclusion Criteria: Patients with urosepsis and congenital anomalies,history of previous ESWL, PCNL ,open surgeries,pregnancy. Consecutive type of non-probability sampling Group A: URSL 25 cases Group B: Lap-UL 25 cases GROUP C: PCNL 25 cases stone-free rate,auxillary procedure if needed, cause of auxillary procedure,operation time, and complications analysed. Results: Laparoscopic ureterolithotomy had highest stone free rate (100%) and no need for auxillary procedure. Auxillary procedure rate was highest in URSL (12%) followed by PCNL (8%). Mean procedure time was highest in laparoscopic ureterolithotomy (110.12 minutes) followed by PCNL (75.24 min) and URSL (65.08 minutes) (p<0.001). Hospital stay was laparoscopic ureterolithotomy (2.08 days), URSL (1.2 days) and PCNL (2.04 days).There was no statistical difference in Laparoscopy and PCNL for duration of hospital stay. No complications were encountered during laparoscopy as against post URSL upper ureteric strictures in 2 patients. Conclusion: Laparoscopic ureterolithotomy while having more operative time still has greater stone clearance rate, less need for auxillary procedure and comparable hospital stay to PCNL without major complications in trained hands. It can therefore be safely considered as alternative method for treating large proximal ureteral calculi especially fearing post laser URSL ureteral strictures that can occur in large impacted ureteral calculi.

   Pelviureteric junction obstruction with crossing vessels whether cause or associated finding: Cross sectional histopathological analysis Top

G. Giniwale, C. Munjewar, S. Singh, A. Srivastava, I. R. Dhayal

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

Introduction and Objectives: Most common cause for pelviuretericjunction (PUJ) obstruction is thought to be intrinsic defect of muscular development or the deficient nerves in the obstructed narrow segment. Other causes include obstruction from outside: crossing vessel (CV), tumor compressing PUJ etc and intramural causes. Congenital Hydronephrosis is associated with crossing vessels in 26% of cases. The purpose of this work is to evaluate histopathological changes in patients of PUJ obstruction with or without crossing vessels. Materials and Methods: This was cross sectional study conducted on 110 patients who underwent laparoscopic pyeloplasty from January 2017 to June 2019. Of these 36 patients had associated crossing vessels. Resected PUJ segment was sent for histopathological analysis of chronic inflammation, muscular hypertrophy, fibrosis, muscle disarray and synaptophysin. Results: Mod to severe chronic inflammation was seen in 16.67% and 40.54 % (P > 0.05) cases with CV and without CV respectively, similarly fibrosis and muscular hypertrophy was seen higher in cases without CV although these were not statistical significant. on contrary muscle disarray shows trend of higher in cases with CV but it was also not statistical significant. Synaptophysin was not positive in cases with CV but positive in 11.11% cases without CV. Conclusions: based on this study there is no significant statistical difference in the histopathological changes in patients with or without crossing vessels.

   Anatomical variation of the left renal vein, lumbar vein and correlation with CT findings in left donor nephrectomy Top

Sharma Laxmi Kant, R. Khera, P. Ghosh, K. Ahlawat, P. Mishra, D. Rathi, S. Kumar

Medanta-The Medicity, Gurgaon, Haryana, India

Wide anatomical variations present in the left Renal vein and lumbar veins, which has got impact on the operative duration, blood loss during left laparoscopic donor nephrectomies. This prospective study was done to determine the intraoperative complications associated with these variations and findings were correlated with the preoperative CT findings. Simplified lumbar vein variation classification has been proposed. Methods: 174 healthy individuals who had underwent Left Laparoscopic Donor Nephrectomy with preoperative CT angiography. Intraoperative the anatomical variations of the left renal vein and lumbar vein were observed and correlated with CT angiography findings. Based on the intraoperative findings a simplified lumbar vein classification was proposed. Results: 0.74 % (10) of donors Retroaortic left renal vein was present, Circumaortic left renal vein was present in 1.72 % (3) donors and in 0.57 % (1) donor left renal vein was draining into the Gonadal vein. The mean operative time was maximum (196.7 minutes) in donors with Circumaortic Left renal vein while other anomalies were having comparatively same operative duration and the mean operative duration was 180 minutes. The estimated blood loss was also high (133 ml) in cases of circumaortic left renal vein while it was least in donors with retro aortic left renal vein (100 ml ) with a mean blood loss of 104.7 ml. Conclusion: In patients with left renal vein anomalies the mean operative time and estimated blood loss was significantly higher than donors with normal anatomy. Preoperative CT angiography helps in appropriate planning and predicts the intraoperative complexity.

   Management of ureteric obstruction caused by idiopathic retroperitoneal fibrosis - A single centre experience Top

L. R. Rakhul, Babatosh Das, Pragnesh Desai, Vikas Singh, Pankaj Panwar, Samit Chaturvedi, Ruchir Maheswari, Anant Kumar

Max Super Specialty Hospital, Saket, New Delhi, India

Introduction: Retroperitoneal fibrosis (RPF) is a rare disease with estimated incidence of 1 in 200,000 to 500,000 per year. Management of ureteric obstruction by RPF requires a step wise approach, with judicious use of medical and surgical treatment options. Materials and Methods: All cases of suspected RPF underwent imaging with CT/ MRI and a functional imaging with DTPA scan. PET-CT is also being used recently to see the disease activity. ESR and CRP were done to confirm the presence of inflammation. Once RPF is confirmed, DJ stenting was performed and patients were started on steroids and tamoxifen/mycophenolate. Inflammatory markers were done every 3 - 6 months. Once the markers are normalized, repeat imaging is done. If there is resolution of fibrosis, stents are removed and patients continued on medical management for additional 12-18 months with annual imaging. In case of non-response to medical therapy, ureterolysis and omental wrap was performed laparoscopically or robotically. Results: The total number of patients treated at our institution till 2019 June is 38(15 males and 23 females), with a mean age of 37 years. DJ stenting followed by medical treatment alone was successful in 12 cases, with an average duration of medical management for 28.3 months and DJS for 22 months. Surgical treatment was required in 26 cases, (13 unilateral and 13 bilateral). Average duration of stent and medical management in the surgically treated patients were 12 and 18 months respectively in the surgical group. Complications include ileus (n = 7), iliac vessel injury(n=1), duodenal injury (1) and open conversion in one patient. Conclusion: Ureteric obstruction due to RPF requires careful evaluation and follow up with combined medical and surgical therapy to prevent nephron loss. Lap/robotic ureterolysis is a safe and effective method for definitive management of ureteric obstruction, with acceptable complication rates.

   Right donor nephrectomy -A large single centre experience Top

Pravin Ladda, Vipin Tyagi, Mrinal Pahwa

Sir Ganga Ram Hospital, Delhi, India

Introduction: Laparoscopic donor nephrectomy (LDN) preferentially involves the left kidney to optimize vessel length, but many times right nephrectomy is preferred. This retrospective study is to evaluate reasons for choosing right kidney for donor nephrectomy and intraoperative events during right donor nephrectomy and to compare outcomes of graft function of right and left LDN. Materials and Methods: A retrospective review was performed among 850 donor nephrectomy performed in our single centre. Among which 210 underwent right DN and 640 left donor nephrectomy . We performed 160 right donor nephrectomy through transperitoneal laparoscopic approach via 4 ports and remaining 50 via open subcostal retroperitoneal approach in cases of short right renal vein, multiple right renal vessels, early branching of renal vessels,obese recepient . Vascular stapler used for ligation of right renal vein in all cases. Parameters from right donor cohorts and long-term renal allograft function was compared with traditional left-sided laparoscopic donor nephrectomy cohorts. Results: Right laparoscopic donor nephrectomy was performed for varying reasons including multiple left renal arteries or veins, smaller right kidney, cystic right renal mass, atheroma/stenosis of right renal artery, significant differential function lesser than left kidney (>10%). 2 patients with IVC bleeding controlled with laparoscopically suturing. Conversion was required in three patients secondary to bleeding from adrenal vein in 2 patients and in 1 patient with grossely enlarged liver . Both surgical and postoperative complications were recorded and compared with left. No significant differences were found for any of the parameters measured including operative time. Conclusion: This study demonstrates that right laparoscopic donor nephrectomy is a skilled but feasible procedure with very less margin of error. Despite substantial differences in the procedures, donor outcome in terms of intraoperative outcomes and graft survival are similar for right and left LDN.

   Feasibility of laparoscopic nephrectomy for emphysematous pyelonephritis- Our experience Top

Ujwal Kumar, R. Jain, S. J. Rizvi

Institute of Kidney Diseases and Research Centre, Ahmedabad, Gujarat, India

Introductions and Objectives: Emphysematous pyelonephritis (EPN) is an aggressive life threatening condition if not recognized early and treated promptly. EPN is managed initially with i.v. antibiotics and diversions in the form of DJ stenting / Percutaneous nephrostomies and other supportive measures. Many cases eventually need nephrectomy for which open surgery has been the main stay but laparoscopic nephrectomy can also be done. Methods: A retrospective data was collected in our unit from December 2017 to July 2019 of the cases presenting with EPN who needed nephrectomy. Results: 11 patients needed nephrectomy of which 1 needed emergency open nephrectomy and all the rest i.e. 10 patients underwent elective trans peritoneal laparoscopic nephrectomy (after stabilization and diversions) successfully with average blood loss of 165 ml and average duration of surgery being 195 minutes. Conclusion: Although traditionally EPN kidneys have needed open ablation but with more and more use of laparoscopic surgeries in other non functioning kidneys (pyonephrosis/ stone disease), with proper experience and expertise, laparoscopic nephrectomies can be done in these kidneys safely, reducing the wound complications and other morbidities in these patients who are diabetic and elderly.


   Medical management of radioluscent renal calculi: Is it effective Top

Rakesh Rollands, Vilas Sabale, Niraj Chaudhary

Dr. D.Y Patil Medical College, Pune, Maharashtra, India

Introduction and Objective: This study was done to compare the efficacy of allopurinol and febuxostat and to establish a protocol for treatment of radiolucent stones. It evaluates the change in urinary pH levels with both treatment methods, along with dietary modification and urinary alkalization and calculates the decrease in size of stones / disappearance of stones with both methods. Methods: Prospective study in which a total of 50 patients were enrolled. 25 in Group A, given Febuxostat 80mg with alkalinizer syrup and 25 in group B with allopurinol 300mg with alkalinizer. Follow up done at 3 months, 6 months with urinary pH, Serum uric acids and CT scan. Results: The Mean HU of stones considered was 582.4. There is statistically significant decrease in stone size at 3rd and 6th month in both groups. The successful dissolution patients have higher pH than unsuccessful patients. Urinary pH increased at 3rd and 6th month. Serum uric acid levels decreases significantly. In group A, 10 patients had response (4 complete and 6 partial) and 5 patients in group B (2 complete and 3 partial). 19 patients showed no response in the study. Conclusion: Medical dissolution therapy may have increasing promise in future. Careful selection of patients with low BMI, higher pH levels at presentation and lower HU on CT scan for stone dissolution therapy may yield higher results for stone dissolution. At least 6-month therapy with adequate follow up should be done.

   Comparison of the F+20 and F-15 diuresis technetium -diethylene triamine pentacetic acid renography protocols for diagnosis of Ureteropelvic junction obstruction in patients with hydronephrosis Top

Vaishnav Ankit, Sarkar Debansu, Pal Dilip Kumar

Institute of Post-Graduate Medical Education and Research and SSKM Hospital, Kolkata, West Bengal, India

Introduction and Objectives: Hydronephrosis secondary to ureteropelvic junction obstruction (UPJO) can be confirmed by diuretic renography with 99m technetium-diethylenetriamine pentacetic acid (Tc-DTPA). The diuretic furosemide (F), is either administered 20 minutes after the tracer for a brisk diuresis (F+20 study) or preceded it by 15 minutes (Fâˆ'15). We here compared results of F-15 protocol with that of the widely established F+20 protocol, to see whether the F-15 is more conclusive. Methods: Patients of any age attending the Department of urology, with unilateral or bilateral primary hydronephrosis of any degree with suspicion of UPJO were included in study after applying pre decided exclusion criteria. Each patient underwent both F+20 and F-15 diuretic Tc-DTPA renography studies at least two days apart and analyzed by single expert analyzer. Results: Out of 91 patients, majority were with unilateral primary hydronephrosis, 20-30 years group and female. Most of the cases with equivocal results by F+20 protocol were converted into obstructive or non-obstructive by F-15 protocol, with significantly low inconclusive results specifically in mild hydronephrosis. In F+20 results, most patients with incidental diagnosis were showing equivocal results, which were converted to non-obstructive in F-15 protocol. Conclusions: In our study F-15 diuretic renogram protocol was found to be more conclusive than F+20 protocol especially in incidentally diagnosed cases of primary hydronephrosis and patients with mild hydronephrosis in ultrasonography, suggesting F-15 to be used as a single test when there is only one opportunity to confirm or exclude the presence of obstruction.

   Thrombocytopenia as a predictor of acute kidney injury and length of hospital stay in patients with emphysematous pyelonephritis Top

A. Anvesh, C. S. Manohar, V. Shivakumar, R. Keshavamurthy

Institute of Nephrourology, Bengaluru, Karnataka, India

Introduction and Objective: Emphysematous pyelonephritis (EPN) is a rare necrotizing infection of renal parenchyma. Role of thrombocytopenia as a predictor for development of AKI in patients with EPN has been investigated in hardly few studies. Hence we aimed to investigate relationship between thrombocytopenia & development of AKI in patients with EPN. Methods: A Retrospective cohort study was carried out from January 2007 to December 2018 (11 years) which included 227 EPN patients. All patients above 18 years with CT confirmed diagnosis of EPN were included in study. Patients with history of urethral fistula, urethral trauma, urethral catheter insertion were excluded from study. Chi-Square test & Fisher Exact test were used to compare percentages between two or more groups. Student's T test was used to compare means between two groups. Level of significance was taken as p<0.05. Results: Study included 162 (71.3%) females & 65 males with mean age of 52.22 years. Mean length of hospital stay was 7.7 days. Of 227 EPN patients, 154 (67.8%) developed AKI. When compared with cohort without AKI, platelet count <1.5 lakhs cells/cumm was a statistically significant predictor of AKI & length of hospital stay (P<0.001). Also Pearson correlation analysis showed platelet count was negatively associated with peak serum creatinine (r=-0.606, P<0.001), peak blood urea nitrogen (r=-0.419, P<0.001), length of hospital stay (r=-0.317, P<0.001). Conclusion: Thrombocytopenia is a significant predictor of development of AKI in EPN patients. Monitoring of early platelet count is valuable guide for AKI risk stratification & length of hospital stay prediction.

   Novel technique of transurethral resection and retrograde DJ stenting of ureteric orifices in obstructive uropathy secondary to carcinoma cervix Top

Chirag Doshi, K. M. Madappa, R. Vijaya Kumar, R. Ravi Kumar, Sachin, V. Manjunath

JSS Medical College, Mysore, Karnataka, India

Background and Objectives: Ureteric obstruction from Carcinoma Cervix is a recognised event with an incidence varing from 14% to 34.5%. Various methods for ureteral decompression like Percutaneous Nephrostomy, Antegrade and Retrograde stenting have been used effectively. But very often retrograde stenting fails if ureteric orifices cannot be identified at cystoscopy and the other methods though effective for decompression, have a significant negative impact on patient's quality of life (QOL). So, a technical modification for stenting obscured ureteric orifices has been discussed here with regards to the outcome, effectiveness, complications and impact on QOL. Materials and Methods: A prospective cohort study was conducted at our institution from September 2016 to February 2019. Forty patients with obstructive uropathy secondary to Carcinoma Cervix included. This technique involves spinal block and lithotomy positioning followed by fluoroscopy guided cystoscopy using 22 Fr sheath. Bladder was assessed and patients whose ureteric orifices were not visualised were subjected to the procedure. Under aseptic precautions sterile methylene blue was injected into the bladder by ultrasound guidance. Bladder was filled to half its maximum capacity and transurethral layered reaction of bladder at 80 W using monopolar current was done till ureteric orifice was identified by efflux of dye.Then a guidewire was deployed and DJ stent railroaded over it. Results: The procedure was successfully completed for all 40 patients.Then mean pre procedure serum creatinine was 4.1 mg/dl. Complete renal recovery was seen in two weeks with serum creatinine <1.5 mg/dl in 72.5% patients. At three months 87.5% presented for follow up and had a mean serum creatinine of <2.5 mg/dl. None required dialysis post stenting. 17.5 % had stent syndrome which was managed with anticholinergics and alpha blockers, one required stent replacement and no patient had vesicovaginal fistula. The QOL pre and post procedure at day 7 and 90 was assessed using Standard Quality Questionnaire Form (SF-36) and scored using SF 36 calculator. The overall mean of physical component health scale and mental component health scale showed significant improvement after procedure with, P<0.05 and 95% CI. Conclusion: This technique can be easily replicated, is as effective as other methods of urinary diversion, provides good renal recovery, is less invasive and scores over other methods.

   Management of intraperitoneal rupture of bladder- our experience with review of literature Top

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

Gauhati Medical College and Hospital, Guwahati, Assam, India

Introduction: Intraperitoneal rupture is seen in 15 % of all bladder ruptures with extra peritoneal ruptures being more common(80%) and a minority of patients(5%) have both intraperitoneal and extra peritoneal rupture. Conversely, 5 to 10% of bladder injury is seen in pelvic fracture. Rupture of urinary bladder occurs when the bladder is distended and intravesical pressure exceeds 300cm of H2O and the weakest point is bladder dome. Immediate catheterisation is very important as the most reliable sign of bladder injury is gross hematuria which is present in 93% to 100% of cases. Materials and Methods: Here we present our experience in single institute over 2 years of 4 cases of intraperitoneal bladder rupture which were managed conservatively. Results: In our series, all injuries had occurred due to trauma, in three due to motor vehicle accident and one due to accidental fall. On investigation(CT urography), they were found to have small intraperitoneal bladder rupture, which was treated conservatively by catheterization of 20 Fr catheter and strict monitoring . Patients underwent Cystogram after 2 weeks and catheter was removed after confirming no leak. Conclusion:Apart from surgical methods of closing intraperitoneal rupture of bladder which seemed to be almost rule in all cases of intraperitoneal bladder rupture, a conservative treatment of small intraperitoneal bladder rupture is also possible. This may increase the options a surgeon has while dealing with such cases.

   Surgical guilt: Fact or fantasy. A survey of Indian urologists perception on tribulation after surgical misadventure Top

Vineet Narang, Dinesh Suman, Satish Gunawant, Jeetender Kumar, Banwari Lal

Indian Spinal Injury Centre, New Delhi, India

Introduction: Surgeons like other humans undergo a gamut of feelings ranging from depression to euphoria. Sometimes the expectation from themselves and their patients is too high that they fall in their own eyes and succumb to a feeling of guilt. Its intriguing too see how different surgeons deal with failure, some feel guilty and some like to lay blame on others. We sought to find whether the entity “Surgical guilt” exists ? and the perception of Indian urologists on distress after a surgical failure/complication. Methods: A 20 question anonymous survey pertaining to the emotional state of urologists after a surgical failure was sent to all members of the USI. Results: • 395 Urologists replied out of to the 2600 (response rate 15%). Majority were in the private sector (83 %). 60 % had experience of less than 10 years. • 87 % of respondents believed and experienced Surgical guilt. • 50% urologists were significantly apprehensive about delivering successful outcome in the pre & Intra operative period and 60 % would take substantial intra-operative risk to achieve it. • Around 70 % experienced significant guilt if an avoidable intra-op complication occurred and if desired outcome was not achieved. • 65 % blamed themselves for the failure and 40 % experienced significant negative emotions. • 30 % urologists did not discuss surgical complication with patient relatives because of fear. • 64 % feared a backlash from patient's relatives in case of a failure & 76% agreed that surgeons are too harsh on themselves in such a scenario. Conclusion: Surgical guilt is a distinct entity and majority of Urologists have faced it in their lifetime. A surgical misadventure takes a significant emotional toll on the mental health of the urologist. It is time that we recognize this entity and create support systems for urologists to deal with regret / failure after a surgical misadventure.


   'Trifecta' outcomes of open nephron sparing surgery in the patients of T1a and T1b stage renal cell carcinoma: A single institutional experience in seventy four patients Top

Mahesh Chandra, Rajesh Gulia, Nikhil Bhachches

Government Medical College Hospital, Chandigarh, India

Objectives: To analyze the trifecta outcomes of open nephron sparing surgery (ONSS) in the patients of T1a & T1b stage renal cell carcinoma. Patients and Methods: In all, 227 patients underwent nephrectomy for renal cell carcinoma between March 2011 to April 2019. Out of all, 74 patients underwent open nephron sparing surgery (ONSS) for T1a & T1b stage renal cell carcinoma. We retrospectively analysed the functional and oncological outcomes of these 74 patients. A 'trifecta' of outcomes in these patients of renal cell carcinoma was assessed, with trifecta defined as a warm ischemia time (WIT) of <20 min, negative surgical margins, and no complications intraoperatively or within 3 months of ONSS. Results: All 74 patients underwent open nephron sparing surgery (ONSS) for T1a & T1b stage renal cell carcinoma successfully with two conversions to radical nephrectomy. The median (interquartile range [IQR]), operative time was 90 (60-124) min. Early renal pedicle unclamping was used in 11(14.9%) patients and zero ischemia was used in 12(16.2%). The trifecta outcomes were achieved in 38 of 66 patients (57.6%) of renal cell carcinoma. The median (IQR) WIT was 15.5 (8.75-20.0) min for the entire cohort. The overall complication rate was 24.1% and the rate of Clavien-Dindo grade ≤II complications was 16.3%. The positive surgical margins were present in four cases (5.4%). The median (IQR) follow-up was 10.5 (2.12-24.0) months. The median drop in estimated glomerular filtration rate at 3 months was 7.0 mL/min/1.72 m2 (11.01%). Conclusion: Our study suggested that ONSS is a safe and effective treatment option for T1a & T1b stage renal cell carcinoma in terms of a trifecta of negative surgical margins, WIT of <20 min, and low operative and perioperative morbidity. Keywords: Open partial nephrectomy, RCC, nephron-sparing surgery, trifecta, robotic surgery.

   Orthotopic neobladders with a short loop ileal pouch for bladder cancer: Does size matter? Top

A. J. P. George, J. C. Singh, A. Devasia

CMC, Vellore, Tamil Nadu, India

Aim: To review the outcome of the orthotopic neobladders using a short ileal loop pouch, in our institution. Materials and Methods: The study spanned 16 years from 2003 to 2019. Patients who underwent an orthotopic neobladder reconstruction using a short loop ileum (35cm+5cm) were included. All patients were taught Kegel's exercises before the surgery. Following surgery all men were trained to void every 3 hours to limit the voided volume to 400ml. Data was retrieved from our electronic database. Pouch capacity, voiding, continence, erectile function, upper tracts and biochemical parameters were assessed. Results: 39 men underwent a nerve-sparing-radical-cysto-prostatectomy and an ileal-orthotopic-neo-bladder construction for TCC(94%) bladder. Mean age was 50.7years (SD 10.5). 34 (87%) men had an 'N'-pouch. Final biopsy revealed upstaging in 15 (38%). Mean follow up was for 54months. 23 (59%) men were continent with occasional leak, at their 4 weeks post op review. 31 (82.8%) men were fully continent at 3 months, with only occasional nocturnal leak (<3times/week). All gained continence with continued Kegel's exercises, by 6 months. All men voided without the need for CISC. The mean Qmax was 22ml/sec (SD12), voided volume 273ml (SD109), PVR 30 (SD 23). 17 (44%) had spontaneous erections. Six others (17%) required PDE-5 inhibitors. Renal function remained stable with no progressive upper tract dilatation in any. Six men received chemotherapy (Neoadjuvant-5; Adjuvant-1), thirty three (84.6%) were tumour free at last review Six men expired(16.6%) with late recurrence and metastasis. Conclusions: Orthotopic neobladder reconstruction using a short loop (35+5cm) had good outcomes in terms of continence, functional capacity, voiding to completion without needing CISC and upper tract and biochemical preservation in a carefully selected patient group.

   Prevalence of HPV16 and HPV18 subtypes in penile cancer patients of Indian origin Top

Harshit Garg, Prabhjot Singh, Prashant Kumar, Raman Kumar, Brusbhanu Nayak, Santosh Kurra, Alpana Sharma

AIIMS, New Delhi, India

Introduction and Objectives: Penile cancer is significantly associated with human papillomavirus (HPV) 16 and 18, which can comprise of upto 15-80% patients. There is a dearth of literature unveiling the molecular mechanism of penile cancer such as the association of telomerase activity and htert promoter methylation in this disease. Materials and Methods: Biopsy proved 38 penile cancer patients and 15 controls (circumcision) were recruited for the study from 2016-2018. HPV 16 & 18 subtype distribution was performed in the recruited study subjects using Genosen's HPV 16 & 18 subtype real time PCR kit. Promoter methylation assay was performed using the methylation specific primers. Results: We observed that 8/38 (21%) patients were HPV 16 positive and 7/38 (18.42%) patients were positive for HPV 18 subtype. Further, collectively 11/38 (28.9%) patients were positive for any of the HPV subtype (HPV 16 & 18). Simultaneously, 1 control showed positivity for both HPV16 &18 whereas another control showed positivity for HPV 18 subtype only. In tissue lysates, significantly increased (p<0.001) telomerase activity in penile cancer patients were recorded compared to controls. Out of 38 cases, 13 patients were pathologically staged II. 1/4 (25%) of Stage 0, 2/4 (50%) of stage I, 5/13 (39%) of stage II, 2/5 (40%) of stage III and 2/9 (22%) of stage IV patients were positive for either HPV 16 or HPV 18. Conclusion: This maiden attempt substantiated the prevalence of HPV 16 & 18 subtypes in penile cancer patients of Indian origin. Further, higher telomerase activity and htert promoter unmethylation in HPV positive subjects suggested their involvement in this disease.

   Significance of matrix metalloproteinase-9 expression and matrix metalloproteinase-9 polymorphism in prostate cancer Top

Bandhan Bahal, Gupta Prashant, Sharma Gaurav, Bhowmik Prasenjit, P. K. Sharma, S. N. Mandal

Calcutta National Medical College, Kolkata, West Bengal, India

Introduction and Objectives: The aim of the study is to assess the expression of the matrix metalloproteinase-9 (MMP-9) gene and -1562 C/T polymorphism in MMP-9 gene promoter in relation to clinicopathological parameters and predicting the clinical outcome of prostate cancer patients. Methods: This is a prospective study conducted from July, 2017 to June, 2019. Fifty patients with adenocarcinoma prostate, proven by histopathology, were included in the study. DNA was extracted from the tissue and the primer sequence for MMP-9 was amplified using polymerase chain reaction. The genotypes of MMP-9 (-1562 C/T) were determined by the polymerase chain reaction-based restriction fragment length polymorphism method. Results: MMP-9 gene expression and MMP-9 polymorphism is associated with higher stage and higher grade of the disease. However it is not correlated with serum prostate specific antigen levels. Conclusion: Our study demonstrated that positive MMP-9 gene expression is associated with advanced prostate cancer. MMP-9 gene studies can help to identify the patients with advanced disease. Keywords: Matrix metalloproteinase-9, Prostate cancer.

   Correlation of PSMA PET CT with serum PSA and gleason grouping in carcinoma prostate Top

Prafull Mishra, Narmada Gupta, Rajiv Yadav, Varun Mittal, Ashok Sen, Laxmikant Sharma, Sunil Kumar

Medanta-The Medicity, Gurgaon, Haryana, India

95 percent prostate cancer cells expresses PSMA antigen on their surface which is utilised by PSAM PET CT at the primary site as well as the metastatic site. This study was done to study correlation between PSMA PET CT with serum PSA and Gleason grouping ,to determine the level of PSA and Gleason Group at which PSMA PET is indicated. Methods: 100 patients with biopsy proven carcinoma prostate underwent PSMA PET CT. The findings of PSMA PET CT (SUV max) was correlated with Serum PSA and Gleason grouping and confirmed with final Histopathogy. Results: All patients demonstrated pathologic tracer accumulation in the primary tumour that exceeded physiologic tracer uptake(SUV-3.5) in normal prostate tissue Range -5.9 to 32 . Tumours with GS of 3+3(Gleason group 1), 3+4 and 4+3(Gleason group 2) showed significantly lower 68Ga-PSMA-11 uptake, with mean SUV max of 14.7 and 12.92, respectively, compared to patients with GS >7(Gleason group 3,4 and 5) (median SUV max: 21.92; p < 0.001). PC patients with PSA ≥20 ng/ml exhibited significantly higher uptake than those with PSA levels <10.0 ng/ml in the same Gleason group .Final HPE revealed up gradation in Gleason Group 1 and 2 and in group 3,4,5 detected higher incidence of Metastatic diseases. Conclusion: The Gleason score and serum PSA level correlated with the intensity of tracer PSMA accumulation in the primary tumours of carcinoma prostate patients on 68Ga-PSMA-11 PET/CT. PSMA PET is indicated in Gleason group 1 and 2 with PSA level more than 10 and in patients with Gleason group 3,4,5.

   Trends in utilization of neoadjuvant chemotherapy in patients with muscle invasive bladder cancer at a tertiary care cancer hospital Top

K. Dholakia, G. Prakash, M. Pal, A. Joshi, G. Bakshi

Tata Memorial Hospital, Mumbai, Maharashtra, India

Introduction and Objectives: To evaluate trends in use of neo adjuvant chemotherapy (NACT) among patients with ≥T2 Bladder cancer and determine renal function ineligibility for cisplatin based chemotherapy. Methods: Retrospective review of all the patients diagnosed with bladder cancer undergoing Radical Cystectomy (RC) between Jan 2014 and May 2019 was performed. Information on clinico-pathological stage , renal function and use of neoadjuvant chemotherapy was collected from electronic medical records . GFR was estimated with Renogram or CKD-EPI equation. Results: 270 Radical cystectomy were performed in the study period. 39(14.44%) were for BCG failure in non muscle invasive bladder cancer and 9 (3.33%) were salvage surgeries after bladder preservation. The utilization of NCT has increased over time from 27.27 % in 2014 to 60 % in 2019 (P < 0.01). 45% ( n=98) patients received neoadjuvant chemotherapy , while 55 % (n =120) patients were operated with upfront cystectomy in patients with ≥ T2 bladder cancer. 66.32 % received Cisplatin based NACT while 28.57 % received carboplatin based NACT. 10.55% ( n=23) patients were ineligible for cisplatin based neoadjuvant chemotherapy and GFR of less than 45 was the commonest reason for this ineligibility. Conclusion: The overall use of NACT in ≥ T2 bladder cancer has been increasing at our institution. Recent figures show our utilization of NACT to be more than that in western literature. The findings of this study also highlights the likely utility of immunotherapy in neoadjuvant setting in cisplatin ineligible bladder cancer patients in India.


   The proactive repeat imaging for high-grade (Grade-IV) renal injury with urinary extravasation does not improve outcomes in the patients of blunt trauma Top

Mahesh Chandra, Seema Wasnik, Tarun Mittal, Aman Gupta

Government Medical College Hospital, Chandigarh, India

Introduction: The AUA guidelines state that blunt high-grade renal injuries with urinary extravasation (UE) may be managed conservatively in hemodynamically stable patients and follow up with routine repeat radiological imaging. Aims and Objectives: To evaluate impact of routine, the proactive follow-up renal imaging for need of urological intervention or risk of urologic-specific complications. Materials and Methods: A retrospective analysis of blunt renal trauma patients treated in our institution from June 2005 to May 2015 was done. All patients identified by record from our institutional surgical emergency registry. Individual patient charts and imaging were reviewed to identify all patients with American Association for the Surgery of Trauma (AAST) Grade IV- renal injuries. Only those patients with UE were included and patients with penetrating trauma or mortality during the hospitalization were excluded. Data collected was analyzed for repeated radiology imaging and its impact on treatment of blunt renal trauma patients. Results: Of the 230 identified with Grade -IV renal injuries, 75 patients met criteria with UE on CECT imaging at clinical presentation and their characteristics includes a median age of 21 years (IQR: 12-48), 70% male gender, 60.0% with injuries due to motor vehicle accident (MVA). Five patients had immediate nephrectomy for UE, although 20% underwent an endoscopic procedure (DJ-Stent or Retrograde pyelogram within 24hours of admission into hospital). Of all patients with UE, 30% underwent endoscopic intervention and three patient ultimately required a nephrectomy. As compared to those without reimaging, patients who had proactive repeat imaging were older but otherwise similar in demographic profile which include gender, mechanism of injury and ISS. Reimaging was not associated with statistically significant difference in rate of urological intervention or time to intervention. Follow up nuclear scan was conducted in 50% at median of 90 days from time to renal injury. Renal salvage (SRF>20%) accomplished in 90% and routine radiological reimaging was not associated with improved long-term renal function. But, the proactively imaged patients had a higher mean number of radiating abdominal scans (2.5 vs. 1.6, p-value <0.01) accomplished in 89.5% and routine reimaging was not associated with improved long-term renal function. Conclusions: Routine repeat imaging does not appear to alter outcomes or change the risk of urological intervention for patients of blunt high-grade (Grade-IV) renal trauma with UE.

   Genetic association of uromodulin gene polymorphism with kidney stone diseases in the population of eastern India Top

Siddharth Saraf, A. Chatterjee, D. K. Pal, M. Das

1Institute of Post Graduate Medical Education and Research, 2Department of Zoology, University of Calcutta, Kolkata, West Bengal, India

Introduction and Objective: Kidney stone disease (KSD) is a major clinical problem imposing a large burden for both healthcare and economy globally. In India, the prevalence of KSD is increasing with nearly 12% of the population getting affected. We aimed to evaluate the association between genetic defects and urolithiasis in population of eastern India. Methods: A group of 50 kidney stone patients were recruited based on radiological investigations. Peripheral blood samples were collected, and whole genomic DNA was isolated using standard protocol. Among these 20 case samples were selected based on demographic and clinical parameters, and were sent for deep sequencing. A total of 50 controls were recruited from the same community. Results: Preliminary screening has identified 2 polymorphisms in UMOD gene that may serve as a potential marker for urolithiasis. We recognized one synonymous variant and one 5-UTR variant rs13335818: p. Val264=, rs12917707 G>T respectively in study individuals. Clinical parameters like, serum creatinine, 24 hour urinary calcium and phosphate was found significantly higher in case samples. There was no significant difference found in intact Parathyroid hormone level in case and control samples. Conclusion: This preliminary study promises that polymorphism in UMOD gene may serve as a genetic marker for early detection of KSD. However, further studies with larger sample size are required to provide conclusive evidence to understand the association of UMOD gene with KSD.

   Validation of acute physiology and chronic health evaluation II scoring system at 24 hours after admission as a prognostic tool in urosepsis: A prospective observational study Top

Praveen Kumar Lakhera, G. Vezhaventhan, G. Chengalvarayan, R. Balasubramaniam

Madras Medical College, Chennai, Tamil Nadu, India

Purpose: Urosepsis implies clinically evident severe infection of urinary tract with features of systemic inflammatory response syndrome (SIRS). We validate the role of a single Acute Physiology and Chronic Health Evaluation II (APACHE II) score at 24 hours after admission in predicting mortality in urosepsis. Materials and Methods: A prospective observational study was done in 178 patients admitted with urosepsis in the institute of Urology from OCTOBER 2018 to JUNE 2019. Patients >18 years diagnosed as urosepsis using SIRS criteria with positive urine or blood culture for bacteria were included. At 24 hours after admission to UROLOGY WARD, APACHE II score was calculated using 12 physiological variables. Results: Mean±standard deviation (SD) APACHE II score was 28.03±6.03. It was 26.31±7.48 in survivors and 34.39±6.09 in those expired (p<0.001). Among patients undergoing surgery, mean±SD score was higher (30.74±4.85) than among survivors (24.30±6.54) (p<0.001). Receiver operating characteristic (ROC) analysis revealed area under curve (AUC) of 0.825 with cutoff 25.5 being 94.7% sensitive and 56.4% specific to predict mortality. Mean±SD score in those undergoing surgery was 25.22±6.70 and was lesser than those who did not undergo surgery (28.44±7.49) (p=0.007). ROC analysis revealed AUC of 0.760 with cutoff 25.5 being 94.7% sensitive and 45.6% specific to predict mortality even after surgery. Conclusions: A single APACHE II score assessed at 24 hours after admission was able to predict morbidity, mortality, need for surgical intervention, length of hospitalization, treatment success and outcome in urosepsis patients.

   The use of single J stent with extraction string vs conventional string DJ stent in females: A randomized study Top

Surya Nihar Seemakurthy, Vilas P. Sabale, Vikram Satav, Sonu Sharma

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

Introduction: Though not proven, it's hypothesized that, the lower coil of the DJ stent is cause of stent related morbidity. We have undertaken study to compare stent related complications using SINGLE J STENT with an extraction string and DOUBLE J STENT with an extraction string. Extraction strings can be advantageous as it obviates the need of another procedure for it's removal. Methods: Female patients undergoing ureterorenoscopy for ureteric calculi were enrolled for the study. Stenting done via retrograde approach. Stent removal was done on POD -14. In all cases, prolene (7-0) was used as an extraction string after a knot 1cm from the lower end. They were randomized into two groups alternatively. GROUP A (n=50) patients had a single j stent with an extraction string (the BLADDER coil of the DJ stent was discarded) GROUP B (n=50) patients had a double j stent with an extraction string. Stent related complications / morbidity was assessed by a standard questionnaire (USSQ) . Results: Single j group had a better morbidity profile with lower average scores of urgency , dysuria and hematuria . They had better pain profile and lesser incidence of reflux. One incident of accidental stent expulsion was noted in each of the group. No incidence proximal stent migration noted. Conclusion: We conclude that the bladder coil of DJ stent might be responsible for the stent related morbidity. Removing it and attaching an extraction string decreases the morbidity. It also saves patient from an additional procedure.

   Performance of quick sequential organ failure assessment score to predict mortality and ICU admission in patients with acute pyelonephritis Top

Ninad Tamboli, V. Shivakumar, C. S. Manohar, R. Keshavamurthy

Institute of Nephrourology, Bengaluru, Karnataka, India

Introduction: Although role of qSOFA as a tool of rapid prognostication in sepsis is emerging, literature regarding it's utility in urosepsis due to acute pyelonephritis is scarce. We investigate the predictive performance of qSOFA in patients with urosepsis due to acute pyelonephritis (APN). Materials and Methods: We prospectively studied 106 patients of APN admitted between June 2018 to June 2019. All the patients with APN diagnosed on CT scan were included. Recurrent pyelonephritis cases presenting within 3 months of previous episodes were excluded. In-hospital mortality and ICU admission were primary outcome. We evaluated the predictive performance to predict in-hospital mortality and ICU admission using AUC of the ROC curve. Results: Out of 106 patients, 11 patients died, and 34 patients were admitted to the ICU. Mean age was 52.51(± 16.58). 63.2% were females.  Pseudomonas aeruginosa Scientific Name Search 6.4%) and E.coli (20.8%) were most common organisms present in urine culture of patients with in-hospital mortality and ICU admission respectively. 48.11% patients were having calculus disease. 38.7 % patient underwent DJ stenting and 10.4% underwent percutaneous nephrostomy. The sensitivity and specificity of qSOFA ≥2 (100%, 84.2%) in predicting in hospital mortality was better than SIRS ≥3 (72.2%,77.9%). The AUC of qSOFA(0.943,0.950) to predict in hospital mortality and ICU admission was significantly greater than that SIRS(0.847,0.783,P <0.001) and comparable to that of SOFA(0.986,0.968), Serum lactate(0.994,0.904) and serum procalcitonin(0.998,0.910). Conclusion: qSOFA is clinically more useful scoring system than SIRS to predict in hospital mortality and ICU admission in patients with acute pyelonephritis.

   Role of cholecalciferol for the prophylaxis against recurrent urinary tract infection among female patients: A randomized study Top

Garg Anurag, S. S. Yadav, Tomar Vinay, Priyadarshi Shivam, Vyas Nachiket, Agarwal Neeraj

SMS Medical College, Jaipur, Rajasthan, India

Introduction and Objective: To explore the role of cholecalciferol for the prophylaxis against recurrent urinary tract infection (UTI) in female patients presenting with UTI. Methods: The study was conducted in the Department of Urology. Our randomized, uncontrolled prospective study included 100 female patients with moderate/severe symptoms suggestive of UTI, consecutively. The patients were randomly allocated to two groups; group-A included 50 patients who received empirical antibiotic therapy, while group-B included another 50 patients who received antibiotics with cholecalciferol. The study population was followed up for 1 year after the start of the treatment. For all the patients enrolled, clinical evaluation, imaging studies (abdominal ultrasonography), and laboratory investigations [including urinalysis and urine culture with antibiotic susceptibility testing for positive cultures] were provided. Results: The incidence rate of recurrent UTI was high among the study population; it was significantly higher among group-A patients (antibiotics alone) compared to those of group-B patients (antibiotics + cholecalciferol). Conclusions: The incidence of recurrent UTI is high among Indian female population. Cholecalciferol supplementation may be protective against recurrent UTI among the female patients without any extra adverse effects.


   Adjustable trans-obtuator male sling - Our initial experience Top

A. Pednekar, T. B. Yuvaraja, S. Waigankar, P. Dev, A. Khandekar

Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India

Introduction: Urinary incontinence is one of the troublesome symptoms after Robot Assisted Radical Prostatectomy (RARP). Few patients are unable to achieve continence even after procedures like male urethral sling or artificial sphincter. Here we present our initial experience of ATOMS in post RARP patients. Materials and Methods: Five patients who failed to achieve continence after RARP even after conservative management between 15.04.2018 and 25.02.2019 were implanted with ATOMS. The average duration of incontinence was around 2.2 years. A radio-opaque silicone cushion was held in suburethral position by two transobturator mesh-arms; titan-port for adjustments was implanted in scrotal pouch connected to it. Adjustments were performed until continence was maintained. Steps of the procedure are shown in the video. The evaluation included preoperative vs. postoperative 24hr pad use, urinary flow and clinical status at 3rd, 6thmonth and 1 year follow-up. Results: Four out of five patients developed continence within 24 hours after the catheter removal (one pad V/S 6-8 pads per day). No intra-operative complications were noted and mean operative time was 50mins. Three patients received top-up(6ml) after 1 month for mild urine leak. One patient required second top-up(4ml) after 3 months. One patient required repositioning of the reservoir port and treatment with antibiotics for his wound infection and is still incontinent. Conclusions: We believe ATOMS system is promising modality for incontinence in post RARP patients with limiting factor being Cost of implant. Longer follow up and more number of patients are needed to evaluate the efficacy of this new device.

   Laparoscopic management of right and left RCC with renal vein thrombus Top

J. Sanjay Prakash, T. Mathisekaran, Nitesh Jain

Apollo Main Hospitals, Chennai, Tamil Nadu, India

Background: Vascular extension of Renal Cell Carcinoma (RCC) occurs in 4-10% and is challenge in terms of oncological clearance and patient morbidity. Traditionally performed via open approach, newer studies have shown promising outcomes with robotic surgeries. However, laparoscopic techniques remained anecdotal. Our objective is to describe our surgical technique of laparoscopic management of RCC with renal vein thrombus and report its safety and efficacy. Materials and Methods: We have performed 16 cases of laparoscopic radical nephrectomy (right -5 and left -11) and present a video of management of right and left side renal tumours with renal vein thrombus. Consent for open surgery was obtained. Standard port placement with additional assistant port was placed and tumour was recovered in a bag with thrombus via a pfannensteil incision completely following the oncological principles. Our techniques shall be described in the video. Observations: Mean operating time was 118mins. None of the cases were converted into open nephrectomy. Mean estimated blood loss was 130mL. Mean hospital stay was 2.4 days. No complications were noted. Conclusions: Laparoscopy can be performed safely in cases of RCC with renal vein thrombus. However patient's safety should not be compromised at any point.

   Our initial experience with 3D laparoscopic radical cystectomy Top

Manoj Kumar Das, Nayak Prasant, Mandal Swarnendu, Agrawal Sumit, Kumar Gautam, Misra Ankit

AIIMS, Bhubaneswar, Odisha, India

Radical cystectomy and bilateral pelvic lymphadenectomy are considered the treatment of choice for patients with muscle invasive bladder cancer. This can be done by Open/ Laparoscopic/Robotic surgery. We are presenting our initial experience with 3-D laparoscopic Radical cystectomy for treatment of Carcinoma Bladder and presenting the video of a preoperatively diagnosed adenocarcinoma of bladder. Materials and Methods: Patients diagnosed with Carcinoma Bladder with T1 (high grade, Bulky disease)/T2/T3 cases were selected. Between Jan 2018 to April 2019, we have done 24 laparoscopic radical cystectomies. We started doing 3D-laproscopic Radical Cystectomy since January 2019. Between January 2019 and June 2019, we did 10 cases of 3D Laparoscopic Radical cystectomy with Extracorporeal Ileal conduit. Results: Ten patients had their records reviewed. Mean age was 54 years (range 36 – 68 years). All were males. Five of them were diabetic. Four had T1G3, four T2N0, one T3aN1 and one T3bN2 on final histopathology report. Eight were transitional cell carcinoma and one patient each of adenocarcinoma and Squamous cell cancer was found. The size of incision for specimen retraction and extracorporeal ileal conduit creation was 8 cms (infra-umbilical) in all cases except in one it was 15 cms (obese). Mean estimated blood loss was 300ml (range 200-500ml). Mean total duration of surgery (including extracorporeal ileal conduit construction) was 6.5 hours (range 4-7 hours). On an average all the patients spent 24 hours in high dependence unit. Orally sips were allowed on post-operative day (POD) 2 and complete orals by POD 4, except one patient who had prolonged ileus, was started orals on POD 7. Per urethral catheter drain was removed on POD 2. Mean time of abdominal drain removal was 8 days, although in 1 patient it was kept for 15 days because of urine leak, which was managed conservatively. All patients except one were discharged on POD7. The one patient who had urinary leak was discharged on POD 28. Wound infection was in 3 patients and all three had history of neoadjuvant chemotherapy. No operative mortality seen. We did a retrospective comparison between 2D and 3D laparoscopic radical cystectomy, which showed a lower mean laparoscopic operating time of 4.5 Hrs Vs 3.4 Hrs respectively.

   Robot assisted laparoscopic simple prostatectomy: A feasible alternative in case of benign enlargement of prostate weighing >100 gms Top

Himesh Gandhi

Ruby Hall Clinic, Pune, Maharashtra, India

Introduction: Benign enlargement of prostate ( BEP) of more than 100gms is the frequently encountered scenario in Indian setting. This video is to present the management of such cases using robotic platform with excellent long-term results. Materials and Methods: Six such patients having BEP (>100gms), with no comorbidities, and having PSA density < 0.15ng/ml/gm with Q-max < 10ml/sec were selected for RALSP. Standard 5 port “Roof Top” configuration was used. Freyer's Transvesical Simple prostatectomy technique with O'Connor modification was used. Standard DVC stitch was applied in all patient. In all the cases, Suture Suspension technique (SST) was used. Trigonisation of the prostatic bed was done. Bladder was closed in two layers. Results: Mean age was 70.1 years. Mean prostate weight was 146.5 gms. Mean Operating time was 176 min. Average Estimated Blood loss was 146 ml. Average Hospital stay was 3.5 days. Average Q max improvement was 17.5 ml/sec from baseline, at 1 year. No change in IIEF score was seen at 1 year. Histopathological report was benign adenomatous hyperplasia in all cases. No urethral strictures were seen on follow-up at 1 year. No urinary incontinence was seen. Conclusion: RASLP is safe and effective treatment for the management of BEP (> 100gms) with excellent long-term results.

   Robotic ultrasound drop down probe – “A friend in need is a friend indeed” Top

Himanshu Sharma, Sunil Kumar Bhat, P. Gregory, R. Vishnu, S. Kiran, T. A. Kishore

Aster Medcity, Kochi, Kerala, India

Introduction and Objective: The video describes the use of Robotic drop down ultrasound probe in diverse scenarios while performing robotic urologic surgery. Methods Case I: Robotic Pyelolithotomy in a case of pelvic kidney: to locate the stone and hilum Case 2: Robotic Uretero-ureterostomy to identify the stricture site Case 3 & 4: Robotic radical nephrectomy to locate the extent of renal and IVC thrombus Case 5: Robotic renal transplant to differentiate between spasm and thrombosis Case 6: To identify the blood supply of kidney in partial nephrectomy after hilar clamping. Results: All the cases were completed safely with the help of robotic ultrasound probe. Conclusions: The robotic ultrasound probe is a valuable tool in the armamentarium of Robotic Surgeon in diverse circumstances.

   Robotic bilateral ileo-inguinal lymphadenectomy in penile cancer - development of a technique using Da Vinci® XI system and its adjuncts Top

G. Prakash, K. Dholakia, G. Bakshi, M. Pal, D. Jain, R. Reddy

Tata Memorial Hospital, Mumbai, Maharashtra, India

Introduction: Ileo Inguinal lymphadenectomy is the treatment of choice for patients with penile cancer and inguinal lymph node metastases. The advantage of robotic technique to perform this surgery for both node negative groins and groins with non-bulky nodes on an Si system has been described. We describe our technique of robotic bilateral ileoinguinal lymphadenectomy using Da Vinci Xi system in a patient with high risk penile carcinoma with palpable lymph nodes. Materials and Methods: A 54-year-old male patient was diagnosed with penile cancer (TNM: cT2N2M 0). We performed a robotic bilateral ileo inguinal lymphadenectomy. This video emphasizes how the Xi system and its adjuncts can be of use in achieving an oncological clearance with minimal surgical morbidity in patients with penile cancer. Results: The entire procedure was performed with the robot-assisted technique. The operative time, median estimated blood loss was 330 min and 100 ml respectively. Conclusion: Robotic bilateral inguinal lymphadenectomy secondary to penile cancer is feasible, safe, and provides a good lymph nodal yield. Xi system and its adjuncts could provide an advantage in performing this surgery.


   Single dock pure robotic nephro-ureterectomy Top

Vikas Kumar Bansal, Rajesh Taneja, Azhar Ajaz Khan, Devpriya Mtra, Vaibhav Sood, Sharwan Kumar

Indraprastha Apollo Hospital, New Delhi, India

Single Dock Pure Robotic Nephro-ureterectomy Introduction Robotic nephro-ureterectomy is the advancement of laparoscopic technique. Initially the procedure required positioning and redocking of the robot. In this video we describe our technique of single dock pure robotic nephro-ureterectomy using da Vinci Si system. Materials and Methods: A total of five patients of upper tract urothelial carcinoma underwent robotic nephro-ureterectomy using da Vinci Si system by single dock method. Patients were placed in standard lateral kidney position. Straight line robotic trocar placement was done in all cases at 15 degrees to cranio-caudal axis with caudal end deviated medially. The robot was docked from side, positioned four inches caudally at a slight angle facing cranially. Results: All cases were completed robotically without any open conversion. The bladder was repaired intracorporeally, after excision of the cuff around the ureteric orifice quite conveniently. The mean operative time was 180 minutes with mean estimated blood loss being less than 50 ml. Histopathology of all patients revealed high grade urothelial carcinoma with negative margins and there were no major intraoperative or postoperative complications. There was no clash of arms either inside or outside abdomen. Conclusion: Single dock method for robotic assisted nepro-ureterectomy using da Vinci Si system is conveniently possible, doing away with the need of repositioning or redocking to dissect the cuff of bladder along with the lower ureter and subsequent repair of bladder defect.

   Laparoscopic partial nephrectomy with lap assisted PCNL in a patient with left mid pole tumour with lower pole calculus Top

V. Surya Prakash, V. Mohan Kumar, K. Seshu Mohan, Milan Patel, Rajesh Reddy

Yashoda Hospital, Somajiguda, Hyderabad, Telangana, India

Introduction: The Minimally invasive partial nephrectomy by laparoscopic or robotic method is an established treatment for small renal masses. The treatment of calculi and tumour in the same kidney is complex. The management depends on the location and size of the renal mass and renal calculi. We present a case of young male with left mid polar renal mass incidentally detected during evaluation for left lower pole 1.9 cm calculus, both treated simultaneously. Materials and Methods: A 32 year male patient presented with left loin pain of 6 month duration. On evaluation by CT Urogram there was 3.1 x 2.5x 2.8 cm lesion in the mid pole of left kidney and a 1.9 cm lower pole calculus in left kidney. Metastatic workup was negative. Results: Laparoscopic partial nephrectomy for left mid pole tumour was done. As the stone was in lower calyx, laparoscopic assisted left PCNL was done after the partial nephrectomy in the same sitting. Postoperative period was uneventful. Renal mass histopathology was clear cell renal cell carcinoma with Fuhrman grade II with negative resection margin. patient in follow up since 6 months. Conclusion: Minimally invasive treatment of renal mass and renal calculi can be done simultaneously by laparoscopic method. To our knowledge this is the first case of simultaneous laparoscopic partial nephrectomy and lap assisted PCNL for tumour located in mid pole and stone in lower pole in the same sitting.

   Techniques for continence preservation in HOLEP Top

P. Bhirud, K. Ramaswamy, R. Raveendran, M. Salim, H. Pothiyedath

Metromed Institute of Advanced Urology and Renal Transplant, Kozhikode, Kerala, India

Introduction and Objectives: Several laser systems including holmium laser system have been applied to the endoscopic surgical treatment of benign prostatic hyperplasia. However, postoperative transient urinary incontinence (TUI) has been observed as a bothersome complication of holep in a small number of patients, occurring in a range of 1.3% to 10.7% of reported cases. Although most cases with tui recover spontaneously within three months, it remains one of the most troublesome complications of this procedure, as it decreases the patient's quality of life. Materials and Methods: About 2340 patients underwent holep for benign prostatic enlargement from December 2014 to July 2019. Perioperative data was collected. Procedure was carried out using a pulsed 100 w holmium:yag laser with a 550 micron end fire laser fiber, initially a 26fr continuous flow resectoscope with a laser bridge - later 24 fr continuous flow resectoscope. Results and Observations: In initial 250 cases - 9 patients had incontinence out of which 5 patients recovered within 1 month with conservative management and 1 patient had prolonged urinary incontinence. Next 250 cases we had 7 cases of transient incontinence. Next 500 cases 6 patients had transient incontinence who recovered within 3 months. 6 patients had transient urinary incontinence in 1001st onwards. Significant correlation of transient urinary incontinence was found with the factors such as age of patient and total operative duration. Conclusions: Transient urinary incontinence, although a bothersome complication observed after holep can be minimized with proper selection of patients and certain precautions during the procedures.

   Robot assisted tanagho repair for total urethral loss Top

Kumar Sunil, Mandhani Anil, Khattar Nikhil, Mishar Prafull, Sharma Laxmikant, Chalkoo Manzoor

Medanta-The Medicity, Gurgaon, Haryana, India

Introduction and Objective: This video highlights the advantage of robot assistance in reconstruction of urethra in a female with total urethral loss following an obstructed labor. To our knowledge this is first reported case of robot assisted Tanagho repair. Methods: A 26 year old lady presented with total incontinence after an obstructed labor. She had total urethral loss with bladder neck opening into vagina with no urethra. Bladder was normal and was having good capacity. Two months following the labor, using standard port arrangement for robot assisted pelvic surgery, bladder neck was mobilized all around with careful separation of posterior bladder neck and anterior vaginal wall. Both the ureteric orifices were cannulated and 5 cm long Tanagho tube was made over the 18 Fr Foley catheter from the anterior bladder wall and a neomeatus was made.Foley catheter was removed at 3 weeks after doing a cystogram. Result: Total operative time was 210 minutes and blood loss was 100 ml. Patient was sent home on 5th post operative day. Micturating cystourethrogram showed a well formed urethra with competent bladder neck. Patient could hold 100 ml of urine. She was put on Anticholinergic and at 3 months of follow up she reported mild stress urinary incontinence at full bladder using a pad. At 9 months follow up she occasionally uses pad. Conclusions: Total urethral reconstruction was feasible by anterior bladder tube with robot assistance with precise tissue dissection and reconstruction.

   Laparoscopic ureteric stump excision with bladder cuff in a ureteric stump recurrence of TCC Top

Mohsin Quadri, Nitesh Jain, Venkat Subramaniam

Apollo Main Hospital, Chennai, Tamil Nadu, India

Introduction and Objectives: This 63 year old gentleman presented with complaints of hematuria since 2 weeks, had Left nephroureterectomy elsewhere done 4 months ago for left renal pelvic tumour, HPE revealed High grade invasive papillary urothelial carcinoma mpT1 Nx Mx, his USG abdomen was normal. Check cystoscopy revealed two bladder tumours one at left lateral wall at the site of left ureteric orifice and the other at posterior wall of urinary bladder. TURBT done after informed consent HPE revealed low grade papillary urothelial carcinoma. PET scan revealed Left Ureteric stump recurrence. He underwent Laparoscopic Left Ureteric stump excision with the bladder cuff, HPE revealed high grade papillary urothelial carcinoma distal bladder cuff free of tumour. He was followed after 3 months check cystoscopy shows no recurrence. Conclusions: Laparoscopic nephroureterectomy with excision of bladder cuff is the ideal surgery for TCC. Sometimes intraoperatively due to difficulty, adequate bladder cuff will not be excised or sometimes ureter will be clipped distally leaving some part of ureteric stump that leads to such kind of recurrences. Here we are presenting a case of Laparoscopic Left Ureteric stump excision with the bladder cuff which the dissection and identification of the ureteric stump will be very difficult to achieve because of adhesions due to previous surgery which needs good laparoscopic skills and patience to progress further in to the pelvis which is a narrow working area not roomy like abdomen with out injuring the blood vessels and surrounding structures.

   Robotic assisted renal transplant surgery with right sided donor kidney allograft Top

S. Kiran, R. Vishnu, S. Himanshu, K. B. Sunil, T. A. Kishore

Aster Medcity, Kochi, Kerala, India

Introduction and Objective: Robotic assisted renal transplant surgery is gaining popularity among the transplant surgeons. Right sided kidney allograft poses a challenge because of the short and thin renal vein. We describe our technique of Robotic assisted renal transplant recipient surgery with right sided live donor kidney allograft in three cases. Methods: Laparoscopic right live donor nephrectomy was performed. Graft kidney was placed into the right iliac fossa of the recipient and vascular anastomosis performed. (Right renal artery to External iliac artery end to side and Renal vein to external iliac vein end to side). The graft kidney was extraperitonealised with a previously prepared peritoneal flap. Results: All the three cases had immediate diuresis and attained normal creatinine values which are stable on followup. Conclusion: Right sided kidney allograft can be a good choice and is feasible for robotic assisted kidney transplant surgery.


   Laparoscopic burch colposuspension: Tips and tricks Top

Banu Teja Reddy Patellugari, A. P. Pavan, J. Jayaraju, K. V. Bhargava Reddy, P. Vedamurthy Reddy, N. Mallikarjuna Reddy

Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India

Introduction and Objective: Stress Urinary Incontinence is the most common type of incontinence and occurs almost exclusively in females. Among the large number of surgical options for SUI treatment is bladder-neck suspension via a laparoscopic Burch colposuspension. When it is properly executed, this procedure offers high long-term success rates, reduced morbidity, and accelerated convalescence. Our objective is to describe the surgical technique, including tips and tricks to performing a laparoscopic Burch colposuspension. Materials and Methods: Back filling the bladder, meticulous dissection, con-current digital vaginal exam during suturing, and tension free knots all maximize the safety, efficacy, and efficiency of this procedure when performed laparoscopically. Results: A 70 years female presented with stress urinary incontinence. After thorough evaluation, we have performed laparoscopic burch colposuspension. There were no intra or postoperative complications. Hospital stay was 4 days. Patient is asymptomatic on follow up. Conclusion: A laparoscopic Burch colposuspension is an efficacious and minimally invasive surgery for patients with stress urinary incontinence.

   Role and outcomes of BMG urethroplasty in female patients of urethral Strictures Top

B. Amit, Sujata Patwardhan, Bhushan Patil

Seth GSMC and KEMH, Mumbai, Maharashtra, India

Introduction: Bladder outlet obstruction is seen in 2.7-8% of women with LUTS. It is caused mainly by idiopathic, trauma, iatrogenic injury, infection, malignancy, and radiation. Various surgical techniques such as serial dilation, meatotomy and urethral reconstruction using flaps/grafts have been described in its management. Methods: 40-year-old female with AUA symptom assessment score 22 and urethral calibre of 12 Fr and UFR -Q max 8ml/sec. Ultrasonography showed elevated post void residue of nearly 150 ml. Urethral stenosis was documented on cystourethroscopy using a Ureteroscope. UDS revealed high peak detrusor pressures >120Cm H20) with poor flow rates of 7 ml/sec. Patient underwent BMG urethroplasty including full thickness buccal mucosal graft harvesting and graft was sutured to urethral edge, quilted over corporal body on dorsal aspect and ventral mucosa reapproximated over the graft. Catheter was removed after 6 weeks. Results: Patient has been on follow up with our department for 1 year and asymptomatic with Q max of 22 mL/s with no residual urine with bell shaped curve on uroflowmetry and no postoperative requirement of instrumentation.12 patients have undergone the procedure with similar outcomes. Conclusions: BMG urethroplasty is a simple, safe and effective approach in carefully selected patients with durable results and no increased risk of urinary incontinence and recurrence.

   Laparoscopic sacrocolpopexy Top

Bansal Rajan, P. Banuteja Reddy, A. P. Pavan, J. Jayaraju, K. V. Bhargava Reddy, P. Vedamurthy Reddy, N. Mallikarjuna Reddy

Narayana Medical College, Nellore, Andhra Pradesh, India

Introduction and Objective: Laparoscopic sacrocolpopexy has evolved from classical abdominal sacrocolpopexy and provides the potential to combine the success rate of an abdominal approach with faster recovery time associated with a minimally invasive technique. Methods: A 58 years female presented with vault prolapsed since 10 years. History of recurrent ulcer over prolapse since 6 months. She underwent abdominal hysterectomy 20 year back. On examination , complete vault prolapsed with healed ulcer over it. Pelvic organ support was assessed objectively using the pelvic organ prolapse quantification scale (POP-Q).Tissue dissection and mesh placement are facilitated by magnification of the operating field using laparoscopic approach. Results: At a 6 months follow-up, symptomatic woman had successful vaginal vault support with no recurrence of prolapse symptoms. Conclusion: Laparoscopic sacrocolpopexy is a safe and efficacious surgical treatment for pelvic organ prolapse. It provides excellent support and good functional outcome.

   A Robotic option to BPH management – Millin's prostatectomy - point of technique and initial experience Top

N. Ragavan, R. Srivathsan, P. Aarthy

Apollo Hospitals, Chennai, Tamil Nadu, India

Objective: For patients with symptomatic large volume BPH, open simple prostatectomy has traditionally been the treatment of choice. In 2008, the first case of robotic simple prostatectomy (RSP) was reported. We herein report our surgical technique and outcome for Millins' Retropubic RSP and initial experience. Materials and Methods: A total of ten patients were taken up for robotic millins' – eight were done extraperitoneally and two transperitoneal. Eight of them were on catheter and the rest two had severe LUTS with average IPSS of 28. The average size of the gland in our series was around 100gms. With the patient placed in Trendelenburg position the steps of the surgery after docking included: dissection of dvc with enmass ligation, capsular incision a few mm below the bladder neck and enucleation of lateral adenoma, enucleation of median lobe with care taken to prevent injury to the urethra; hemostasis and capsular closure. Results: The International Prostate Symptom Score improved to 7 at the end of 3months. The average console time was 100 minutes. The median estimated blood loss was 75 mL with no requirement of transfusion. The resected prostate weight was 100gms. The hospital stay was 1-2 days (daycare setting). The catheter was removed after 7-10 days with no incontinence. The patient gained significant improvement in maximum urine flow rate (preoperative vs. postoperative 8.8 mL/min vs. 17 mL/min, (p < 0.001) and postvoid residual urine (preoperative vs. postoperative 125 mL vs. 10 mL, p < 0.001). the advantage of millins over frayers is the bladder is not opened and recovery faster. Conclusion: Robotic simple prostatectomy is a safe & feasible alternative for large prostates. The dexterity offered by the robot is very useful.

   Adult glanular epispadias repair Top

Abhiyutthan Singh Jadaon, M. C. Arya, J. Prakash, Vasudeo Vivek, Singhal Ankur, Gandhi Ajay

Sardar Patel Medical College, Bikaner, Rajasthan, India

Introduction: Here we present a video of adult glanular epispadias managed with modified Cantwell-Ransley repair. Materials and Methods: Total 12 cases of epispadias were managed in our department in last 5 years. 7 Male and 5 female cases. Male Epispadias repair consists of correction of dorsal chordee, glanular and urethral reconstruction and closure of penile skin. The modern modified Cantwell-Ransley repair advances the urethral meatus to an orthotopic position, utilising a reverse meatal advancement and glanulopasty technique (IPGAM). Female epispadias repair is done along with mons plasy and clitoroplasty(genitoplasty). Results: Out of 12 cases 7 became group 1 continent (bhatnagar classification, dry during day and nigdrht for more then 2 hours, no stress incontinence), 3 became group 2 continent (dry during day for more then 1.5hours,occacional wetting at night less then 2 episode/week) ,and 2 cases were preoperatively continent. Conclusion: Epispadias is a rare entity ,which needs meticulous repair by experts.

   “A blessing in disguise” - laparoscopic donor nephrectomy for triple renal artery with retro-aortic renal vein Top

C. Alagappan, K. Rahul

Apollo Speciality Hospital, Tiruchirappalli, Tamil Nadu, India

Introduction: LDN has been proven to be one of the standard method of retrival in Renal Transplantation. LDN beyond doubt maximizes the donor pool. Previously vascular anomalies were considered relative contraindications for LDN. Though at present, with proper planning and meticulous dissection, LDN for complex vascular anomalies has been proven to be feasible and safe, they are performed only in few centres. Here we present a case of combined, complex vascular anomaly for which LDN was successfully performed. Materials and Methods: 43 year Donor on evaluation for his brother for ESRD , had excellent tissue matching but, CT Angio revelaed left side (multiple) 3 renal arteries and Retro Aortic Renal vein (Type 4). Right side had two renal arteries and two short renal veins. Being the only available donor, and that too with a 6/6 HLA match, we didnt want to reject the donor. After discussion with nephrologist and vascular surgeon as well as transplant family, Left Lap Donor Nephrectomy was planned, as right was even more complex. Of course possibility of conversion to open was counselled. Transperitoneal 4 port technique used. Kidney with all 3 renal arteries procured via left low iliac fossa incision. after perfusion of all three arteries, revascularisation was done with Internal iliac , extrnal iliac and inferior epigastric arteries on the recepient side. Results: Procedure completed Laparoscopically . MOT - 170 mts Blood loss - 20 ml WIT - 190 sec LOS - 3 days Recepient graft - uniform , good perfusion , Brisk diuresis , Creat D5 - 1.2 . After 1yr creat - 1.2 The low lying Retro-aortic Renal vein not only provided more than adequate length , but also left the hilum,, free for a clear and undeterred dissection of all 3 arteries satisfactorily. Conclusion: Laparoscopy gave excellent magnification and the presence of this Venous anomaly, made, handling of this complex Arterial anomaly relatively easy & hence a Blessing in disguise rather being a blight or curse !!.


   Unusual foreign body in the bladder Top

Ankush Sharma, S. V. Kotwal, Vikram B. Kaushik, Sandeep Harkar, Mohit Jain

Artemis Hospital, Gurgaon, Haryana, India

Introduction: Intravesical foreign bodies may result from iatrogenic injuries, sexual abuse, self-insertion, assault, and migration from adjacent sites. Obtaining an accurate history from patients with this condition may be difficult, especially for patients who insert objects for sexual pleasure. We present a case here where patient did not give a proper history and was found to have a foreign body in the bladder. Case Report (Materials and Methods): 27 years old patient, no comorbidities presented to us with c/o passage of foreign body per meatus which had fragmented. Pt refused insertion of any such foreign body. Pt had a create of 0.87 and urine routine was suggestive of 60-70 pus cells and full field RBC. NCCT KUB was done suggestive of distended bladder with thin linear foreign body seen curled inside the urinary bladder. Patient was immediately taken up for surgery, Cystoscopy was done suggestive of multiple false tracts in the urethra, about 1 feet long foreign body (wire) was present in the bladder coiled, removed cystoscopically. Pt was discharged the next day and was advised psychiatric evaluation. Patient never returned for follow up. Discussion - Self-insertion is a major contributor in incidence of foreign bodies in the urinary bladder. Usually it is performed for sexual gratification. These patients are often embarrassed and present late and may even attempt self-removal which leads to further migration. Some of these patients may have psychiatric disorders such as schizoid personality disorder or borderline personality disorder, intoxication, mental confusion, or sexual curiosity. Sometimes foreign bodies are inserted to relieve retention or urethral itching. Patients often present with anxiety and pain. Patients may remain asymptomatic or may present with acute cystitis, lower abdominal pain, hematuria, acute urinary retention, urethral discharge, strangury, and fever.

   3D laparoscopic lower ureteric reconstruction Top

P. Datson George, George P. Abraham, Vijay Radhakrishnan, Vignesh

Lakeshore Hospital, Kochi, Kerala, India

Introduction and Objective: Ureteral strictures may result from various causes. We present a video demonstration of 2 techniques of laparoscopic management of lower ureteric strictures. Methods: Case 1: A Female , 60 yrs, underwent a lap Bilateral salphingo oopherectomy 1 week back. Ct Urogram Revealed a complete cut off of the right ureter below the iliac level. 4 ports were used. The right ureter was found to be having a Cautery injury with devascularised tissue. Unhealthy ureteric tissue was removed, Bladder mobilized well. Ureter was spatulated well on the posterior side and anastamosed to the bladder on the dome in an antireflux fashion over a DJS. Case 2: 25 yr Female presented with left long segment lower ureteric stricture due to Endometriosis. Laparoscopic boari flap was contemplated. Four ports were utilised. Ureter trimmed and spatulated. Bladder mobilised. A wide Boari flap was generated based on posterior bladder. The apex of the flap was anastamosed to lower ureteral margin. Ureteral stent was placed and the flap was tubularised. Bladder was closed. Both patients are on follow up. Results: Total 61 patients were treated with laparoscopic approach for lower ureteric strictures. Mean operative time was 94 min. Mean blood loss was around 190 ml. Mean hospital stay was 3 days. Conclusion: Minimally invasive management of lower ureteric strictures is easier with a 3 D laparoscopic approach . Laparoscopic management has the advantages of early ambulation, shorter hospital stay, with equivalent functional outcomes compared to open surgery.

   Testing the limits of laparoscopic partial nephrectomy Top

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

Gauhati Medical College and Hospital, Guwahati, Assam, India

Introduction and Objective: Renal cell carcinoma(RCC) is the most common type of kidney cancer in adults, approximately 90-95% of cases. More than half of cases of RCC are detected incidentally on imaging. With progression of minimally invasive surgery laparoscopic partial nephrectomy has become standard of care for small renal mass. Likewise laparoscopic surgery is also advocated for adrenal mass. The objective of this video is to show that laparoscopic partial nephrectomy with adrenalectomy for incidentally detected small renal mass and adrenal mass can be performed safely and efficiently in experienced hands. Methods: It is a videographic presentation of a single patient. Our patient, a 43 years diabetic lady, presented with incidentally detected left renal hilar mass. On contrast enhanced computed tomography evaluation left renal hilar enhancing mass 3.5cm x 2.9 cm and left adrenal adenoma 3cm x 2 cm was detected. Adrenal adenoma was non functional on metabolic evaluation. Patient underwent laparoscopic partial nephrectomy with adrenalectomy on May, 2019. Results: Operative time was 96 minutes with blood loss of approximately 200 ml. Post operative ultrasound Doppler showed normal renal perfusion with resistive index(RI) of 0.46. Patient had uneventful post operative recovery and discharged on 2nd post operative day. Histopathological examination of specimen showed clear cell carcinoma, Fuhrman grade 1, margin clear. Conclusion: Laparoscopic partial nephrectomy for small renal mass is very safe in experienced hands with early patient recovery. Adrenal mass if detected along with renal mass should also be resected.

   Continent catheterisable stoma with augmentation cystoplasty and mace for a child with urinary and fecal incontinence Top

O. Karthikesh, A. P. Pavan, Banu teja Reddy, P. Vedamurthy Reddy, N. Mallikarjuna Reddy

Narayana Medical College, Nellore, Andhra Pradesh, India

Introduction and Objective: The goals of Cutaneous catheterizable channel creation in the neurogenic bladder population are successful urine elimination, renal preservation, continence. An ideal channel is one that is short, straight, and well supported by associated blood supply and surrounding adventitia, so as to minimize difficulty with catheterization. We are presenting a video of Open Augmentation cystoplasty with Yang-Monti and MACE in patient with neurogenic bladder with fecal incontinence. Methods: A 13 year old child presented with urinary and fecal incontinence with paraparesis. Past history suggestive of surgery for lumbar meningomyelocele with VP shunt placement at 6 months of age with recurrent episodes of pyelonephritis. Ultrasound shows bilateral moderate hydroureteronephrosis. UDS showed poorly complaint small capacity bladder. MCUG showed bilateral Grade V vesicoureteric reflex. DTPA renogram showed GFR of 31.9ml/min and 22ml/min on left and right side respectively. Results: In view of small capacity neurogenic bladder with urinary and fecal incontinence, Open Augmentation cystoplasty with Yang-Monti and MACE surgery was done. Patient recovered well postoperatively and was on regular follow up for 6months. Patient is compliant with CIC through Monti. For MACE he requires 540ml of water for complete evacuation. Conclusion: Augmentation cystoplasty with Yang-Monti and MACE is a standard surgery in patients with neurogenic bladder with urinary and fecal incontinence to improve quality of life, renal preservation and minimize morbidity.

   Retrograde intrarenal surgery for calculi in calyceal diverticulum Top

Pankaj N. Maheshwari

Fortis Hospital Mulund, Mumbai, Maharashtra, India

Introduction and Objectives: Calyceal diverticulum is a rare congenital anomaly. Commonly it presents with symptomatic calculi in the diverticulum. The treatment options are shock wave lithotripsy, percutaneous nephrolithotomy or retrograde intrarenal surgery (RIRS). This decision is based on the neck of the diverticulum & size of the calculus. RIRS is usually indicated for diverticulum with single small calculus or multiple small calculi. If neck is identified, procedure becomes easy. The neck can be dilated or enlarged by holmium laser and the calculus is fragmented and removed. The presented technique is needed when the neck is not visualized during RIRS. Methods: Presented in this video is the technique for identification of the neck of the calyceal diverticulum during RIRS using methylene blue (Blue Spritz technique). After proper exploration for the calyceal neck, if neck is not visualized, the pelvi-calyceal system is filled with methylene blue (1 in 10 dilution). The irrigation of RIRS is re-started. The methylene blue from the PCS gets washed out. Now look for a point of efflux of the methylene blue in the desired calyx. That is the neck of the diverticulum. Once identified, it is enlarged with laser and the calculus in the diverticulum managed on merit. If blue spritz technique fails, in selected patients, direct puncture of the thin mucosa over the calculi can be done. This is done under fluoroscopy guidance. Results: Methylene blue to identify neck was tried in five patients, of these neck got identified in three patients. In the two patients where it failed, they were managed by blind incision as the calculi could be seen behind thin mucosa. Conclusions: RIRS is a safe technique for calyceal diverticular calculi. Instillation of methylene blue or direct puncture of thin mucosa can help treat this complex situation.

   Laparoscopic assisted percutaneous nephrolithotomy in pelvic kidney with retained DJ stent Top

Jibhakate Nikhilesh Ashok, Patwardhan Sujata, Patil Bhushan

Seth GSMC and KEMH, Mumbai, Maharashtra, India

Introduction: A 39 years male came with C/o left flank pain. Patient had lap assisted open Pyelolithotomy 3 years back. On CT KUB found to have multiple calculi in ectopic pelvic kidney and vesical calculus along retained DJ stent. Patient underwent cystolithotripsy followed by Lap assisted PCNL of ectopic pelvic kidney. Post op -imaging showed no residual calculi. Methodology: We present a video presentation of a 39 years male with ectopic pelvic kidney and retained DJ stent. RGP done to locate kidneys, laparoscopy done and bowel mobilized, ureter and renal vessels identified and renal puncture taken. Discussion -Renal lithiasis in the pelvic kidney can be managed by means of open surgery, extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), laparoscopic or ultrasound guided PCNL, and retrograde intrarenal surgery (RIRS). Open surgery has increased morbidity due to bowel mobilization, larger scar, and increased pain. ESWL in the pelvic kidney has a success rate of only about 54%. PCNL, in a pelvic kidney, has to be conducted in a supine position, posing additional risk to the overlying bowel and blood vessels. Hence , the need for renal puncture and dilatation under vision. Conclusion: Laparoscopy-assisted PCNL offers advantages in ectopic pelvic kidneys in achieving good stone clearance, especially in patients with a large stone burden.


   3D laparoscopic heminephrectomy for large polar renal tumours Top

P. Datson George, George P. Abraham, Vijay Radhakrishnan, S. Vigneswara

Lakeshore Hospital, Kochi, Kerala, India

Introduction and Objectives: Resecting at least 30% of renal parenchymal mass is defined as heminephrectomy. We present video demonstration of 2 cases of 3D laparoscopic heminephrectomy for t1b polar renal tumours. Materials and Methods: Case1: A 38 year old male, with incidentally detected 5cm heterogenously enhancing, partially exophytic lesion in upper pole of left kidney underwent 3D laparoscopic upper polar heminephrectomy. Case 2: A 64 year old male, with incidentally detected 5cm enhancing, partially exophytic lesion in lower pole of left kidney underwent 3D laparoscopic lower polar heminephrectomy. No Bolster was used, No calyceal or vessel suturing was done. Single layer closure was done. Results and Observations: HPE of both the patients was clear cell RCC with radial negative margin and both had uneventful post operative period. Out of 613 lap partial nephrectomy patients in our series 61 had underwent laparascopic heminephrectomy. Mean tumour size was 5.6cm. Mean blood loss was around 100 ml. Mean hospital stay was 3 days. Conclusions: Heminephrectomy for polar renal tumours is feasible with laparoscopy and is made easier with a 3 D laparoscopic approach. It has the advantages of early ambulation, shorter hospital stay, with equivalent functional outcomes compared to open surgery.

   Singh is king Top

B. Amit, Sujata Patwardhan, Bhushan Patil

Seth GSMC and KEMH, Mumbai, Maharashtra, India

Introduction and Objective: Penile incarceration by encircling object is an uncommon urological emergency. Treating such patients especially with metallic constricting devices is a challenge involving removal of constricting object without injuring the penis. Methods: We report series of 6 middle-aged men who presented with painless swollen penis incarcerated by metallic nut. Patient was started on antibiotics and taken for emergency surgery. Techniques like needle aspiration and decompression of distal swelling, string method were attempted to remove the metal nut but were unsuccessful. Electrician Mr Singh was summoned each time to operation theatre and using Bosch electric circular saw, nut was cut open and obstruction was relieved. Precautions while applying this technique are protecting the penis from the saw by keeping a forceps beneath the metallic cut and prevent thermal injury from the sparks produced while cutting by continuous spray of water. Results: All patients recovered with healing of the superficial injuries to skin and was able to void and attain erection within 3-4 days of procedure. Conclusion: Surgical acumen, knowledge of various techniques and timely intervention is imperative in management of incarceration of penis. Whenever a metallic constricting device is involved, an electrician who can help with electric saw is the best resort among all other techniques to release the constricting device and thereby treat this emergency condition successfully.

   Laparoscopic pelvic ectopic kidney pyeloplasty our experience with 3 cases Top

P. M. Siddalinga Swamy, V. Chandra Mohan, P. Ramakrisnha, Manas Babu, G. Soundarya

Preeti Urology and Kidney Hospital, Hyderabad, Telangana, India

Introduction: Pelvic ectopic kidney has an incidence of 1 in 2200 to 1 in 3000. These kidney are most of the times malrotated and will have anomalous blood supply. Pelvic ectopic kidney with uretero pelvic junction obstruction (UPJO) has an overall incidence of 22% to 37% out of these ectopic kidneys. Traditionally these cases were managed by open pyeloplasty. We describe 3 cases of pelvic ectopic kidney UPJO who underwent laparoscopic pyeoloplasty. Materials and Methods: All cases had ultrasound, IVP and intraoperative RGP for better delineation of anatomy. All cases were done under general anaesthesia in supine position as described in the video. Case 1: 30 yr old male, left pelvic ectopic UPJO. Case 2: 24 yr old male, left pelvic ectopic UPJO Case 3 : 35 yr female, Left Pelvic ectopic UPJO All patients post operatively Foleys was removed on 3 rd POD , drain was removed on 4 th POD and discharged. Results: All patients were male. Mean age was 25+/-3 yr. Mean Operative time was 130 +/- 15min. Mean Follow up period was 26+/-2 months. Follow up renogram done at 1 yr post operatively showed good clearance of the radionuclide. Conclusion: Pelvic ectopic kidney UPJO can be operated laparoscopiclly with good outcome and with less morbidity.

   Robotic ureteropyelostomy in a 10 months child with complete duplex kidney with ectopic ureter Top

V. Surya Prakash, Mohan Kumar, K. Seshu Mohan, Milan Patel, Rajesh Reddy

Yashoda Hospital, Somajiguda, Hyderabad, Telangana, India

Introduction: Renal duplication anomalies are common in children with varied presentation. In children with well-functioning Obstructed moieties, preservation of renal parenchyma by common-sheath reimplantation, ureteropyelostomy, ureteroureterostomy is the standard treatment. We present a left complete duplex kidney with ectopic ureter managed robotically in an infant. Materials and Methods: Ten months male child presented with recurrent UTI with history of left antenatal hydronephrosis .On evaluation found to have complete left duplex with Upper moiety moderate hydroureteronephrosis with ectopic insertion into prostatic urethra with preserved parenchyma and excretion on CT urogram. MCUG showed low grade reflux into lower moiety. DMSA scan showed reduced upper moiety function. Results: Robotic left sided uretero pyelostomy was done. Dilated upper moiety ureter was transected and anastomosed to lower moiety pelvis in end to side fashion.DJ stent was placed across the anastomosis in to the upper moiety ureter. Post operative period was uneventful and the stent was removed after 6 weeks. Conclusion: We believe that upper-tract robotic reconstruction is feasible in the infants and it is a safe option.

   Exstrophy repair Top

Mukesh C. Arya, J. Prakash, Vasudeo Vivek, Abhiyutthan Singh Jadaon, Singhal Ankur, Gandhi Ajay

Sardar Patel Medical College, Bikaner, Rajasthan, India

Introduction: Exstrophy is a rare developmental defect which affect multiple system including genitourinary and gastrointestinal tracts,musculoskeletal system,pelvic floor musculature and bony pelvis. Materials and Methods: Total of 13 cases of exstrophy were managed.12 were neonates or infants and 1 was adult female. Staged repair was done by a single surgeon in all bladder exstrophy cases. urinary bladder, posterior urethra and abdominal wall closure were done in first stage at presentation given adequate bladder plate was there and no hydroureteronephrosis. we present a video of male new born exstrophy closure. Results: Out of 13 cases, only one case required redo-closure for partial dehiscence. Conclusion: Successful first stage repair and resultant incontinence with balanced posterior outlet resistance is very important for decreased inflammation and fibrosis of bladder. which results in improved bladder growth and decreased need for urinary diversion. tension free closure and pelvic immobilisation are of paramount importance for successful closure of exstrophy.

   Nephron sparing surgery in renal allograft renal cell carcinoma - technical caveats Top

Rathi Deepak Kumar, Sunil Kumar, Laxmikant Sharma, Prafful Mishra, Manav Suryavanshi, Anil Mandhani

Medanta-The Medicity, Gurgaon, Haryana, India

Introduction and Objectives: Renal transplantation is therapy of choice for ESRD. All recipients have increased risk of malignancy. The incidence of RCC in allograft is around 0.2%. Currently there are no standard guidelines for management of RCC in graft kidney. Due to technical difficulties, usually graft nephrectomy is done in large tumours which makes the patient dialysis dependent. We are presenting a case of graft renal mass managed with partial nephrectomy. Methods: A 38 year old male, with renal transplantation 19 years ago, presented to us with biopsy proven papillary renal cell carcinoma of size 5 x 4.6 cm with pre op creatinine 1 mg/dl. After evaluation he was planned for totally extraperitoneal NSS. Results: Due to adhesions, peritoneum was opened. Tumour was demarked with intraoperative USG. En mass clamping of vessels was done. Total ischemia time was 15 minutes and nephron sparing surgery could be completed. His post op creatinine settled to 1.8 mg/dl and he was dialysis free. Conclusions: RCC in renal allograft is rare entity and there are no standard guidelines for its management. But in carefully planned cases, partial nephrectomy can be done which keeps patient dialysis free.


   Salvage robotic radical prostatectomy, post HIFU Top

Venkatesh Kumar, Ashish Sabharwal, Ajit Saxena

Indraprastha Apollo Hospitals, New Delhi, India

Introduction: With the advent of newer minimally invasive treatments like HIFU, more and more patients are opting for these treatments. These therapies often fail to treat the prostate cancer. We present one such patient of ours who had previously undergone HIFU and we treated him with Robotic Radical prostatectomy. We present the difficulties in decision making, During the robotic surgery and his outcomes in the 2 years followup in terms of Cancer control , Urinary continence and Return of Sexual function. Methods: A 55 year old Male presented to me in 2012 with Gleason 6 cancer and PSA of 9. Digital Rectal Examination, MRI Pelvis and Bone scan were negative.We discussed the various treatment options including robotic radical prostatectomy, radiotherapy, watchful waiting and HIFU.He underwent HIFU in January 2013. PSA dropped to 0.2ng / ml.Then it started rising gradually. PSA in April 2015 was 1.17ng/ml. We discussed options of salvage radiotherapy vs. Salvage Robotic Radical Prostatectomy. Patient opted for salvage robotic radical prostatectomy. Following Surgery,He was started on long term bladder rehabilitation in form of Anticholinergics and Kegel's Excercises and Penile Rehablation in form of Tadalafil and Vacuum erection Device. We will present our Video of Salvage Robotic Radical Prostatectomy, the intraoperative difficulties and post-operative results in terms of cancer control, urinary incontinence and sexual function. Results: Prostate Biopsy of the Radical Prostatectomy Specimen showed Negative margins, Vas and Seminal Vesicles were uninvolved. PSA 2 years after surgery is 0 ng/ml. He was fully continent (Diaper Free) after 3 months of surgery, He was able to achieve natural erections strong enough for penetration after 1 year of surgery. Conclusion: Salvage Robotic Radical Prostatectomy is a very good treatment option after failure of focal therapies of prostate cancer, but it is technically challenging and should be done only by experienced hands. Patients can have excellent functional outcomes in terms of urinary control and sexual function, provided they are operated by an experienced surgeon, and combined with long term bladder and penile rehabilitation.

   Surmounting difficult PUJ obstruction by laparoscopic pyeloplasty Top

Amit Singh Malhotra, P. P. Singh, Jagdeep Balyan, Bhaskar Borah

PSRI Hospital, New Delhi, India

Introduction: Pyeloplasty is the gold standard therapy for ureteropelvic junction obstruction. Difficult situations encountered during laparoscopic pyeloplasty can significantly add to the difficulty of operation. This presentation provides tips for intraoperative dissection and repair in patients with difficult situations of previous attempts at PUJ repair, solitary kidney with chronic kidney disease, crossing vessel, multiple renal calculi, small intrarenal pelvis, pyelonephritic kidney. Techniques presented may aid in successful completion of laparoscopic pyeloplasty in the face of difficult situations noted above. Materials and Methods: The study is a retrospective analysis of challenging PUJ obstruction done by laparoscopic Anderson-hynes dismembered pyeloplasty. Between April 2008 to June 2019 we had done 323 laparoscopic pyeloplasty. Out of this in three patients where difficult situations were encountered are included. The first patient had solitary kidney with multiple renal calculi with CKD and small intrarenal pelvis. The second patient had lower pole crossing vessel in pyelonephritic kidney with failed endopyelotomy. The third patient was redo laparoscopic pyeloplasty. All patients were symptomatic. The had preoperative evaluation by CT urography or diuretic renography. Post surgery DJ stent was removed after 4 weeks. Results: All 3 patients had resolution of symptoms with diuretic renogram revealing free drainage. Conclusion: Laparoscopic pyeloplasty is challenging but safe operation in difficult PUJ obstruction. It allows better visualization and delineation of tissue planes when dense adhesions are present. It increases our approach in difficult access areas.

   Male genitoplasty in cases of 46XXDSD with congenital adrenal hyperplasia Top

M. S. Ansari, Sarita Syak, Priyank Yadav

SG PGIMS, Luknow, Uttar Pradesh, India

Male genitoplasty in cases of 46XXDSD with congenital adrenal hyperplasia Background: In congenital adrenal hyperplasia (CAH) with genital ambiguity, assigning gender of rearing can be complex, especially If genitalia is highly virilized. Apart from karyotype, prenatal androgen exposure, patient's gender orientation, sociocultural, financial and parental influences play a role. Objective: Here in the authors describe surgical steps for male genitoplasty in cases of 46 XX Congenital Adrenal Hyperplasia (CAH) presenting with severe virilization and assigned a male gender. Materials and Methods: All of them were assigned the male sex and subsequently underwent laparoscopic removal of the female adnexa and staged male genitoplasty. Staged male genitoplasty included; chordee correction, male urethroplasty, and bilateral testicular implantation. Results: There were 3 patients with the mean age at presentation of 5.5 years. The mean stretched penile length at last follow up was 7.5 cm. Aesthetic outcome was good and acceptable by the patients/families. All reported good morning erections. The stream was good (Qmax > 12 cm/ml). One of the patients had urethrocutaneus fistula that was managed subsequently. All reported positive self- esteem and enjoyed a fairly good social/school status. Appropriate hormonal supplementation was offered after puberty. Conclusion: Male genitoplasty in cases of 46XX DSD with CAH with severely virilisation gives good results. This helps patients to develop a positive self- esteem and fairly good social/school status.

   Partial nephrectomy in RCC of supernumerary fused kidney Top

Vijay Kumar Shukla, H. Gandhi, Priyank

Ruby Hall Clinic, Pune, Maharashtra, India

   Transurethral enucleation of prostate by plasma kinetics Top

S. P. Yadav

Pushpanjali Hospital, Gurgaon, Haryana, India

Purpose: We evaluated the transurethral enucleation of prostate in patient with urinary symptoms due to BPH using the plasma kinetics system. Materials and Methods: We retrospectively analyzed the records of 79 patients from 2016-2019. We assessed the International Prostate Symptom Score, quality of life score, peak flow rate and post-void residual urine volume preoperatively. Enucleation time, enucleated tissue weight, catheterization time, hospital stay and long-term complications were recorded. Results: No Patient had significant blood loss or signs of transurethral resection syndrome. mean catheter time was 1.8 +/- 0.4 days hospital stay was 1-2 days. Postoperative complications SUI in 20% cases. Conclusion: Transurethral enucleation by plasma kinetics of prastate appears to be a good alternative to transurethral resection of the prostate and open prostectomy. It may be done even in glands up to 25ogm.

   Minimal invasive pyeloplasty in congenital anamolous and complex kidneys - A challenging experience Top

J. Jayaraju, A. P. Pavan, Bhargav Reddy, P. Vedamurthy Reddy, N. Mallikarjuna Reddy

Narayana Medical College, Nellore, Andhra Pradesh, India

Introduction and Objective: Congenital anomalies of kidneys accounts for about 2-7% of patients. Minimal invasive pyeloplasty has become the standard of care in ureteropelvic junction obstruction. Laparoscopic pyeloplasty in anomalous kidneys will certainly be a challenge for a experienced surgeon even in modern day practice. We present our series of surgeries done in congenital anamolous obstructed kidneys. Materials and Methods: Case 1- A 69 year old male patient with ectopic kidney with bilateral pelvic calculus with left ureteropelvic junction obstruction. Case 2: A 27 years old male patient with pelvic ectopic kidney with UPJO. Case 3: A 34 years old male patient with Horseshoe kidney with Bilateral UPJO with Bilateral renal calculus. Results: All patients underwent complete laparoscopic surgery successfully and were discharged on post op day 3. Patient after 6 months of follow up show no obstruction and calculus. Conclusion: Minimal invasive procedure has become the standard of care for obstructed renal systems, but experience makes a real difference in complex congenital obstructed systems.


   A rare presentation of reno-colic fistula Top

B. Krishna Mohan, Appu Thomas, Rohan Rajendran

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Introduction: Fistulas of the upper urinary tract with the gastrointestinal system are rare conditions. It has been reported after percutaneous nephrolithotomy but its incidence after ureteral double-J (DJ) stenting is extremely uncommon and rarely reported. b) Methods: Case report c) CASE REPORT: A 55-year-old male, a known case of urolithiasis presented initially with left sided loin pain to an outside hospital and underwent Left DJ stenting for obstructive upper ureteric calculus. Presented three weeks later to us, he had no specific complaints and was planned for Left Ureteroscopy (URS). A week later he had presented with respiratory distress and breathlessness for which he was admitted under Pulmonology and procedure was postponed for a later date after respiratory status stabilises. Computed Tomography of Abdomen done showed Multiple calculi in left ureter, proximal end of stent lying outside the renal parenchyma and low density collection was seen in upper pole of left kidney in perinephric space and para renal space. Patient was taken up for Left URS, Retrograde Pyelography done showed contrast draining into descending colon through a thin fistulous tract and he was re-stented. Patient was managed conservatively without a nephrectomy and patient is under regular follow-up and is doing well with no issues. Conclusion: Reno-colic fistula are rare entities by itself and in the context of post DJ stenting, it has been reported only once in literature so far. So this case report is being presented for its rarity.

   Supine percutaneous nephrostomy with antegrade dilatation and stenting of ureteroenteric anastomotic stricture in a case of post radical cystectomy with ileal conduit Top

Kanabur Ishwar, Sreeharsha, K. Mohan

Fortis Hospitals Ltd., Bengaluru, Karnataka, India

Introduction and Objectives: Ureteroenteric anastomotic strictures in post radical cystectomy patients can be difficult to manage endoscopically, because they are difficult to access in retrograde fashion. They are managed by percutaneous puncture in prone position and dilatation /stenting. Sometimes this can be challenging as there is no control over the distal guidewire. Here we present a case of ureteroenteric anastomotic stricture in a post radical cystectomy with ileal conduit ,which was managed effectively with supine percutaneous access. Materials and Methods: 45 year old male patient was admitted with complaints left flank pain. CT ABDOMEN & PELVIS : Left kidney shows hydroureteronephrosis? anastomotic site Stricture. In this case serial dilatation was done upto 10fr with Teflon ureteric dilators and 8fr stent was inserted. An 8 F nephrostomy drainage catheter was placed and this was removed in 48-hours following a satisfactory nephrostogram. Results and Observations: The ability to have distal control over the guidewire is very advantageous in a patient with ureteroenteric anastomotic stricture as this provides for effective dilatation of tough fibrotic strictures. this makes serial dilatation and stenting of a strictured area easier.6 weeks after the procedure stent was removed. CT urogram was done 4 weeks after the stent removal , which showed resolution of hydronephrosis with prompt drainage of contrast at the ureteroenteric anastomotic site. Conclusions: Percutaneous antegrade dilatation and stent placement in supine position is a safe and effective method for management of ureteroenteric anastomotic strictures.

   Intraoperative injuries in holmium: Yag laser lithotripsy in treatment of ureteral and renal calculi Top

Bansal Rajan, P. Banuteja Reddy, A. P. Pavan, J. Jayaraju, K. V. Bhargava Reddy, P. Vedamurthy Reddy, N. Mallikarjuna Reddy

Narayana Medical College, Nellore, Andhra Pradesh, India

Introduction and Objective: Endoscopic laser lithotripsy is the most common intracorporeal procedures performed by urologists to treat urolithiasis. Today, the most common and most effective laser in the treatment of stones is the Holmium : YAG laser. The Zone of thermal injury is approximately 0.5 -1.0mm. Most are minor and can be treated in a conservative manner by ureteral stenting without long term consequences. Minor complication includes mucosal abrasion and ureteral wall perforation. Methods: Holmium : YAG laser lithotripsy was performed with rigid and flexible ureterorenoscope in 97 patients from 2017 to 2019. Laser lithotripsy for ureteric stone was done in 62 patients and for renal stone in 35 patients. Results: Mucosal abrasion was seen in 21 patients and ureteral wall perforation was seen in 4 patients. Calyceal perforation seen in 1 patient. All patients were managed conservatively and ureteral stenting was done. Post operatively , stent were removed after 1 month. Conclusion: Holmium: YAG laser lithotripsy with a ureteroscope is effective and safe treatment for ureteric and renal calculi. However , disadvantage to perforate the urothelium will be there if activated within close proximity to the wall of collecting system.

   Calculus in an ureteric diverticulum: A rare entity Top

Mekhala Deepak Naik, M. D. Naik, R. K. Garg, M. G. Andankar, H. Agarwal

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

Introduction and Objectives: Ureteric diverticulum is a rare finding with only 48 cases reported so far. We report a case of a 52 year old lady presenting with pyelonephritis who was subsequently detected with a calculus in an ureteric diverticulum. Case History: A 52 year old lady presented with right lower abdominal pain, was detected with a 8mm lower ureteric obstructing calculus with periureteric collection on Computed Tomography. On cystoscopy with retrograde pyelography there was obstruction in the lower ureter. A double J stent was inserted. After two weeks, ureteroscopy was done and a calculus was found in a diverticulum arising from the medial wall of right ureter as confirmed on retrograde pyelography. Patient underwent LASER lithotripsy with complete fragmentation of the calculus and stenting of ureter. Discussion Ureteric diverticuli have been reported in literature to be asymptomatic or presenting with pyelonephritis, painless hematuria, being confused for pelviureteric junction obstruction, or even harboring transitional cell carcinoma. Our experience shows difficulty in diagnosing ureteral stone in a diverticulum. The diverticular orifice might be mistaken for ureteral stricture during transurethral lithotripsy possibly resulting in perforation. Conclusion: Ureteric diverticulum is a rare finding, with diagnostic dilemmas. In our case the diverticular calculus presented as pyelonephritis. Radiological studies and high index of suspicion helped in the eventual management of this case.

   Ureteric orifice injury- a little emphasised complication of transurethral resection of prostate - 3 case reports Top

Samson Ravirajendran, Natarajan kumaresan, Chandru Thirunavukkarasu, Neelakandan Ramasamy

Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Objectives: Injury to the ureteral orifices is a recognised but little emphasised complication of transurethral resection for prostatic enlargement. We report three cases of post TURP distal ureteric stricture managed surgically. Methods: A 75 year male post TURP (130cc) with distal ureteric stricture and right HUN was treated by right PCN followed by ureteric reimplantation. A 60 year male post TURP (97cc) with right HUN was treated by ureteric orifice resection and DJ stenting. A 63 male post TURP for (70 cc) with left HUN was treated by ureteric reimplantation . Results: All three patients recovered well with no intraoperative/postoperative complications and are doing well on follow up. Conclusion: Thermal injury to the ureteral orifice occurs more commonly than most of us suspect especially during resection of large prostate. If the mechanism behind this complication is understood, the injury can be avoided This possible complication of TURP and the subsequent problems should be anticipated especially during resection of large prostate and treated long before the patient has lost a kidney or is desperately ill.

   Variation in corelation of age, PSA and prostatic volume, in men with BPH, undergoing TURP, with and without acute retention of urine, in south indian men and its comparison with north indian population Top

Vaibhav Vishal, M. Manikandan, K. V. Shanmughadas, A. T. Rajeevan, K. M. Dineshan, A. V. Venugopalan, Felix Cardoza

Calicut Medical College, Kozhikode, Kerala, India

Introduction: The aim of study is to find correlation between age, PSA and prostate volume in histologically proven case of BPH in patients with AUR and without AUR who underwent TURP surgery. We also compare PSA and prostate volume of south Indian and north Indian men to find any difference in these two genetically and culturally different group of men but citizen of same country. Methods: Retrospective, single center study of patient undergoing TURP from 2016 to July 2019. Patient divided in two group, on basis of mode of presentation,with retention and without retention.All PSA test of men with AUR was done 2 weeks after catherisation. Results: Total 530 patient were part of study,mean age of TURP was 65 years and mean PSA and prostate volume was 5.18 and 52.93 cc . PSA was positively related to age and prostate volume . Mean age of group with AUR and without AUR was 64 and 65 years respectively but PSA and prostate volume in group with AUR was more, PSA=7.10, vol=57 cc vs PSA=4.2 and volume=48 cc in group without AUR (p=0.001) Patient with AUR had stronger correlation between PSA and prostate volume (r=0.46) as compared to group without AUR (r=.2324). Conclusion: North and South Indian men had similar profile for age, PSA and prostate volume . Men with AUR had larger prostate volume,higher PSA and stronger correlation between PSA and prostate volume.

   To evaluate the impact of different catheter size on the urodynamic parameters and its clinical implication Top

V. Tyagi, M. Patel, P. Vasudeva, Y. M. Prashanth, V. Prasad, K. Saurav

VMMC and SJH, New Delhi, India

Introduction: 6-8Fr catheters are current ICS standard for UDS. Limited number of studies have evaluated effect of urethral catheters on various urodynamic parameters There is no consensus on the ideal size of urethral catheter to be used during UDS. Hence, we prospectively study the effect of different size transurethral catheters on urodynamic parameters. Materials and Methods: This was a prospective randomized comparative study which included consecutive adults ≥18 years old. Randomization was done using computer generated randomization table. After randomization,50 patients in each arm underwent two urodynamic studies 45 minutes apart with 5 and 8 Fr catheters in group 1 and in with 6 and 8 Fr catheters in group 2. Results: All sizes of catheters used during pressure flow study significantly decreased Qmax and VV when compared to Qmax obtained during free uroflowmetry. The impact of 8F catheter was more than a 5F or a 6F catheter with no significant difference between 5Fr or 6Fr catheter. Though, the mean BOOI increased significantly with 8Fr catheter compared to 5Fr or 6Fr catheter, there was no statistically significant upstaging between 8F and 5F or 6F catheter. The mean BCI similar with different sizes of catheters except between 5Fr and 6Fr catheter, which was significantly different. Conclusion: Catheters of different sizes in the urethra do decrease the Qmax compared to free Qmax, but from a statistical standpoint, the catheter size (between a 5/6/8F) did not significantly alter the BOOI / BCI.

   Xanthogranulomatous prostatitis - Two disparate presentations of a rare entity Top

V. Aswin, V. Kamaraj, N. Muthulatha, M. Ilangovan, M. Sivasankar, M. Griffin, P. A. Arjun

Saveetha Medical College, Chennai, Tamil Nadu, India

Xanthogranulomatous prostatitis is a rare benign granulomatous inflammatory lesion of prostate that can clinically mimic prostatic carcinoma. The distinctive feature is the presence of large number of “foamy macrophages” (histiocytes) in the inflammatory cell infiltrate, accompanied by lymphocytes and plasma cells. The etiology and pathogenesis remains unknown. It is thought to represent a reaction to inflammatory products and altered prostatic secretions released from obstructed ducts. On transrectal ultrasonography (TRUS) and magnetic resonance imaging (MRI) there is no pattern that allows a specific diagnosis of granulomatous prostatitis or differentiate it from prostatic carcinoma. Hence, the diagnosis of xanthogranulomatous prostatitis is made on histological examination of prostate. We are presenting two different cases encountered by us, which were histopathologically proven as Xanthogranulomatous Prostatitis. The first case was a mimic of prostatic carcinoma and the second was a prostatic abscess which was found to be Xanthogranulomatous Prostatitis postoperatively. The first case report and description of this entity was made in Poland by MiekoÅ' et al in 1986, with less than 20 cases being reported in literature till date. Xanthogranulomatous prostatitis presenting as prostatic abscess is even rarer, with only about 4 cases reported till date.

   Modified clavien grading of bipolar TURP complications Top

Anurag Dubey, R. Ravichandran, Vincent D. Paul

Meenakshi Mission Hospital, Madurai, Tamil Nadu, India

Background and Objectives: TURP is gold standard treatment for BPH. Complications in TURP are less but not absolute. Modified Clavien Dindo Grading System is well established classification for post operative complications Oncology but in endourologic surgeries where complications are usually less and low grade efficacy of this classification has to be proven. Our purpose of thesis is to assess evaluation of complication of bipolar TURP as per MCG. Methods: This study conducted from April 2017 to March 2019. Study included all patients who were admitted for bipolar TURP. Results: we have enrolled 110 cases in our study out of them 21 (19.9%) patients developed complications. Out of 21; 11 (52.4%) grade I, 5 (23.8%) grade II, 2 (9.5%) grade IIIa, 1 ( 4.8%) grade IIIb, 1 (4.8%) in each grade IVa and IVb. Conclusion: The Modified Clavien Grading System represents a straightforward and easily applicable tool that may help urologists to classify the complications of TURP in a more objective and detailed way. It may serve as a standardized platform of communication among clinicians allowing for sound comparisons.

   Safety and efficacy of bipolar versus monopolar transurethral resection of bladder tumor: Systematic review and meta-analysis Top

G. Sharma, A. P. Sharma, S. K. Devana, R. M. Mavuduru, G. S. Bora, A. K. Mandal

PGIMER, Chandigarh, India

Introduction and Objective: Bipolar energy devices have numerous advantages over monopolar such as better hemostatic property, lower power and less current dispersion. Aim of this study was to systematically review the literature and provide comparative safety data of the two techniques i.e. monopolar transurethral resection of bladder tumor (mTURBT )and bipolar TURBT. Methods: Systematic literature review with metanalysis was performed following PRISMA (Preferred reporting items for systematic reviews and meta-analysis) guidelines. We included both randomized and non-randomized studies. Primary outcome was incidence of obturator jerks and bladder perforation in the two groups. Results: In this study, 19 studies were included of which 9 were RCT's and rest were cohort studies (9 prospective and 1 retrospective). Two groups were not significantly different in incidence of obturator jerks (odds ratio (OR) 0.76 CI (confidence interval) [0.44, 1.29], p=0.30) and bladder perforation (0.82% vs. 1.1% (p=0.12). Catheter time was significantly shorter with bipolar group whereas, overall complication rates, resection time and blood transfusion rates were similar in two groups. Subgroup analysis of data from randomized studies and studies with mixed tumors (both muscle invasive and non muscle invasive) revealed significantly lower rates of bladder perforation but similar rates of obturator jerks. Most of the studies in this review were at high risk of bias. Conclusion: Bipolar TURBT is safe and efficacious in patients with bladder tumors however further high quality RCT's are recommended with adequate number of patients and appropriate methodology to show its superiority over monopolar TURBT.

   Spontaneous ureteric rupture Top

Jibhakate Nikhilesh Ashok

Seth GSMC and KEMH, Mumbai, Maharashtra, India

Introduction: A 25 years male came with C/o acute severe left flank pain. Patient had left lower ureteric calculus which was managed medically. On IVU there was left ureteric rupture with contrast extravasation for which PCN was inserted. Left PCN gram reveals opacification of the pelvicalyceal system of left kidney and upper 2cm of left ureter is seen with cut off seen at L2 level. RGP shows contrast extravasation passing beyond L4 level upwards. Left Ileal Ureter reconstruction was done. Methodology: We present a video presentation of a 25 years male with Left Spontaneous ureteric rupture and ileal ureter reconstruction. Patient undergone Cystourethroscopy with Left RGP with Left PCN gram. contrast extravasation passing beyond L4 level upwards.On table PCN gram done contrast cut off seen at L2 level. Long segment stricture upper ureter was noted intraoperatively. Ileal interposition was used to repair defect. Discussion - Spontaneous ureteral rupture is a surprisingly rare condition. The most common cause for spontaneous ureteral rupture are obstructing ureteral calculi. Other reported rarer causes include tumour, retroperitoneal fibrosis, pregnancy, connective tissue disorder and acute urinary retention. The condition is best diagnosed with a delayed CT scan post-intravenous contrast. This modality will confirm a urinary leak and can accurately define the site of rupture. Due to the rarity of this clinical condition, there are no guidelines or recommendation on its management. Conclusion: Spontaneous ureteric rupture is a very rare condition and can be managed by diversion initially followed by definitive reconstructive procedure.

   Zinner syndrome: An unusual cause of bladder outflow obstruction Top

S. P. Yadav, Kamal Gurjar

Pushpanjali Hospital, Gurgaon, Haryana, India

Purpose :- Zinner syndrome is a rare condition comprising a triad of unilateral renal agenesis, ipsilateral seminal vesicle obstruction and ipsilateral ejaculatory duct obstruction We present the case of a 29-year-old patient where the initial presentation of this condition was bladder outflow obstruction. Materials and Methods: A 29-year-old patient presented with a longstanding history of bladder and voiding problems. Suprapubic pain followed by terminal dribbling and urinary retention necessitating admission. He had a previous childhood history of recurrent urinary tract infections, nocturia and suprapubic pain when the bladder was full. A CT examination of the urinary tract demonstrated a small atrophic renal remnant in the left renal fossa. In addition, there was ectopic insertion of the left ureter behind the bladder neck associated with cystic ureteric bud . Seeman Examination of the patient was normal. Results: On cystoscopy huge cystic Swelling is seen at left bladder neck. We restricted the roof of the cyst . Now patient is symptoms free. Conclusion: These usually occur in males between the second to fourth decades of their life. The usual symptoms that are caused by the seminal vesicle cysts are bladder irritation and obstruction as well as pain in the perineum and scrotum. Nowadays transurethral deroofing of the cyst may be required if symptomatic.


   Adenocarcinoma in cystitis cystica ET glandularis: Fact or myth? Top

Amit Agrawal, S. Tripathy, Deepak Kumar, Bharath Kumar, Puneet Aggarwal

1Command Hospital (SC), Pune, Maharashtra, India, 1Armed Forces Hospitals, Tabuk, Saudi Arabia

Introduction: Since its first description by Morgagni et al in 1761, the natural history of Cystitis Cystica et Glandularis (CCEG) has eluded the clinicians. 1950 onwards after Immergut first implicated CCEG as a precursor for adenocarcinoma of bladder, various other studies seconded this notion. However, subsequent studies found no truth in this correlation and in fact many authors labelled it as chronic and quiescent histologic lesion without any clinical significance. Materials and Methods: All patients diagnosed to have CCEG between Jan 2010 to Jun 2019 were included in the study. The clinical details were obtained from the hospital's data base which included the patient's demographics and the follow up data. This was a multicentric study with a total of four hospital participating in the study. Institutional ethical committee clearance was obtained prior to starting the study. Results: A total of 97 patients were included in the study. 6 were excluded as the follow up data were missing from the records. The remaining 91patients were analysed for this study. The mean age of the patient at diagnosis was 30.41 years (Range 20 to 41 years) and all of them were male. The follow up ranged from 0.5 to 9.5 years with the mean follow up period of 4.70 years. No patient was found to develop adenocarcinoma of the Urinary bladder on follow up. Conclusion: Although adenocarcinoma would take a long time to develop but the definite evidence of it developing in a case of CCEG seems to be lacking.

   A Rare presentation of Xp11.2 Translocation renal cell carcinoma with Metastasis to hard palate and brain: A kidney in mouth situation Top

Chirag Doshi, R. Vijaya Kumar, B. R. Ravikumar, Sachin Dharwadkar, V. Manjunath

JSS Medical College, Mysore, Karnataka, India

Introduction: Xp11.2 translocation renal cell carcinoma (RCC) with transcription factor E3 (TFE3) gene fusion is a rare tumor, and the prognosis of this tumor is poorer compared with that of other subtypes of RCC. Case Report: A 30 year old hypothyroid female who was diagnosed as intracranial tumour 6months back with ill-defined soft growth in hard palate since 2 months which was gradually increasing in size, presented with intermittent gross hematuria and flank pain since 7days. CECT subsequently showed two ill defined heterogenously enhancing lobulated solid mass lesions arising from upper and lower poles of left kidney s/o neoplastic etiology (RCC). Patient underwent left radial nephrectomy. The histopathological, immunohistochemical (IHC) examination and fluorescent in situ hybridization (FISH ) confimed the diagnosis of Xp11.2 translocation papillary RCC type 2 with TFE3 gene fusion. Histopathology and Immunohistochemistry (IHC) from hard palate lesion was positive for CD10 and suggestive of metastasis from renal carcinoma.Post operatively she was started on chemotherapy and she responded well. Conclusion: Patient with metastatic papillary renal cell carcinoma (pRCC) showed a increased risk of cancer specific death, when compared to non-metastatic pRCC. - These tumors are more commonly encountered in children rather than in adults, and adult Xp11.2 translocation RCC is associated with a poorer prognosis compared with its pediatric counterpart -RCC metastasizing to the oral cavity, especially the buccal mucosa is extremely rare and has a very poor prognosis. -Study and immunohistochemistry helps in clinching in a rare diagnosis. - However, there is currently no established effective treatment for Xp11.2 RCC.

Keywords: Renal cell carcinoma, transcription factor E3 gene fusion, Xp11.2

   Spontaneous large perinephric hematoma secondary to small renal angiomyolipoma: A lesson learnt the hard way Top

H. S. Talwar, A. Mittal, S. Kumar, K. J. Mammen, V. K. Panwar, S. Navriya

All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Introduction: Renal angiomyolipomas represent benign tumors of the kidney consisting of blood vessels, smooth muscle and varying levels of adipose tissue. The risk of bleeding in these tumors is related to size of tumor and the presence of thick walled vessels with associated formation of microaneurysms. Materials and Methods: We herein present a case of 55-year-old male with no comorbidities, diagnosed as 3 cm renal angiomyolipoma on regular follow up for 3 months. He presented with right flank pain radiating to back for 15 days. Abdominal examination was unremarkable. Ultrasonography revealed a well defined hyper echoic lesion in the right kidney suggestive of angiomyolipoma with a perinephric collection. Contrast enhanced CT scan confirmed a 3 x 2.5 cm angiomyolipoma at upper pole of right kidney with a large approximately 16 x 8 cm collection in the right perinephric area. There was no fall in hemoglobin. A diagnosis of small right angiomyolipoma with spontaneous right perinephric hematoma was made and was planned for angioembolisation. Digital subtraction angiography revealed an aneurysm of the right posterior segmental artery supplying the upper pole. It was selectively embolised using a mixture of lipiodol and n butyl cyanoacrylate (NBCA). Results and Discussion: Procedure was uneventful and patient was discharged within 36 hours in a stable condition. On follow up USG, perinephric hematoma resolved spontaneously and patient was doing well.A review of literature on renal angiomyolipoma shows that most of the small (4 cm in size. Conclusion: This case report thus highlights the clinical scenario of a patient with no comorbidities and a renal AML less than 3 cm in size with an unusual finding of a large 16 cm hematoma which was successfully managed with angioembolisation. Also further raising the question whether preemptive angioembolisation is required in AML s less than 4 cm to prevent disastrous consequences.

   Bladder cancer in the first trimester of pregnancy: Management dilemmas. A case report with review of the literature Top

B. Krishna Mohan, K. V. Sanjeevan, Georgie Mathew

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Introduction: Malignant tumours are rare in pregnancy and the overall incidence is around 2.35/10,000. The most common tumour in pregnancy is a malignant melanoma, followed by cancer of the cervix and breast. Urological tumours are very uncommon in pregnancy but they represent particular problems in diagnosis and management. We report a new case of bladder cancer in the first trimester of pregnancy. Methods: Case report. Case Report: 22-year-old female, was initially diagnosed with bladder mass in routine first trimester antenatal scan. She had undergone Cystoscopy and biopsy in second trimester in outside hospital. Histopathology was a Papillary Urothelial Neoplasm of Low Malignant Potential. Slide and block reviewed showed Low Grade Papillary Urothelial Carcinoma. Computed Tomography of abdomen done in the 2nd post-partum day showed proliferative lesion with narrow stalk seen arising from the right posterior-lateral wall measuring 2.7x3.4cm, another similar lesion measuring 1.1x1.2cm was seen along the base of the bladder at the trigone, no transmural extension and no nodal metastasis. Patient underwent Transurethral resection of bladder tumor on Post-partum day 3. Patient and child are doing well, and under regular follow-up. Conclusion: Limited literature has resulted in a paucity of information on the optimum management of pregnant women with bladder cancer. However, reports of single cases, or small series, highlight the difficult decisions needed and the potential conflict between the management of the tumour and the avoidance of harm to the foetus, as illustrated in our case. This case is presented for its rarity.

   Granulomatous prostatitis after intravesical BCG for superficial transitional cell carcinoma bladder Top

D. Patel, R. Shimpi

Ruby Hall Clinic, Pune, Maharashtra, India

Objective: The objective of this study was to evaluate incidence of granulomatous prostatitis and its management, in patients treated by intravesical BCG-therapy for superficial TCC of the bladder. Materials and Methods: A retrospective study was performed on the cases of granulomatous prostatitis observed among patients treated with intravesical BCG instillations between January 2010 and December 2019. A total of 153 men were treated for high-risk or intermediate-risk superficial bladder cancer according to the usual recommendations. The attenuated Connaught strain of BCG was used at a dose of 120 mg. Induction treatment consisted of six, every weekly instillations and was followed by maintenance treatment for a period of 6 months, every monthly. Results: Six patients developed granulomatous prostatitis (4% of cases). On average, this complication occurred after about 12 week of starting BCG therapy(10-15). Two patients had hematuria with occasional hematospermia. Ultrasound-guided biopsies were indicated in view of the lesion found in prostate during routine follow up study, and conï¬ rmed the tuberculoid granulomatous lesion of the prostate in each case. All patients received standard 6 month four drug anti bacillary treatment. All patients had resolved lesion at the end of anti-koch treatment. Conclusion: The early identification of intravesical BCG therapy related granulomatous prostatitis allows their effective treatment. However, when a histological diagnosis of asymptomatic granulomatous prostatitis is made, the execution and type of treatment are controversial.Prostatic carcinoma must be systematically excluded by ultrasound-guided biopsies in all patients with clinical granulomatous prostatitis three months after intravesical BCG instillations.

   Kidney stones with IVC thrombus: A hidden surprise Top

Vikas Singh, Panwar Pankaj, Maheshwari Ruchir, Banerjee Kinjal, Kumar Anant

Max Superspeciality Hospital, Saket, Delhi, India

Renal pelvic Squamous cell carcinoma (SCC) is a rare entity. Renal stones are important risk factors for its development. Only case reports are available in literature and there is no consensus on best line of management. IVC involvement is usually by invasion and seen in advanced stage. Isolated IVC and renal vein thrombus with kidney stones should alert the Urologist about possibility of underlying SCC. We report another unique presentation of this aggressive cancer in the form of isolated renal vein and IVC thrombus without any tumour on imaging in kidney.

   Metastatic Ewing's sarcoma of the adrenal gland in a young male: A rare fate Top

H. S. Talwar, A. Mittal, S. Kumar, K. J. Mammen, V. K. Panwar, S. Navriya

All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Introduction: Ewing's sarcoma is one of the most common malignant bone tumors seen in young adults. It is known for its aggressive and malignant behaviour and typically seen in long and flat bones and rarely in soft tissue and solid organs. Ewing's sarcoma of the adrenal gland, is very rare and only a few cases have been reported in literature so far. Materials and Methods: We report a case of a young Indian male who presented with complaints of dragging sensation over the left flank radiating to left. On examination, a vague lump was palpable in the left hypochondrium and lumbar region. After a preliminary ultrasound, a CECT scan done revealed a 16 x12 cm mass in left suprarenal region with infiltration into the left kidney and left crus of diaphragm displacing the surrounding organs (figure). Endocrine analysis revealed a normal functional work up ruling out pheochromocytoma. Metastatic work up revealed multiple osteoblastic skeletal metastasis. A core needle biopsy showed features of malignant small round cell tumor and immunohistochemistry (figure) was strongly positive for CD99 consistent with a diagnosis of Ewing's sarcoma. He received Vincristine, Adriamycin, Cyclophosphamide alternating with Ifosfomide and etoposide chemotherapy with a palliative intent and local radiotherapy for bone metastases. Results: Ewing's sarcoma is a highly malignant tumor arising from neuroectodermal cells and includes a family of tumors with characteristic chromosomal translocation of ESWR gene on chromosome 22. We report a rare case of de novo metastatic Ewing's of the adrenal gland, and it occurring in a young boy of 20 years adds to its rarity. He is being treated with VAC/IE regimen with local radiotherapy. After 2 cycles of chemotherapy, the patient is doing well. Conclusion: Ewing's sarcoma should be amongst the differential diagnoses of a large non functional adrenal mass. The treatment of metastatic Ewing's is not standardized and thus the aim is to add to the existing literature on patients who present with upfront metastatic Ewing's sarcoma and to find out whether systemic chemotherapy will benefit patients with such poor prognosis so as to preserve valuable resources and avoid toxicity.

   Genital sparing radical cystectomy and ileal neobladder in a rare case of leiomyosarcoma of urinary bladder: Oncological and functional outcome Top

Ankit Gupta, Singla Anurag, Jain Harsh, Goel Hemant, Sood Rajeev

Dr. PGIMER and RML Hospital, New Delhi, India

Introduction: Leiomyosarcoma (LMS) is rare tumor of urinary bladder and accounts for <0.1% of all bladder cancer. LMS generally have poor prognosis because of high-grade and stage at presentation. There is no consensus about standard treatment due to rarity of disease and paucity of literature. Materials and Methods: We present a case of 23 y/F having C/C of hematuria since 1 year. On evaluation 4x4 cm tumor was diagnosed in urinary bladder which recurred after TURBT and HPE was suggestive of LMS. She underwent genital preserving radical cystectomy (RC) with ileal neobladder (studer) followed by adjuvant radiotherapy (RT). After 1 year of follow up patient had no day and night time incontinence and have normal menstrual cycle with no e/o recurrence of disease at 1 yr follow up DISCUSSION: LMS of UB is a rare malignancy with ~ 200 cases reported in literature. Most common presentation is haematuria. Prognostic factors includes presence of free margin, size, grade (mitotic activity, tumor differentiation &necrosis )& local invasiveness . they are considered highly aggressive tumour. Current treatment modalities involve aggressive surgical therapy ± RT/chemotherapy. MC procedures performed are partialcystectomy/radical cystectomy with ileal conduit. Only in handful of cases RC + PLND + neobladder were made. We performed Genital sparing radical cystectomy in our patient in view of nulliparous status and young age. Further technical challenges which may be encountered in future during pregnancy may be performing Upper segment caeserian section (instead of LSCS) and Management of hydrouretronephrosis and recurrent UTI.

   Kaposi's sarcoma presenting as paratesticular tumor in immunocompetent patient: An exception to the dictum Top

Anuj Sharma, A. Sharma, K. M. Parmar, S. K. Singh, A. Thakur, A. K. Mandal

PGIMER, Chandigarh, India

Introduction and Objectives: Kaposi's sarcoma is an angioproliferative disorder. Association with Human herpes virus 8 and AIDS related illness has been classically seen in most of the cases. In Genitourinary system Kaposi's sarcoma has been seen in patients post renal transplant involving skin and genital region. We report an extremely rare presentation of Kaposi's Sarcoma as a paratesticular mass in an immunocompetent patient. Methods: A 45 years male with no comorbidities presented to our outpatient department with a right painless scrotal swelling since 3 months. The size of the swelling had gradually increased in size since then. Examination revealed a firm 3X2X2 cm firm, non tender swelling separately palpable from the right testes. On MRI imaging of the pelvis it was a heterogeneous signal lesion in the right epididymis 34X36X27mm with thickened right spermatic cord. The patient underwent right high inguinal orchiectomy from right inguinal incision. He had a negative HIV serology(ELISA) with CD-4 counts >500/dl. Results: The histopathology of resected specimen was suggestive of Kaposi's sarcoma with paratesticular tumor cells showing vascular differentiation. Immunohistochemistry was consistent with CD31, CD34, FLI-1 and D2-40 positivity and negative for SMA, S-100 and CK. Patient since then is on follow up for the last 1 month with no evidence of any local recurrence. Conclusion: This is a rare presentation of Kaposi's Sarcoma in the paratesticular region in a immunocompetant patient that breaks our myth about this rare entity which is usually associated with immunocompromised states especially AIDS related illness.

   Primary signet ring cell carcinoma of urinary bladder- treated with radical cystoprostatectomy with ileal conduit: A case report and review of the literature Top

T. Manjunath, Mandeep Phukan, Sasanka Kumar Barua, Saumar Jyothi Baruah, T. P. Rajeev, Puskal Kumar Bagchi, Debanga Sarma

Gauhati, Assam, India

Introduction: Adenocarcinoma is about 0.5 to 2% of all malignant tumors of the bladder, and the mucinous subtype is extremely rare as a primary bladder lesion. Urachal remnants and exstrophy bladder are risk factors for this histological variant of urinary bladder tumour . It carries poor prognosis and resistant to radiotherapy and chemotherapy. Methods: We report a case of primary signet-ring cell carcinoma of urinary bladder .A 52-year-old male presented with one episode of painless hematuria- 4 months back. He had mucusuria on and off. (CECT) of abdomen revealed a 7.8 × 5.2x 5.9 cm ill defined irregular outline heterogeneously enhancing polypoidal lesion seen on anterior wall of urinary bladder, infiltrating the wall with perivesical extension, without evidence of locoregional lymphadnopathy. Results: Radical cystoprostatectomy with bilateral pelvic node dissection with ileal conduit was done. Histopathology of the extirpated tumour was consistent with primary mucin secreting adenocarcinoma of the bladder with signet ring differentiation and the margins were free of tumour and Immunohistochemistry confirmation was done. Conclusion: The PSRCC of the bladder is a rare tumour which carries risk of poor prognosis. Immunohistochemistry also plays an important role. CECT imaging with PET CT and CEA and CA19-9 levels may be helpful for follow-up and early identification of recurrences. In case of recurrence modified FOLFOX-6 regimen which is commonly used to treat metastatic gastrointestinal cancers may be used. PSRCC of urinary bladder needs strict follow up and patient must be compliant enough to help detect recurrence.

   Clear renal cell carcinoma with angioleiomyomatous stroma in a non- inherited renal cancer syndrome - Is it a different entity? Top

Shanmugasundaram Rajaian, Pragatheeswarane Murugavaithianathan, Karrthik Krishnamurthy, Lakshman Murugasen

MIOT International, Chennai, Tamil Nadu, India

Introduction and Objectives: An unusual group of renal cell tumours has been reported to contain rich leiomyomatous or angioleiomyoma-like stroma that is so prominent as to raise consideration of two admixed neoplasms. We present a case of Renal cell carcinoma with angioleiomyomatous stroma in a patient with non-inherited renal cancer syndrome. Materials and Methods: A 69 year old female had presented with abdominal pain, vomiting and fever of one week duration. She was managed for urosepsis and imaging revealed incidentally detected enhacing heterogenous endophytic right upper polar renal tumour of 4x 4cm size. Her past history was significant for early hysterectomy for large multiple fibroids at the age of 35 years. Her renal function was normal. After she became afebrile and her general condition improved, she underwent right open partial nephrectomy. Her post-operative period was uneventful and she recovered well. The histopathology report revealed clear cell carcinoma with rich angioleiomyomatous stroma with thin walled capillaries. Immunohistochemical study revealed positivity of the stroma for vimentin, Cathepsin K and HMB45. Results and Observations: Pathological evaluation of partial nephrectomy revealed clear cell carcinoma with angioleiomyomatous stroma suggesting a possibility of tuberous sclerosis complex (TSC). As her clinical features and the imaging of nervous sytem was negative for any TSC features and earlier hysterectomy and multiple leiomyomas in the skin, a possibility of Hereditary Leiomyomatosis and Renal Cell Carcinoma Syndrome (HLRCC) was also thought off. Cytogenetic study was not suggestive of the syndrome. Conclusions: Presence of Clear renal cell carcinoma with angioleiomyomatous stroma signifies a separate entity of renal cell carcinoma classification. The presence of two histologies presents confusion in the diagnosis and categorization. This has to be clearly differentiated to prognostic well.

   Synovial sarcoma of testis, a rare tumour: A case report Top

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

Gauhati Medical College and Hospital, Gauhati, Assam, India

Introduction: Testicular tumours are mostly germ cell tumours. Testicular synovial sarcoma is an exceedingly rare entity and other rare tumours include stromal cell tumours, lymphoma etc. Sarcomas of the spermatic cord, epididymis, and testis are the most common genitourinary sarcomas in adults Materials and Methods: Here we present our experience in single institute of one case of synovial sarcoma of testis which has been followed since 2 years. Results: A 30 years old young male had presented to our out patient department with complaints of increase in size of left testis over 3 months. It was painless and he did not give any history of trauma. MRI of scrotum showed enhancing testicular mass lesion with areas of necrosis, among his tumour markers, alpha feto protein was only marginally raised. He underwent High inguinal orchiectomy .He turned up again with a recurrent mass at the scar site with previous histopatholgy suggestive of synovial sarcoma. He underwent wide local excision after being fully investigated and his final biopsy report along with immunohistochemistry markers were positive for synovial sarcoma. He underwent local radiotherapy and ifosfamide and doxorubicin chemotherapy. He is on a strict follow up since 2 years. Conclusion: Primary testicular sarcoma is rare and this is the second case of synovial sarcoma of testis being reported. It must be kept in mind in the differential diagnosis of soft tissue tumour in unusual locations. It must be treated aggressively with local radiotherapy and chemotherapy decreasing the chances of local recurrence.


   Post vasectomy urethrocutaneous fistula - Righting the wrong Top

B. N. Kumar, A. A. Jha, A. S. Sandhu

Base Hospital, Delhi, India

Introduction and Objective: Urethrocutaneous fistula (UCF) as a surgical complication usually occurs after hypospadias repair or secondary to treatment of a urethral growth (condyloma or papillary tumour). We present a case of iatrogenic UCF after vasectomy in a young individual, managed successfully. Methods: A 32 years old male underwent a non-scalpel vasectomy under local anaesthesia on outpatient basis elsewhere. The same evening he had presented with acute urinary retention and was catheterised and sent home. Catheter was removed a week later, but he reported the next day with urine leak from the left vasectomy scrotal incision site (separate incisions had been given for both vasectomies). He was once gain catheterised perurethrally and later referred to our urology centre. He was observed for 2 weeks on perurethral catheter, but he continued to have minimal urine leak from the scrotal wound. He underwent suprapubic cystostomy (SPC) catheter placement and retrograde urethrogram (RGU) under local anaesthesia. RGU revealed an UCF in the form of a single point leak of contrast from proximal penile urethra. Patient was managed conservatively on SPC, antibiotic and anticholinergic. Results: Patient underwent RGU and micturating cystourethrogram (MCU) after 1 month, which revealed a very minimal kinking of penile urethra at the initial injury site with no contrast leak. SPC was removed. Presently patient is on follow up with good urine flow. Conclusion: UCF after vasectomy is a very rare complication not documented before in literature and the same can be managed successfully with SPC placement.

   Different modes of surgical treatment of urethral diverticulum in male patients Top

B. Amit, Sujata Patwardhan, Bhushan Patil

Seth GSMC and KEMH, Mumbai, Maharashtra, India

Introduction: Urethral diverticulectomy a rare entity in men. There are only some case reports or case series related to Male Urethral Diverticulum in literature. We present case series of acquired male urethral diverticulum with different clinical profile who underwent different surgical procedures. Selection of operative technique is dictated by site and location of UD, caliber of entire urethra and presence of infective focus. Materials and Methods: All patients had different clinical presentation. Retro Grade [RGU] and Micturating Cystourethrogram [MCU] was done to characterize diverticulum. Cystourethroscopy was done before surgery. Depending on site and size of diverticulum, urethral caliber and presence of infection different operative techniques were used. They were urethral diverticulectomy with primary reconstruction, excision of UD with perineal urethrostomy and stage 1 urethroplasty with drainage of abscess. Excision of diverticulum and primary repair of the urethra is feasible in patient with normal urethral caliber and healthy plate. Presence of an unhealthy urethral plate and infective focus was managed by staged urethroplasty. Perineal urethrostomy was done when anterior urethra is cicatrized, and patient was not willing for staged procedure. Results: All three patients had unobstructed urination without UD recurrence or UTI up to a follow-up period of 1 year. Conclusion: Urethral diverticulum is a condition which can be managed successfully if surgical procedure is tailormade to the size and location of diverticulum, urethral caliber, urethral plate, presence of infection and patient's wishes.

   Outcomes of buccal mucosal graft urethroplasty in a tertiary setup: Five years experience Top

P. Jaipuriya, K. V. Bharagava Reddy, J. Jayaraju, P. Vedamurthy Reddy, N. Mallikarjuna Reddy

Narayana Medical College, Nellore, Andhra Pradesh, India

Introduction and Objectives: Urethral stricture is a challenging condition to treat and several approaches including direct visual internal urethrotomy (DVIU) and anastomotic or augmentation urethroplasties based on the use of flaps and graft have been reported. The use of Buccal Mucosa Graft (BMG) urethroplasty represents the most widely used method of urethral stricture repair. We present our long-term experience with buccal mucosal grafts placed dorsally. Methods: We repaired 220 anterior urethral strictures with BMG from 2015 to 2019.Mean follow up was 24 months. Mean patient age was 41 years. The graft was harvested from the cheek under local anaesthesia. The graft was placed on the dorsal urethral surface. Results: Mean stricture length was 4.5 cm (range 1.5 to 10 cm) with mean follow up of 24 months. 10 patients (4.5%) were found to develop stricture at anastomotic site. The most common complication was wound infection. 15 patients (6.8%) developed wound infection, of which 7 patients (3.18%) presented with urethrocutaneous fistula. Conclusion: BMG urethroplasty represents a reliable therapeutic option for patient with urethral strictures of more than one centimetre (cm) length with fewer side effects. Complications are more common in patients having complex penile stricture with associated co morbidities.

   Case report of rectourethral fistula Top

Nagori Rupesh, Sharma Pradeep, M. K. Chhabra, Choudhary Gordhan, R. K. Saran

SN Medical College, Jodhpur, Rajasthan, India

A rectourethral fistula (RUF) is an uncommon complication that is mostly iatrogenic in origin, but can also be caused by a neoplasm, infection, inflammation or trauma. We present a case of RUF due to Iatrogenic injury for treatment of stricture urethra. The case was evaluated with Mcu, MRI and cystoscopy. There was fistula between membranous urethra and rectum. Patient underwent spc followed by definitive management with spc in situ and colostomy.

   DSD management - 30 years experience of a single tertiary care centre in North India Top

Banthia Ravi, Yadav Priyank, Sayal Sarita, Srivastava Aneesh, Singh Udai Pratap, M. S. Ansari

SGPGI, Lucknow, Uttar Pradesh, India

Objective: Disorder of sexual development is a major cause of psycho-social anxiety both to patient and parents if not managed properly. Our experience in management of sexual development disorder patients is being presented here. Materials and Methods: We retrospectively reviewed clinical records of all patients with disorder of sexual development managed surgically at our institute in last 30 years between December 1989 and June 2019. Relevant history, clinical examination, investigations and surgical procedures performed were recorded and analysed and results were assessed in terms of cosmetic, functional and psychosocial and sexual outcomes. Results: A total number of 126 patients were retrospectively analysed.Age of diagnosis ranged from new born to 32 years. Most common cause of genital ambiguity in our patients was 46 XX DSD. Masculinizing and feminizing genitoplasty was done according to gender of rearing, genital anatomy, and parental choice. among 64 patients diagnosed as 46 X XDSD 54 patients (84.37%) reported satisfactory cosmetic outcome and 48 patients (75.00 %) had satisfactory functional outcome on long term follow-up. Among the 37 patients diagnosed as 46 XY DSD 31 (83 .78 %) patient have reported satisfactory cosmetic outcome and 27 (72.9 %) have reported satisfactory functional outcome. In patients with mixed gonadal dysgenesis and ovotesticular DSD satisfactory cosmetic and functional outcome was seen in 68 % patients. Conclusion: Managing disorder of sexual development according to gender of rearing, genital anatomy and parental choice mostly carries a good prognosis in terms of cosmetic, functional and psychosocial and sexual outcome.

   Male urethral diverticulum uncommon entity: our experience Top

Gaurav Sharma, Bhowmik Prasenjit, Bahal Bandhan, Gupta Prashant, P. K. Sharma, S. N. Mandal

Calcutta National Medical College, Kolkata, West Bengal, India

Introduction and Objectives: Male urethral diverticulum (UD) is a rare entity. The objective is to present an updated review of acquired male UD, according to clinical presentation, diagnostic imaging findings, management, complications, and outcomes. Materials and Methods: We present 2 cases of acquired male UD. Case 1: 32 year male presented with obstructive lower urinary tract symptoms. Clinically he had hard mobile swelling at penoscrotal junction. Retrograde urethrogram revealed large diverticulum in proximal penile urethra. Patient was managed with penoscrotal exploration, stone removal, diverticulum repair and urethroplasty. Case 2: 52 year male with history of neurogenic bladder since birth presented with large scrotal swelling. On evaluation found proximal penile diverticulum with large calculus in prostatic urethra. Cystourethroscopy was done followed by open cystolithotomy. Patient was planned for diverticulectomy and urethral reconstruction. DISCUSSION: The most common symptoms of UD are obstructive lower urinary tract symptoms. Congenital UD develops due to imperfect closure of urethral folds, Acquired UDs occurs secondary to stricture, infection, trauma, long standing impacted urethral stones or scrotal / skin flap urethroplasties. Retrograde urethrogram and Micturating cystourethrogram are the best imaging technique to confirm the diagnosis. Urethral diverticulectomy with urethral reconstruction is the recommended treatment for UD. Conclusion: An acquired male UD is rare and must be considered in the differential diagnosis of suspicious penile and scrotal masses. If there is significant urinary stasis, recurrent UTIs, or urethral calculi, thorough clinical examination followed by surgical correction is the standard procedure. Keywords: Cystourethroscopy, Diverticulectomy, Urethral Diverticulum.

   Prospective study to evaluate and compare the outcomes following end to end vs buccal mucosal graft urethroplasty for intermediate length bulbar urethral strictures Top

Vijay Pal Singh, V. Rajagopal, Sharma Dvsln

Apollo Hospitals, Hyderabad, Telangana, India

Introduction and Objective: Urethroplasty for bulbar urethral strictures is considered the definitive procedure. End to end and buccal mucosal graft urethroplasty is performed for short and long segment stricture urethra respectively. However for intermediate length strictures (2 to 3 cm), the choice of procedure depends upon the surgeon's expertise and preference. The objectives of the study were to compare outcomes following end to end and BMG urethroplasty in terms of retrograde urethrography/cystoscopy, operative time, flow rates and proportion of various etiologies contributing to stricture urethra. Methods: 49 patients underwent either end to end or BMG urethroplasty for stricture length measuring 2 to 3 cm. RGU, Q max and cystoscopy was done at baseline and at repeat follow up. Intraoperative events (anaesthesia, bleeding) were recorded. Results: 49% had iatrogenic, 34.7% had inflammatory and 16.3% had idiopathic stricture. 29 patients underwent end to end while 20 patients underwent BMG urethroplasty. Mean operative times in end to end and BMG urethroplasty were 131 and 183 minutes respectively. Mean hospital stay was 3.28 for end to end and 4.05 days for BMG urethroplasty. Mean Q max at follow up for end to end and BMG urethroplasty was 14.4 and 11.7 ml/sec respectively. Success rate of end to end and BMG urethroplasty was 89.7% and 75% respectively. Conclusions: Iatrogenic strictures followed by inflammatory stricture are the predominant cause of stricture in Indian patients. In our study, results of end to end are better than BMG urethroplasty in terms of operative time, hospital stay, Q max.

   False passage anastomotic urethroplasty – an avoidable error Top

K. Seshu Mohan, V. Surya Prakash, V. Mohan Kumar, Milan Patel, Rajesh Reddy

Yashoda Hospital, Hyderabad, Telangana, India

Introduction: Bulbo prostatic anastomotic urethroplasty is the 'gold standard' treatment for pelvic fracture urethral injuries (PFUI) and generally has a high success rate in experienced hands. If proper precautions are not taken during end-to-end posterior urethroplasty, false passage anastomosis is possible, leading to surgical failure Here we present two cases who suffered for more than a decade because of false passage anastomotic Urethroplasty. Methods: CASE 1: 32year male with a history of road traffic accident(RTA) and PFUI 17 years ago which was managed by urethroplasty and follow up dilatations. Patient was referred to us for further management. On evaluation the distal urethra was anastomosed to false passage and the corrective urethroplasty performed. After catheter removal patient voided well and patient in follow up since 3 months and voiding well Case 2: 37 year male with history of RTA and PFUI which was operated 8 times (3 times urethroplasty, optical internal urethrotomy and Urethral stent placement)and presented to us with recurrent infections and poor stream. on evaluation false passage anastomosis was found and corrective urethroplasty was done and post operatively patient doing well. Results: In both cases corrective urethroplasty was successful. Conclusion: False passage anastomosis to urethra is a possibility and a dreadful complication to the patient which is avoidable in all cases if proper intra operative care is taken to delineate proximal and distal ends of urethra.

   Comprision of surgical outcomes of perineal midline vertical incision, inverted U incision and inverted Y or lambda incision in the urethroplasty: A prospctive randomized study Top

Arshad Hasan, Gourab Kundu, P. K. Yadav, P. K. Mohanty, S. Panda, G. P. Singh, D. Hota

SCB Medical College and Hospital, Cuttack, Odisha, India

Introduction: Urethroplasty, initiated in 1876, has become a gold standard treatment for urethral strictures now. Perineal approach is one of the most classic methods to reconstruct bulbar and posterior urethral strictures. Generally, 3 approaches of perineal skin incision were more commonly applied, namely inverted-U and vertical midline and inverted Y or lambda. These incisions have their own merits and demerits and preferred on surgeons choice. At present, numerous urological studies have indicated that the evolution of surgical approaches could improve patients' outcomes to a certain extent. Objective: This study compare surgical outcomes between the perineal inverted-U, vertical midline and inverted-Y or lambda incision approaches of the urethroplasty to analyze complications and risk factors & to know the superiority of incisions. Methods: All male patients who underwent urethroplasty via a perineal incision due to posterior and bulbar urethra stricture. All patients will be randomized into 3 equal groups. Patient and procedure related factors like age,history of addiction ,any comorbidity, character of stricture ,operative status ,hospital stay,complications (Infections,UC fistula,Re- stricture) were analysed. Results: A total of 36 male patients, from June 2017 to september 2019 were recruited, who underwent the urethroplasty via perineal midline vertical or inverted-U incision approach. Surgical site infection (SSI) in perineal inverted-U group was highest. Other complications are also more in inverted-U group . Mean hospital stay were almost equal in all groups were. Conclusion: Inverted-U incision have higher SSI and higher hospital stay. vertical incision are safer approach.

   Bilateral simultaneous full length ureteral replacement using yang monti principle Top

Jaydeep Arun Date

Deenanath Mangeshkar Hospital, Pune, Maharashtra, India

Introduction: Long segment ureteral stricture/Ureteral loss is a difficult clinical situation for reconstructive surgery. Full length ureteral reconstruction is usually managed by ileal replacement which is fraught with complications, Young monti principle has been introduced to reduce complications of ileal replacement however this has been used mostly in partial replacement or in unilateral cases. We report use of Yang monti Ileal replacement in bilateral simultaneous full length ureteral replacement with 2 years follow up. Case report - 50 yrs. Old female underwent laparoscopic Wartheim's hysterectomy followed by post op EBRT ,developed Bilateral full length stricture, which could not be managed on B/L DJ stents and was on B/L PCN's for 2 years As she was disease free for 2 years it was decided to re construct B/L Ureter by Yang Monti procedure. Ref: 1) Thomas Maigaard et al (2015) Yang-Monti ileal ureter reconstruction, Scandinavian Journal of Urology, 49:4, 313-318 2) Application of Yang-Monti Principle in Ileal Ureter Substitution: Is It a benefi cial Modifi cation? M. Esmat, A. Abdelaal, D. Mostafa Vol. 38 (6): 779-787, November - December, 2012 Department of Urology, Ain Shams University, Cairo, Egypt.

   Anastomotic non transecting augmented bulbar urethroplasty- an addition in the armamentarium of the reconstructive urologist- description of the technique and postoperative result Top

Nagesh Kamat, Saurabh Jambu, Arnav Kamat, Rakesh Vaidya

Kamat Kidney and Eye Hospital, Vadodara, Gujarat, India

Introduction: We present the technique and result of ANTABU, anastomotic non transecting augmented bulbar urethroplasty in a patient with a mid and proximal bulbar urethral stricture. Materials and Methods: In a 67 yr patient , the operative steps include: 1) Exposure of the bulbar urethra and dissection of the urethra, as for a dorsal buccal mucosa urethroplasty 2) Dorsal urethrotomy to expose the stricture, methylene blue staining to demarcate the strictured urethra 3) Intraoperative urethroscopy to confirm that the normal level of urethra is reached. 4) Excision of the strictured segment and mucosa to mucosa anastomosis with 5-0 Vicryl suture. The mobility of the bulbous urethra facilitates a tension free anastomosis. 5) Dorsal buccal mucosa grafting in the usual manner with meticulous care for proper apposition of the graft to the urethral mucosa margins. (intraoperative photos included). Results: Preoperative uroflow was 4 ml/sec, post operative uroflow was 20 ml/sec. Surgery duration was 3 hours. Pre operative urethrogram showed a 2.5 cms stricture in the mid and proximal bulbar urethra. Postoperative urethrogram showed a normal caliber urethra, and the site of anastomosis was barely noticeable. Post operative at 11 months the uroflow of the patient is maintained, and no procedure has been necessary . Conclusion: ANTABU has a definite role in obliterative mid bulbar urethral strictures. Besides having a vascular advantage due to its non transecting nature, it is versatile in nature, as it can be used in marginally longer segment bulbar urethral strictures.

   Outcomes of BMG cuff in permanent perineal urethrostomy for complex anterior urethral strictures with extensive lichen sclerosus Top

Pankajkumar Zanwar, S. K. Patwardhan, B. P. Patil, R. Velhal, Y. Pamecha

Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India

Introduction: Complex anterior recurrent urethral strictures with extensive lichen sclerosus where anterior urethra is not suitable for reconstruction are challenging situations for urologists due to failed multistage repairs, and requires permanent perineal urethrostomy. Permanent perineal urethrostomy in such patients has high stenosis rate due to disease activity in native urethra and surrounding skin. In such cases we performed permanent perineal urethrostomy with BMG cuff to prevent stenosis and reviewed the outcome with respect to symptom improvement, graft uptake, improvement in uroflowmetry parameters, urethral caliber and complications if any. Methods: 4 patients of extensive lichen sclerosus with recurrent urethral strictures with failed reconstruction were evaluated with Urethral calibration, uroflowmetry, urethral plate biopsy, previous procedures. These patients underwent permanent perineal urethrostomy with BMG cuff between urethral mucosa and perineal skin. Patients followed up post operatively at 1 month, 3 month, 6 month and 12 months, with symptom improvement, local examination, urethral calibration and uroflowmetry and results analyzed. Results: 3/4 patients had excellent graft uptake with urethral caliber of >22fr, one patient had graft fibrosis with lumen calibre of 16 fr at 6 months. At one year, 3/4 patients were asymptomatic and had successful outcomes, with Q max >15ml/sec and no post operative instrumentation requirement. One patient required regular self caliberation. Conclusion: To avoid restenosis of perineal urethrostomy due to lichen sclerosus requires excision of entire anterior urethra and membranous urethra and cuff of buccal mucosa rolled into a tube helps in refashioning of perineal uethrostomy and prevents restenosis.


   Isolated solitary metachronus perirenal metastasis in a distal gastric cancer: Rare entity and management Top

Bhirud Deepak Prakash, Chaurasia Sunil, Mittal Ankur, Mammen Kim Jacob, Panwar Vikas, Navriya Shivcharan

AIIMS, Rishikesh, Uttarakhand, India

Introduction and Objective: Gastric carcinoma is the second cause of cancer death worldwide. Forty percent of gastric cancer are metastatic. Most common site is liver. Isolated metachronus perirenal metastasis are not reported in distal gastric cancer. Metastatasis to perirenal space are predominantly from lung, malignant melanoma, breast, prostate carcinoma and gastrointestinal tract. Methods: A 46 year old male patient, a known case of carcinoma stomach, with a history of distal gastrectomy and adjuvant CT/RT in 2015 on regular follow up. Follow up CT scan in 2019 showed as 3x3x3 cm(figure) mass in right perirenal space which was FDG avid on PET CT. He underwent Robot assisted laparoscopic metatstatectomy. Results: Histopathology showed adenocarcinoma suggestive of metastasis. Patient received 6 cycles of chemotherapy. Eight month after surgery patient is free of recurrence and metastasis. Conclusion: To the best of our knowledge in scientific medical literature, this is the first case of isolated metachronus perirenal metastasis from adenocarcinoma stomach. This case highlights the importance of regular follow up in malignancies.

   Ganglioneuroma presenting as an adrenal incidentaloma- managed by adrenal sparing approach Top

R. Ranjan, A. Mittal, K. J. Mammen, S. Kumar, V. K. Panwar, S. Navriya

All India Institute of Medical Science, Rishikesh, Uttarakhand, India

Introduction: Adrenal tumours are always a big dilemma in urology due to its various presentation and different management protocol for each. Here, we present a rare case of a rare adrenal tumour i.e. Ganglioneuroma (GN) and will discuss its diagnosis and a novel method of adrenal sparing surgery for treating such benign adrenal mass, which is not mentioned in the literature. Methods: A 15 years old girl presented with mild right flank pain for 3 months. Routine laboratory tests and serum Metanephrine, Normetanephrine and LD-DST Cortisol was within normal ranges. Adrenal protocol computed tomography revealed ill-defined heterogeneously enhancing lesion in right suprarenal region measuring 39x48x49 mm with delayed contrast washout. She underwent Robot-assisted excision of mass with adrenal sparing surgery without any complication. Histopathology showed Ganglioneuroma. Discussion - Ganglioneuroma is a rare, well differentiated, tumour arising from the neural crest cells. Discovered incidentally and accounts for 0.3%-2% of all adrenal incidentalomas. Definitive diagnosis is through histopathological examination but Adrenal protocol CT will be helpful to rule out other causes of typical adrenal mass. Adrenalectomy is now the gold standard for its management. Overall, excellent prognosis after surgical resection, without any recurrences or need for adjuvant therapy. Conclusion: Ganglioneuroma should be considered in differential diagnosis of benign looking adrenal mass, and shouldn't be confused with adrenal adenoma and pheochromocytoma. Although adrenalectomy is gold standard for ganglioneuroma but minimal invasive enucleation of mass with adrenal sparing surgery should be preferred, whenever it is possible, as GN is not known to recur or metastasize.

   Mature cystic teratoma of adrenal, a case report Top

Gaurav, R. K. Tiwari, A. Ahmad, V. Chandra, Bharti Vishrut

IGIMS, Patna, Bihar, India

Introduction and Objective: Primary adrenal teratoma is a rare tumor. Adrenal teratoma was searched in the PubMed database, and very few published case reports found. We report an unusual case of mature cystic teratoma of adrenal. Methods: Case report. An 28-year-old female presented with complain of pain in right upper abdomen for last 1 year. There was no history of hypertension, headache, palpitation, perspiration and recent gain in weight. The abdominal examination revealed mild tenderness in right lumbar region without any palpable mass. Per vaginal examination was normal. Computed tomography (CT) examination after admission revealed a mass of heterogeneous density in the right adrenal gland, with peripheral calcification, consisting mainly of fat tissue; a small number of calcifications and soft tissue density shadows were visible. The mass was sized ~9.3×4.9 cm . The results of complete blood counts and routine biochemical assessment, including kidney and liver function tests, revealed no major abnormalities. The test results for serum cortisol, plasma epinephrine, plasma norepinephrine and urinary vanillylmandelic acid were unremarkable. Therefore, the clinical diagnosis was right adrenal mass. Subsequent lap right adrenalectomy was successfully performed. The total operating time was 120 min and the estimated blood loss was 50 ml. Postoperative recovery was uneventful. The patient was discharged on the fifth postoperative day. Results: After the tumor was completely removed, gross postoperative examination revealed a grayish-yellow multicystic mass, sized 8.5×6.0×4.0 cm, including visible gray cartilage tissue and bone-like hard tissue. Under examination with an optical microscope, multiple sections studied from intervening septum and wall of the cyst shows tissue originating from all the three germ layers like bony trabeculae,cartilage,adipose tissue,keratin flakes and central nervous system. Based on these findings, the pathological analysis of the specimens from the right adrenal gland suggested the diagnosis of mature cystic teratoma.

   Advantages and outcome of laparoscopic NSS using satinsky clamp for hilar control: SKIMS experience Top

Malik Abdul Rouf, Mohd Saleem Wani, Arif Hamid, Abdul Rouf Khawaja, Muzai Iqbal, Manzoor Dar, Prince Muzzafer

SKIMS, Srinagar, Jammu and Kashmir, India

Introduction: Nephron sparing Surgery (NSS) is a well established surgical management for patients with small /bilateral renal masses . During the procedure hilar control can be achieved by using bulldog clamps individually on the renal vessels, the renal artery alone without clamping the vein, or a laparoscopic Satinsky clamp for enbloc hilar clamping. In our series we describe the outcome of lap NSS using Satinsky clamp. Materials and Methods: In this case series all eligible cases in whom the diagnosis of renal mass was confirmed were advised nephron sparing surgery. The short term outcomes studied were warm ischemia time ( using satinsky clamp especially when CT angiography was not available), drop in hemoglobin, and length of post-operative hospital stay. The oncological outcome was evaluated by noting the surgical margins of histopathological specimen, local recurrence and distant metastasis. Results: Out of 15 cases 10 were male. The mean age was 54.25 years. 12 cases were T1a stage on pre operative evaluation and rest 3 T1b stage, 2 tumors were located in upper pole, 2 in mid-pole posteriorly and 11 in lower pole. 13 patients had low complexity score on RENAL scoring (i.e. 4-6) and 2 patients medium complexity score (i.e. 7-9). Average drop in Hb was 1.4 units, warm ischemia time was 25.46 min which is comparable to published literature and postoperative stay was 4.55 days .Histopathology all lesions were clear cell RCC with margins free of tumor with no recurrence till 2 years of follow up. Conclusion: Enbloc hilar clamping in proper axis using satinsky clamp, the multiplicity of renal vessels is not an issue, especially in the hands of beginners.

   Role of laparoscopic radical prostatectomy in locally advanced and high risk prostate cancer: Safe and effective approach Top

G. Giniwale, C. Munjewar, S. Singh, A. Srivastava, I. R. Dhayal

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

Introduction and Objectives: Locally advanced prostate cancer is defined as cancer that extended beyond prostatic capsule, with invasion of the pericapsular tissue, apex, bladder neck, or seminal vesicle but without lymph node involvement or distant metastasis. Significant proportion of patients present with locally advances disease with inherent high risk of local recurrence and systemic relapse after initial treatment. Historically, patients with locally advanced and high grade disease have not been viewed as good candidate for radical prostatectomy(RP). Role of RP for locally advanced and high grade disease is controversial and focus of debate. Objective of study is to evaluate the role of RP in the treatment of locally advanced and high grade disease. Materials and Methods: We conducted retrospective study of 110 patients who underwent laparoscopic RP from January 2014 to June 2019, of which 32 patients were locally advanced and high grade prostate cancer. The following characteristics are noted; margin status, biochemical progression, local recurrence, distant metastasis, clinical progression, overall and cancer specific survival. The results were compared with localized disease cases. Results: Margin status were positive in 9.37% cases, at 2 and 5 year overall survival was 88 and 78%, and cancer specific survival was 94 and 86% respectively. At 2 and 5 year clinical progression was 22 and 44%, local recurrence 8 and 36%, distant metatsasis 14 and 35% and biochemical progression was 21 and 54% respectively. Conclusion: Based on this study it is very likely that RP is an effective and safe approach for locally advanced and high grade disease but further studies require to clarify.

   Management of post robotic assisted radical prostatectomy urinary leak by multi fenestrated foley catheter Top

K Seshu Mohan, V. Surya Prakash, V. Mohan kumar, Milan Patel, Rajesh Reddy

Yashoda Hospital, Hyderabad, Telangana, India

Introduction: Robot Assisted Radical Prostatectomy is a major Oncologic Urological surgery that can have high morbidity if complications occur. Anastomotic leaks are one of such complication with high morbidity. We present a case of noninvasive management of a case of post robotic Radical Prostatectomy urinary leak by a simple technique. Methods: 60 year old patient from Uganda a case of localized carcinoma Prostate underwent Robotic Assisted Radical Prostatectomy in May 2019. Intra operative bladder neck reconstruction was done by Van Valthoven technique using 2-0 barbed sutures. Patient had persistent high drain output of around one liter in the post-operative period. It was confirmed to be urine by analysis. CT Cystogram done showed leak in posterolateral aspect of urethra near the anastomosis. The drain persisted in spite of conservative measurements such as traction and anticholinergics and wide bore catheter. Results: We changed the Foley catheter with the Foley catheter of same size but with additional fenestrations made with the help of 3.5 mm aortic punch just below the bulb. The intention was to keep the anastomosis dry with the fenestrations as near to the leak site as possible. The leak subsided after the placement of fenestrated Foley catheter. Conclusions: The use of a multi fenestrated Foley is a simple and efficient method of managing post prostatectomy leak. It avoids any surgical intervention.

   Anatomical significance of presence of lumbar vein in relation to renal artery and renal vein in laparoscopic donor nephrectomy Top

Zeeshan Kareem, Abhijit Patil, Abhishek Singh, Arvind Ganpule, Ravindra Sabnis, Mahesh Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Introduction and Objective: Laparoscopic Donor Nephrectomy (LDN) has become standard of care in renal transplant. . Surgeons should have a thorough understanding of renal vasculature and the various anomalies that can be present. We intended to predict presence of lumbar vein by knowing pre-operative relationship of renal artery with renal vein and also the location of renal artery according to presence of lumbar vein in LDN. Methods: We retrospectively analyzed video recordings of 52 LDN and compared it with pre-operative CT angiography. The relationship between renal artery (RA), renal vein (RV) and lumbar vein (LV) were noted. Results: LV was present in 37/52 (71.1%) and absent in 15/52 (28.8%). When LV was present, RA was either behind (22/37,59.2%), or caudal (15/37, 40.5%) to RV. When LV was absent, mostly RA was cranial (11/15, 73.3%) to RV. RA was behind RV in a few cases (4/15, 26.6%) when LV was absent. RA was cranial (n=11, 21.1%), behind (n=26, 50%), or caudal (n=15, 28.8%) to RV. LV was absent in all patients with RA cranial to RV. LV was present in 22/26(84.6%) cases with RA behind RV and in 15(100%) cases where RA was caudal to RV. Conclusion: We can predict the presence of LV according to relation between RA and RV determined preoperatively on CT angiography and can reduce the intraoperative complications associated with inadvertent injury to the lumbar vein during dissection. The presence of lumbar vein can also predict the probable location of RA, thus helping in focusing the dissection area.

   Robotic assited partial nephrectomy in a large angiomyolipoma Top

Azhar Ajaz Khan, Rajesh Taneja, Vikas Kumar Bansal, Vaibhav Sood, Shrawan Kumar

Indraprastha Apollo Hospital, New Delhi, India

A 70-year-old female presented with pain right flank pain radiating to back MRI revealed Large exophytic mass 12.5 x 11.4 x 10.8 cm lesion along the lateral margin of the kidney. Patient was taken up for angioembolisation followed by Robotic Right partial nephrectomy. HPE revelaed Angiomyolipoma.

   Open partial nephrectomy in a general urological setup- our experience over 4 years Top

Saurabh Jambu, Nagesh Kamat, Rakesh Vaidya, Arnav Kamat

Kamat Kidney and Eye Hopital, Vadodara, Gujarat, India

Introduction: We report our experience of open partial nephrectomy in an independent general urological practice . Materials and Methods: Our retrospective data over last 4 years is presented. We performed 26 nephrectomies for malignant renal tumors, out of which 11 were partial nephrectomies. All partial nephrectomies were done by standard open technique. Pre, peri and postoperative data were analysed. Results: Out of the 11 patients, 7 were male patients and 4 were female patients. 7 were right sided tumors and 4 were left sided. 4 were lower polar tumors, 4 were mid polar, out of which one was hilar, 3 were upper polar tumors. Average time of surgery was 5 hours with an interval of 1 hours for the the frozen section report. Blood transfusion was needed in 3 patients. Average cross clamping time is 35 minutes. None had any vascular or urinoma complications. Open technique ensured that nephron sparing surgery could be performed for complicated hilar tumors too, where individual vessel dissection was necessary and advantageous. The long term follow up showed good function of the residual kidney with the anatomical defect seen clearly in the CT scan images. Financially the open partial nephrectomy had a budget which was 1/4th of the robotic partial nephrectomy. Conclusion: Open partial nephrectomy has a role in general urological practice in era of robotic and laparoscopic partial nephrectomy. It is safe and versatile procedure , with good oncological and functional outcomes, with a limited budget , and has a definite role in the present Indian scenario.

   Robotic-assisted ureteral re-implantation: A single center experience Top

Pravin Ladda, Vipin Tyagi, Mrinal Pahwa

Sir Ganga Ram Hospital, Delhi, India

Objectives: To report our single centre experience with robot-assisted laparoscopic ureteral reimplantation (UR). Introduction: The open reconstructive surgery of lower ureter requires large incision and is associated with increased morbidity, whereas laparoscopic reconstruction is associated with steep learning curve, prolonged operative time and difficult . We report our experience from one of the largest single institution series on robotic-assisted reconstructive surgery of distal ureter. Materials and Methods: From 2014 to 2018 total 27 patients (age range 6-50 years) underwent robot-assisted ureteral reimplantation for various underlying pathologic conditions . The da Vinci surgical system was utilized. We analyzed epidemiological characteristic of each patient, underlying pathology, unilateral or bilateral involvement, operative time, hospital stay and peri-operative or long term complication. Results: Total 27 patients underwent robotic assisted ureteral reimplantation, out of which 8 were male and 19 were female. Inflammatory ureteral stricture was predominant underlying pathology with total 9 cases, followed by iatrogenic ureteral stricture (7 cases). Uretero-vaginal fistula, obstructed megaureter and VUR contributed for 3 cases each. 2 cases were for ectopic ureter. Unilateral involvement was present in 21 cases with Bilateral involvement was present in 6 cases. Only ureteral reimplantation was sufficient in 17 cases, UR with psoas hitch was needed in 9 cases and 1 case required boari flap. Mean operative time, mean docking time and mean console time were recorded. Mean blood loss and mean hospital stay were 250 ml(range 50-500 ml) and 3 days (range 2-6 days), respectively. According to Clavien-Dindo classification, there were 4 grade 1, 1 grade 2 and no grade 3 complications. Conclusion: The robotic assisted urethral reimplantation is not only technically feasible option but also give comparable outcome with minimal morbidity and better aesthetic.

   Ureteral metastasis from carcinoma cervix presenting as left proximal ureteric stricture- A rare case Top

B. Hruday Kumar, Baskar Prakash, P. Velmurugan, K. Sriram, S. Venkatramanan, K. Natarajan

Sri Ramacahandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

A 40 years female, a known case of carcinoma cervix and sjogrens syndrome had undergone chemoradiotherapy followed by radical hysterectomy in 2017. She presented with left loin pain with raised serum creatinine( 3 mg/dL). Retrograde pyelography revealed a long segment stricture(3cm) in the left proximal ureter starting from pelviureteric junction. Preliminary DJ stenting improved the serum creatinine to 1.1 mg/dL. Subsequently excision of the stricture segment with pyeloureterostomy was done. Dense adhesions were noted around the stricture segment. Histopathological examination of the stricture segment revealed infiltration by squamous cell carcinoma cells. Patient is now planned for second line chemotherapy. Ureteric metastasis is extremely rare and there are few cases reported in English literature. Iam present an interesting case of ureteric metastasis arising from a primary cervical malignancy.

   Anastomosing hemangioma, a rare vascular tumor of kidney: A case report Top

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

BJMC and Civil Hospital, Ahmedabad, Gujarat, India

Introduction: Anastomosing hemangioma (AH) is a rare subtype of primary vascular tumor that can clinically and radiologically, mimic malignant renal tumors such as renal cell carcinoma (RCC) and angiosarcoma and poses a diagnostic dilemma. Case: A 25 year male patient presented with h/o right flank pain and subsequently diagnosed as RCC based upon imaging. The patient was managed with Laparoscopic Right radical nephrectomy. The Histopathology showed tumor tissue composed of tightly packed capillary channels with a focal anastomosing sinusoidal like pattern. Endothelial lining vessels showed focal hobnailing, F/S/O Anastomosing Hemangioma. Immunohistochemistry was done which was s/o Capillary hemangioma. Discussion: AH is a rare subtype of hemangioma unique to the genitourinary system, first described by Montgomery et al. Anastomosing hemangioma is a great mimicker of some tumors, most importantly capillary angiosarcoma. AH of the kidney shares clinical and imaging features with other vascular tumors of the kidney, with concerns for malignancy, hence the need for histopathological review and immunohistochemical studies for accurate diagnosis. It appears to run a benign course and it is amenable to surgery without evidence of disease recurrence during follow up. Conclusion: Anastomosing Hemangioma is a rare subtype of primary vascular tumor that mimics renal cell carcinoma (RCC) and angiosarcoma. Clinicians should have a high level of suspicion due to overlapping features it shares with other renal tumor.


   Urethral stricture in females: Dilatation is not always the solution Top

Siddharth Dube, D. K. Jain, Ashish Yevale

Bharti Vidhyapeeth Medical College and Hospital, Pune, Maharashtra, India

Introduction: Female urethral stricture (FUS) is a rare clinical condition with no consistent definition nor unified diagnostic criteria. The treatment options include urethral dilation, self-catheterization, urethrotomy and reconstruction depending on the severity and location of the stricture. Though with a high recurrence rate, urethral dilation is still the first line of management as no specific treatment algorithm exists. Materials and Methods: In our study we present a series of 3 patients with history of multiple failed cystoscopic dilatations who presented with poor flow and feeling of incomplete voiding. Preoperative evaluation included urinalysis, urine culture, uroflowmetry, residual volume and micturating cystourethrogram. All cases underwent dorsal vaginal graft urethroplasty and were followed up for 6 months. Outcome was documented as improvement in clinical symptoms, residual urine on USG and uroflowmetry. Results: Site and length of stricture assessed with 6 fr pediatric scope was mid urethral in two cases (1.1, 1.4 cm) and proximal urethral in third case (1.5 cm). All cases were discharged on 5th post operative day with foley's catheter. No significant postoperative pain or wound discharge was reported and patients voided well on catheter removal after 2 weeks. No incontinence was noted on follow up. None of the patients had evidence of any vaginal bleeding or graft necrosis. Conclusion: Dorsal vaginal graft urethroplasty is an effective treatment for FUS and can be considered as a primary treatment modality. However further studies with more patients and long follow-up are required to measure the success of this procedure.

   Primary bladder neck obstruction in a young woman: A novel technique of bladder neck incision using holmium laser Top

Bhabatosh Das, Panwar Pankaj, L. R. Rakhul, Kumar Anant

Max Superspeciality Hospital, Delhi, India

Management of Primary bladder neck obstruction (PBNO) in women is difficult. Surgical treatment in the form of Bladder neck Incision (BNI) is indicated in many cases. There is no defined consensus on the best surgical technique of Bladder neck Incision (BNI) in women. We present our technique of BNI in such casesusing pediatric cystoscope and Holmium laser, which can increase the safety and efficacy of this procedure.

   Fibrin sealant closure in small vesicovaginal fistula: Our experience Top

Bandhan Bahal, Gupta Prashant, Sharma Gaurav, Bhowmik Prasenjit, P. K. Sharma, S. N. Mandal

Calcutta National Medical College, Kolkata, West Bengal, India

Introduction and Objectives: Vesicovaginal fistula is a communication between the urinary bladder and vagina and frequently occurs as a complication of prolonged labour, gynecologic surgeries or radiation. Treatment of vesicovaginal fistula is primarily surgical. However fibrin sealants can be used to close small vesicovaginal fistulas and in patients unfit to undergo surgical repair. Methods: We used fibrin sealant (Tisseel) in three patients with small (<0.5 cm) supratrigonal vesicovaginal fistulas with cystoscopy and suprapubic trocar assistance. Per-urethral catheter was kept for 4 weeks in all patients. Follow-up cystogram was done at 8 weeks. Results: Two patients had no leak per-vaginum after per-urethral catheter removal, and cystogram showed closure of fistula, however one patient had leakage after catheter removal and underwent definitive surgical repair. Conclusion: Use of fibrin sealant is a viable option for small vesicovaginal fistulas. This allows avoidance of more morbid surgical procedures. Long-term durability of fibrin sealant closure is unknown. Keywords: Fibrin sealant, vesicovaginal fistula.

   Role of tanagho anterior bladder wall flipped repair in complex female urethral injuries Top

V. Patidar, S. Dias, R. Namdev, S. Prakash, V. Shrivastav, S. Trivedi, U. S. Dwivedi

IMS, BHU, Varanasi, Uttar Pradesh, India

Introduction: Female urethral injuries with loss of bladder neck (BN), although rare, constitute a formidable surgical challenge. Common modes of injury include fracture pelvis and prolonged obstructed labour. Management options include reconstruction with vaginal graft/flap, labial flap, BN reconstruction using part of bladder wall or urinary diversion. Here we report 3 cases of female urethral injury & complete BN disruption, managed with TANAGHO Anterior bladder wall flipped repair. Materials and Methods: 1. 52 year old female, developed acute retention (AUR) following RTA with fracture pelvis. SPC was done after failed catheterisation. MCU at 3 months showed complete BN disruption. Cystoscopy revealed complete block at mid-urethra. 2. 12 year old girl presented with AUR following RTA with pelvic fracture. SPC was placed after failed PUC. MCU at 3 months showed complete BN disruption. 3. 28 year old lady with history of prolonged labour presented with complete urinary incontinence. Cystoscopy showed a large urethrovesicovaginal fistula, with loss of BN, proximal urethra and part of trigone. Anterior bladder wall flipped tube repair (TANAGHO) was performed to establish urethral continuity. Rationale behind this repair was direction of the muscle fibres in the anterior bladder wall and creation of a long, narrow neourethra which adds in urinary continence. Results: At 3 months, all 3 patients were voiding with good flow, minimal PVRU and no need of CIC. One patient developed mild stress urinary incontinence, on PFMT at present. Conclusion: TANGHO repair is an appropriate option in complex female urethral injures with damaged BN.

   Post-traumatic bony impingement into vagina: A rare cause of urethrovaginal fistula Top

N. K. Dharmapraksh, Vishwajeet Singh, Satya Narayan Sankhwar, Apul Goel, Rahul Janak Sinha, Manoj Kumar

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

A 22-year-old woman met with road traffic accident 6 months back following which she underwent exploratory laparotomy with intraperitoneal bladder rupture repair. She presented with urethrovaginal fistula due to a fragment of fractured pubic bone impinging into the anterior vaginal wall. The findings were confirmed on CT scan and cystoscopy. The patient was managed with removal of the bony spicule and transvaginal repair of urethrovaginal fistula with Martius fat pad interposition.

   Uereteral endometriosis (intrinsic compression) - A rare case report Top

Akshay Nathani, S. Shivde

Deenanath Mangeshkar Hospital, Pune, Maharashtra, India

The involvement of the ureter by endometriosis is often asymptomatic or leads to non-specific symptoms. Ureteral endometriosis is endometriotic involvement of the ureter that can be either intrinsic or extrinsic. When the diagnosis is delayed, Ureteric Endometriosis may lead to persistent hydronephrosis and eventually loss of renal function. We report a case of ureteral endometriosis presenting as ureteric colic due to intrinsic compression, which is a rare cause. Ultrasonography is the first-line technique for the assessment of Ureteric Endometriosis; alternatively, magnetic resonance imaging provides an evaluation of ureteral type involvement. The surgical treatment of ureteral endometriosis aims to relieve ureteral obstruction and avoid disease recurrence. Ureteral endometriosis represents a diagnostic and therapeutic challenge for the clinicians and high clinical suspicion is needed to identify it.

   Urological problems during pregnancy and their management - A prospective study Top

Pavan Joshi, G. R. Manjunath, C. S. Manohar, R. Keshavamurthy

Institute of Nephrourology, Bengaluru, Karnataka, India

Introduction: During pregnancy anatomical and physiological changes in the urinary tract can result in pathological conditions such as asymptomatic bacteriuria, symptomatic UTI, hydronephrosis which may adversely affect the maternal health and outcome of pregnancy. Some of the urological conditions are silent and incidentally detected. We have prospectively studied various urological conditions in pregnant women and their management. Materials and Methods: We prospectively studied 200 pregnant women presenting to our hospital from 2016 to 2018. All inpatient and OPD patients with urological symptoms underwent urine analysis, culture, USG KUB and renal function test. Pregnant women incidentally diagnosed with urological problem were also included. They were followed up post partum for a minimum period of 6 weeks. Results: The most common urological problem was asymptomatic bacteriuria(42.5%) followed by calculus disease(19.5%), hydronephrosis of pregnancy(14.5%), UTI (14%), pyelonephritis (6.5%), Post partum AUR (1.5%), intrapartum bladder perforation(1.5%). The most common symptom was pain abdomen (38.5%). E coli was the most common organism isolated in patients with positive urine culture. Most common comorbidity was anemia (12.5%). 17% had preterm delivery and 1% had miscarriage. 13.5% neonates were LBW. 7% underwent DJ stenting .1 % cases required bladder repair and one patient underwent URSL. Conclusion: The incidence of preterm delivery and LBW was significant in pregnant women with asymptomatic bacteriuria and UTI respectively, in spite of timely treatment with appropriate antibiotics. In India, sizable population of low socioeconomic status, illiteracy, and social taboos even the symptomatic conditions are under reported. Hence identifying urological problem and its timely management during pregnancy can prevent maternal and fetal morbidity.

   Triple extrusion - A rare complication with TOT repair Top

Suraj P. Hegde, Gaurav Kalra, Narendra Pai, T. P. Rajeev

K S Hegde Medical Academy, Bengaluru, Karnataka, India

Introduction and Objective: Midurethral tapes used in the management of stress urinary incontinence is regularly performed procedure by urologist and gynecologist which is losing its charm due to complications. Here we present a case of mesh extrusion into the vagina and bilateral inguinal folds. Methods: A 54-year-old female presented to our OPD with a history of vaginal discharge and bilateral thigh pain which started one year after surgery for stress urinary incontinence performed by a gynecologist four years ago. She had dyspareunia and persisting stress incontinence, on examination she had mesh extrusion into the vagina with a defect of 1x1 cm with foul-smelling discharge. around 0.5 cm of mesh was seen extruding through both inguinal folds. As per the International Urogynecological Association (IUGA)/International Continence Society (ICS) joint terminology and classification, the complication in our patient would be classified as 3Cc/T4/S1. Results: The patient was started on antibiotics and she underwent exploration and excision of mesh from the vagina and bilateral inguinal folds.The patient was planned for autologous tissue placement for correction of stress urinary incontinence but was lost to followup. Conclusions: Sling procedures using synthetic meshes are now considered the gold standard for the surgical management of stress urinary incontinence. It is imperative that we understand the complications associated with these surgeries. Awareness of these complications should help us in proper patient counseling as well as stimulate further investigations of the underlying mechanisms.

   Inflammatory pseudotumor of the urinary bladder presenting as spontaneous bladder perforation Top

Lal Darsan, K. V. Shanmugha Das, A. T. Rajeevan, K. M. Dineshan, A. V. Venugopalan, Felix Cardoza

Government Medical College, Kozhikode, Kerala, India

We report a case of a 28-year-old male patient presented to the emergency department with features of acute peritonitis. The patient was paraplegic for the past 2 months following a traumatic spinal cord injury and was on foley drainage of the bladder the same period. There was no history of blunt abdominal trauma, Genitourinary tuberculosis, diabetes mellitus or past abdominal surgery. He was a smoker and a marijuana addict. Intraoperatively, urinary ascites was encountered. A well-demarcated mass lesion on the bladder dome, measuring 12x5x3cm, with central gangrene and perforation was identified. Partial cystectomy of the mass lesion was done. Pathological features of fibroblast proliferation, intense transmural inflammation extending up to perivesical fat and ulceration lead to a diagnosis of Inflammatory pseudotumor of the urinary bladder. We describe the gross and microscopic features of this rare entity in light of differential diagnoses of spontaneous bladder perforation.

   Survival analysis and predictors of long term outcomes following radical nephrectomy with inferior vena cava thrombectomy in renal cell carcinoma Top

Harshit Garg, Brusabhanu Nayak, Amlesh Seth, Ashish Kumar, Prabhjot Singh, Rishi Nayyar, Aashir Kaul

All India Institute of Medical Sciences, New Delhi, India

Introduction and Objectives: Renal cell carcinoma (RCC) presents with Inferior Vena cava (IVC) thrombus in 10-30% cases and surgical management forms the mainstay of the treatment. The objective of this study is to assess the outcomes of the patients undergoing radical nephrectomy with IVC thrombectomy Materials and Methods: A retrospective analysis of patients undergoing open radical nephrectomy with IVC thrombectomy between 2006 till 2018 was done. Results: 56 patients were included. The mean (±SD) age was 57.1 (± 12.2) years. The number of patients with level I, II, III and IV thrombus were 4, 29,10 and 13 respectively. The mean blood loss was 1851.8ml and the mean operative time was 303.3minutes. Overall, the complication rate was 51.7% while the peri-operative mortality rate was 8.9%. The mean duration of hospital stay was 10.6± 6.4 days. The majority of the patients had clear cell carcinoma (87.5%). There was a significant association between grade and stage of thrombus (p=0.011). Using Kaplan Meier survival analysis, the mean (± SD) overall survival (OS) was 37.8 (± 28.1) months and the mean (± SD) Recurrence-free survival (RFS) was 33.7 ± 27.8 months. Age (p=0.03), presence of systemic symptoms (p=0.01), radiological size (p=0.04), histopathological grade (p=0.01), level of thrombus (p=0.04) and invasion of thrombus into IVC wall (p=0.01) were found to be significant predictors of OS. Conclusion: Although the management of renal cell carcinoma with IVC thrombus poses a major surgical challenge, it offers good overall survival and recurrence-free survival.

   Preoperative and postoperative urodynamic studies in patients with vesicovaginal fistulas Top

Saqib Mehdi, S. N. Sankhwar, Apul Goel, Vishwajeet Singh, Bhupendra Pal Singh, R. J. Sinha, Manoj Kumar

King Georges Medical University, Lucknow, Uttar Pradesh, India

This study aims to characterize various urodynamic parameters in patients with vesico-vaginal fistulas in the pre and postoperative period. A total of 34 women with vesico-vaginal fistula were enrolled in this study. Preoperative urodynamic study was done in all patients after packing the vagina with sterile paraffin gauze and urodynamic parameters were reported. At a follow-up of three months urodynamic study was repeated in eight patients with successful repair with lower urinary tract symptoms. The mean age was 34.26 years (range, 26-41). Type I fistula (not involving the closing mechanism) were noted in 24 patients (Group A) and type II fistula (involving the closing mechanism) were noted in 10 patients (Group B). In Group A, the mean pre-operative urodynamic parameters with respect to first sensation(ml), cystometric capacity (mL), maximum voiding pressure(cm H20) , and maximum flow rates (mL/s) were 101, 373.5, 20 and 9.85 respectively; while in Group B, the values were 81.22 , 274.8, 26.8 and 4.55 respectively. In Group A, postoperatively these parameters were 198, 334, 35.33 and 27.4 respectively; while in Group B, the values were 154, 248, 28.54 and 13.6 respectively. Preoperatively urodynamic stress incontinence, detrusor instability, impaired bladder compliance and and voiding dysfunction were seen in 8,10,12 and 20 patients respectively in group A and 0,4,2 and 10 patients in group B respectively. Postoperatively these findings were seen in 0,0,0 and 2 patients respectively in group A and 4,2,4 and 0 patients in group B patients respectively. Urodynamic abnormalities are not uncommon after VVF repair. More studies are needed to understand the bladder behaviour after repair.

   Intravesical protrusion of prostate- A useful tool to predict success of trial without catheter Top

Saini Sashank, M. Nazar, Thomas Tony, Pr Shazu, Misra Nishant

Government TD Medical College, Alappuzha, Kerala, India

Introduction: This is an ongoing prospective study to assess if intravesical protrusion of the prostate affects the success of trial without catheter. We are presenting the results of the initial 10 months of the study. Materials and Methods: Patients presenting to the urology OPD after Foley's catherization for a first episode of acute urinary retention were enrolled in this study. All patients were started on an alpha blocker (tamsulosin 0.4 mg/silodosin 8 mg). After taking alpha blockers for a minimum of 3 days, trial without catheter was performed. ultrasound scan of the bladder was performed after 2 hrs. and intravesical prostatic (IPP) if any was measured in the sagittal plane. Patients who failed to pass urine were re catharized and if trial void was successful, a repeat bladder scan was performed. Post void residue of less than 100 ml was defined as a successful trial. Patients were followed up with uroflowmetry. Results: Out of the 50 patients studied,33(66%) had a successful trial. Mean IPP in the successful group was 1.72 cm and 2.11 cm in failed group. IPP, prior alpha blocker and age of the patient correlated with success of trial without catheter. IPP corelated with BOO in the follow up period. Conclusion: IPP correlates significantly with BOO; it should be used as a predictor of trial in men with LUTS.


   Case series of seven cases of distal penile gangrene in CKD patients Top

Jatin Soni, Sathish Kumar

Government Medical College, Thiruvananthapuram, Kerala, India

Background: Around 50 patients of penile calciphylaxis due to ESRD has been reported till date by various authors all around the world. Still this is a rare condition and here we are having a case series of seven patients at our department of urology and nephrology. Methods: All the patients of End Stage renal disease presenting with distal penile gangrene to the department of nephrology and urology are taken in our study. Results: All of these patients were having some form of renal replacement therapy in form of dialysis or renal transplant. Derangements in levels of calcium, phosphorus, and parathormone levels were seen. High calcium and phosphorus product was seen in all these patients in range of above 72. Most of these patients died in 3 months of follow up. Another different thing with these patients when compared with other penile gangrene patients is the response to aggressive treatment of any form. These patients do not respond to these aggressive therapies as other patients do. Furthermore these patients die of other coexisting comorbities. Conclusions: This rare phenomenon of distal penile gangrene has an association with high calcium and phosphorus product and these patients responds very poorly to aggressive therapies of any form. Secondly most of these patients die withim short follow up period.

   Congenital ureteric valves masquerading as secondary pelviureteric junction obstruction in a case of single system ureterocele Top

Dumra Anuj, Shekar Ashwin, Kochhar Gaurav, S. Santhosh, R. Prathik, Reddy Dinesh

Sri Sathya Sai Institute of Higher Medical Sciences, Anantapur, Andhra Pradesh, India

Introduction and Objective: Ureteral valves are a rare clinical finding. Frequently they are associated with other urological anomalies such as complete or incomplete renal duplication, ectopic ureter, vesicoureteral reflux and horseshoe kidney. Hydronephrosis is the most common clinical sign.We report a case of proximal ureteric valve with single system ureterocele which was masquerading as secondary pelvic ureteric junction obstruction (PUJO) thereby causing renal detoriation and persistent hydronephrosis following ureterocele incision. Patients and Methods: A 9-month-old boy presented to us with antenatally detected left hydroureteronephrosis after an uncomplicated gestation. Ultrasound showed gross left hydroureteronephrosis with thinning of parenchyma. Diuretic renogram confirmed an obstructive-uropathy and with hold up at the pelviureteric junction (PUJ).We made a provisional diagnosis of left single system ureterocele with secondary PUJO and he underwent an ureterocele incision. A repeat diuretic renogram showed persistent obstruction probably at level of PUJ. The MR urogram showed features suggestive of PUJO. Due to persistent obstruction we planned for an open pyeloplasty. Intra-operatively retrograde pyelogram (RGP) showed complete blockage at level of PUJ and it was not possible to pass a 3-Fr catheter through the stenosis. The proximal ureter was resected and a dismembered pyeloplasty was performed. Examination of the resected segment showed a ureteric valve which was confirmed histologically. Results: Eight months follow up has been uneventful. DTPA renogram post surgery has shown unobstructed drainage. Conclusion: Congenital ureteral valves are a rare cause of ureteric obstruction. The diagnosis in our case was suspected after RGP and was confirmed at surgery and by histological examination.The management of ureteral valves is surgical and should be guided by complementary examinations.

   Harris in urology; a lesser known entity Top

Z. K. Sayed, S. K. Choubey, C. S. Venugopal, V. N. Kaushik, R. Y. Saboo, S. Mittal

St. John's Medical College, Bengaluru, Karnataka, India

Introduction and Objective: Asymptomatic constitutional macrothrombocytopenia (ACMT) is a sub-type of inherited giant platelet disorder and is characterized by decreased platelet count, macro-platelets and no bleeding symptoms. ACMT is also known as Harris Syndrome (HS). This condition is being diagnosed more frequently in populations of West Bengal, Nepal and Bangladesh. In patients with HS, we studied the spectrum of urological diagnoses, any additional investigations/interventions done for thrombocytopenia, incidence of haemorrhagic complication and ABO blood group relationship. Materials and Methods: The patients who were of inhabitant West Bengal and Bangladesh with platelet count <150 x 103/μL, admitted in the Urology ward of our Medical College Hospital, during the period of January 2015 to December 2018 were included for this observational study. Haematological opinion was taken for all such patients and the diagnosis of HS was confirmed. The data collected was tabulated and analysed. Results: Three most common diagnoses were Urolithiasis 44.14%, Malignancy 19.81% and Urinary tract infection 15.31%. The incidence of haemorrhagic complication in mild thrombocytopenia for Endourological procedures was 5.94%, Open procedures was 3.96%, Laparoscopy was 0.99% and ESWL was 0%. HS was most commonly associated with O Rh+ blood group at 38.88%. Conclusion: Once diagnosed with HS, there is no need for any further evaluations or additional interventions for thrombocytopenia. Thereby avoiding and bringing down the instances of unindicated investigations/interventions. This would lead to reduction in the anxiety due to this additional diagnosis, inpatient stay, treatment cost and unnecessary delay in rendering the definitive management.

   Transverse testicular ectopia with persistent mullerian duct syndrome in an adult presenting with penoscrotal hypospadias - A rare association Top

Sharma Manas, Neeli Siddalingeshwar

JN Medical College, Belgaum, Karnataka, India

Introduction: Transverse testicular ectopia (TTE) is a rare developmental anomaly in which both the testes wander towards the same hemiscrotum. Persistent Mullerian Duct Syndrome (PMDS) is rare form of pseudohermaphroditism which is characterised by presence of uterus and  Fallopian tube More Detailss in a normally masculinised 46XY phenotypic male. TTE is known to be associated with PMDS in less than 20% cases. The Mullerian duct derivatives usually involute due to the presence of Mullerian Inhibiting Substance in males. However, infrequently they persist and can be localised intra-abdominally or may herniate through inguinal canal. Case Presentation: We present an interesting case of a 37 years old man presenting with penoscrotal hypospadias with chordee, irreducible right inguinal hernia and left non-palpable testis. A diagnosis of transverse testicular ectopia was suspected on ultrasound and CT imaging followed by its confirmation at diagnostic laparoscopy. Right inguinal exploration revealed both the testes and mullerian duct remnant (later confirmed as uterus) as a content of hernial sac. Right inguinal hernioplasty and transseptal orchidopexy was done followed by Stage I hypospadias repair. Conclusion: Learning points In case of TTE with PMDS the optimal surgical approach with orchidopexy and excision of mullerian duct remnants is often required along with long term follow-up to detect malignant transformation. Surgeons who often repair inguinal hernias should be mindful of this condition and the appropriate surgical management options.

   A rare case of male pseudohermaphroditism-persistent mullerian duct syndrome with transverse testicular ectopia Top

J. Mohammed Farooq, K. Saravanan, R. Govindarajan, G. Chengalvarayan, P. R. Saravanan, G. Vezhaventhan, Ezhil Sundar

Madras Medical College, Chennai, Tamil Nadu, India

Introduction: Persistent Mullerian duct syndrome (PMDS) is a rare type of male pseudohermaphroditism. Transverse testicular ectopia (TTE) is characterized by one testis moving to the opposite side and both testes traversing the same inguinal canal. Case Presentation: An 11-month-old boy presented with bilateral cryptorchidism. The left testis was not palpable; the right testis was canalicular with a right inguinal hernia. Ultrasound showed both testes located in the right inguinal canal. Right inguinal exploration revealed two testes with intact spermatic cords. A primitive uterus with fallopian tubes was also identified on opening the processus vaginalis. After herniotomy, bilateral orchidopexy was carried out (left orchidopexy through a trans-septal approach). Karyotyping confirmed a male gender (46XY). One year after the operation, ultrasound showed both testes to be in good condition. Discussion PMDS is caused by defects in the gene that encodes Antimullerian hormone(AMH). Treatment aims to correct cryptorchidism and ensure appropriate scrotal placement of the testes. Malignant transformation is as likely as the presence of abdominal testes in an otherwise normal man. Failing early surgical correction, gonadectomy must be offered to prevent malignancy. Division of the persistent mullerian duct structures is indicated only in patients where persistence interferes with orchidopexy. Conclusion: TTE should be suspected in patients presenting with inguinal hernia on one side and cryptorchidism on the other side. Herniotomy and bilateral orchidopexy is optimal. Removal of mullerian structures may injure the artery to vas deferens and is hence not recommended. Follow-up for fertility assessment in the latter years should be counselled.

   An incidental detection of synchronous medullary thyroid carcinoma in patient with bilateral adrenal pheochromocytoma on 18 fdg-pet leading to diagnosis of Men 2A: A case report Top

Sanket Kalpande, K. Sarvanan, P. R. Sarvanan

Institute of Urology, MMC, Chennai, Tamil Nadu, India

Introduction and Objectives: MEN 2A is an autosomal dominant disease characterised by predisposition to developing medullary thyroid carcinoma, pheochromocytoma & other manifestations. Here we are presenting a case of young male who was diagnosed having bilateral adrenal pheochromocytoma and incidental detection of MTC. Methods: 29 year male presented with chief complaints of palpitation, excessive sweating, episodic hypertension since 1 year. Patient visited primary care physician where he was diagnosed as essential hypertensive and started on anti-hypertensive. He also had dull aching loin pain which he neglected for almost 1 year. On further imaging evaluation with ultrasound and CT, he was found to have bilateral adrenal mass. On biochemical evaluation, mass was confirmed to be pheochromocytoma. Patient was subjected to 18-FDG PET. It showed increased uptake in bilateral adrenal area along with enlarged right lobe of thyroid with heterogeneously enhancing lesion with increased metabolic activity. There was no metastases and lymph nodes uptake. USG guided FNAC confirmed it as medullary thyroid carcinoma. Patient underwent bilateral adrenalectomy. He had uneventful post-op recovery. Later patient also underwent total thyroidectomy with central lymph node dissection. Results: This incidental finding of synchronous MTC on 18FDG-PET in patients with bilateral pheochromocytoma led to diagnosis of MEN 2A. Subsequent genetic testing confirmed a rearranged during transfection proto-oncogene mutation on exon 11, confirming the clinical diagnosis of MEN 2A. Conclusion: The unexpected incidental finding of synchronous MTC highlights the importance of considering MEN in differential diagnosis when encountered with bilateral pheochromocytoma. 18 FDG-PET has diagnostic utility in such cases.

   Nonspecific granulomatous prostatitis: A clinical surprise Top

Mebin B. Thomas, M. Nazar, Tony Thomas John

TD Medical College, Alleppy, Kerala, India

Introduction and Objectives: Granulomatous prostatitis is a rare inflammatory condition of prostate. The radiological findings and serum prostate specific antigen levels are non- specific in their diagnosis. Methods: A 36-year-old male presented to our OPD with dysuria and hesitancy. On digital rectal examination, prostate was hard in consistency with rectal mucosa not freely mobile. Urine Analysis was within normal limits. Ultrasonography abdomen suggested 30gm of prostate and normal upper urinary tract. Serum Prostate Specific Antigen levels were 2.59 ng/l. Results: MRI pelvis was taken which suggested a lesion in peripheral and transition zone of prostate on left side with extension to rectum and left neurovascular bundle. Lesion is also abutting levator muscle on the left. Transrectal ultrasound guided prostate needle biopsy was done and histopathological examination revealed ill formed granulomas in the fibromuscular stroma, comprising of multinucleated giant cells of both Langhans and foreign body type, lymphocytes, fibroblasts, with central areas of necrosis, negative for Ziehl Neelsen staining. Tissue sent for Tubercular- Polymerase Chain Reaction was negative. Urine sent for gene expert was also negative. Hence a diagnosis of nonspecific granulomatous prostatitis was made. Conclusions: Granulomatous prostatitis continues to be a histological surprise for the treating urologist. It is very difficult to anticipate this entity on clinical evaluation and there are no specific radiological features. The definitive diagnosis can be established only by histopathological examination. The importance of diagnosing granulomatous prostatitis lies in the fact that some of the cases clinically mimic malignancy.

   Renal replacement lipomatos- A rare phenomenon Top

K. R. V. Rajesh Reddy, V. Surya Prakash, K. Seshu Mohan, V. Mohan Kumar, Milan Patel

Yashoda Hospital, Hyderabad, Telangana, India

Introduction: Renal replacement lipomatosis (RRL) is a rare condition, which is usually due to atrophy of renal parenchyma, with proliferation of excessive lipomatous tissue in renal sinus, renal hilum and perirenal space. The etiological factors include calculus disease, renal tuberculosis and infarction . Methods: A 66 year male who is a known diabetic and hypertensive with history of fever and left loin pain and on ultrasound evaluation found to have left staghorn calculus with large perinephric collection of 8x9cm collection extending into splenic area. Patient managed initially conservatively and left pigtail catheter was inserted into the abscess cavity and patient recovered symptomatically and send to us for further evaluation. On re evaluation CECT abdomen and Ultrasound abdomen were done and we suspected left renal replacement lipomatosis as the total kidney was completely replaced by adipose tissue surrounding the centrally placed stone. DTPA Renogram was showing non functioning kidney. Results: Patient was operated for left open nephrectomy expecting the dense adhesions because of the inflammatory changes due to previous intervention and possibility of Xanthogranulomatous changes. On table the whole kidney was replaced by large mass of adipose tissue and there was no renal outline except for a central stone bearing area. Postoperative histopathology confirmed renal replacement lipomatosis. Conclusion: Renal replacement lipomatosis though is a rare condition, yet possible to diagnose radiologically if we have the suspicion and sufficient experience to diagnose it.

   Spontaneous rupture of renal angiomyolipoma in early pregnancy: A case reoprt Top

P. D. Chari, M. R. Prabhudesai, V. Gaude, A. L. Cardoso, P. T. N. Mandrekar, U. Oza

Goa Medical College, Bambolim, Goa, India

Introduction and Objectives: Renal angiomyolipoma is a benign mesenchymal tumour of the kidney with a tendency of aneurysm formation at risk of rupturing. The association with pregnancy is rare and related with an increased risk of complications, including rupture with massive retroperitoneal hemorrhage. Materials and Methods: We report a case of a spontaneous ruptured renal angiomyolipoma in a 13 weeks pregnant woman. Results: A 37 year old female, Gravida 2 Para 1, at 13 weeks of pregnancy presented with severe abdominal pain in left flank and vomiting. Patient was hemodynamically stable. Ultrasonography and MRI Abdomen revealed large fat containing mass arising from the posterior cortex of the lowerpole of left kidney with associated large hematoma along the lowerpole of left kidney. Imaging characteristics were suggestive of left sided renal angiomyolipoma with spontaneous rupture. The patient underwent left partial nephrectomy with evacuation of perinephric hematoma with the foetus being left in-utero. There was no post-operative complications and the pregnancy is continued and patient is following up with Obstetrician. Conclusion: A multidisciplinary approach in tertiary care center is extremely necessary to salvage the kidney while maintaining pregnancy for optimum outcome of mother and baby. Nephrectomy should be the procedure of choice if salvaging the kidney results in threat to maternal health.

   Epidemiology of renal stone disease in Nellore, AP Top

Raj Kumar Sharma, Reddy P Banuteja, A. P. Pavan, J. Jayaraju, Reddy K. V. Bhargava, Reddy P. Vedamurthy, Reddy N. Mallikarjuna

Narayana Medical College, Nellore, Andhra Pradesh, India

Indroduction and Objectives: Renal stone disease is prevalent in India, with an expectancy of 12% of population reported to be prone to urinary stones. Prevalence is more in north India compared to south India. We present our experience from Nellore, Andhra Pradesh. Materials and Methods: From June 2018 to May 2019 , 370 stone samples of all age groups, admitted in our Medical College, were sent for stone analysis. These were compared with the National data. Results and Observations: There were 185 (50%) cases of Ca Oxalate of which, 86 (46%) were Ca oxalate monohydrate and 28 (15%) were Ca Oxalate dihydrate and 71 (38%) were mixture of both, 112 (30%) Cases of Ca Phosphate, 54 (14.5%) cases of uric acid , 14 (3.7%) cases of Ammonium urate and 5 (1.3%) cases of Cystine stones, which is different from the national data, where majority composition is Ca Oxalate Stones (75-90%), followed by uric acid (5-20%), Ca Phosphate (6-13%). Conclusions: Our study reveals that the stone distribution in Nellore is different from that in other parts of the country.

   Primary neuroendocrine tumour of the penile urethra: A rare case presentation Top

Ashishkumar N. Asari, T. B. Yuvaraja, Santosh Waigankar, Preetham Dev

Mumbai, Maharashtra, India

Introduction: Neuroendocrine tumors (NETs) are neoplasms that rarely occur in genitourinary tract, NETs are epithelial tumors with neuroendocrine differentiation characterized by neuroendocrine hormone secretion. They are very few cases have been reported in the literature. Extra-pulmonary small cell neuroendocrine carcinomas are aggressive neoplasms with a high rate of metastases. Case History: 27 year old male patient presented with 15 days history of lower urinary tract symptoms along with palpable mass over ventral aspect of penis. On evaluations, 3-4 cm mass lesion was noted in penile urethra, almost occluding the lumen, biopsy from mass showed small cell carcinoma. MRI Pelvis along with FDG PET CT was done - 3.8cm penile urethral mass lesion involving the corpora spongiosum. Total penectomy with perineal urethrostomy was done. Final pathology report stated high grade poorly differentiated small cell tumor of penile urethra with vimentin expression, extending into corpora spongiosum and without infiltration of corpora cavernosa. He has completed his adjuvant chemotherapy with VAC/ IE regimen (Vincristine+ Doxorubicin+ Cyclophosphamide/ Ifosamide+ Etoposide) with growth factor support given 3 weeks apart. Conclusion: Small cell carcinoma of the urinary tract is a distinct histological and biologic disease entity with an aggressive clinical course and poor prognosis. Adjuvant chemotherapy and radiotherapy to the regional lymph nodes should be considered in case of penile NETs because of their anticipated worse outcome. The present case is of particular interest because it illustrates that very uncommon tumors of the genital tract, can be asymptomatic and present later as metastatic disease.

   Ten years single center experience in management of infant renal stone disease with percutaneous nephrolithotomy Top

S. Nitesh, Tarun Javali, H. K. Nagaraj, Prakash Babu

Ramaiah Medical College, Bengaluru, Karnataka, India

Renal stone disease in pediatric age group is often challenging experience in treating the patient. The available options in today's practice include Extra corporeal Shock Wave Lithotripsy, Percutaneous NephroLithotomy (PCNL) and in recent years, pediatric RIRS. The challenge arises in treating a larger stone (> 2cm). RIRS in young is still debatable so the only feasible option available at large in India is PCNL. In this study, we analyse the management of infant renal stone disease who underwent PCNL in a single centre. a total of 14 ( 16 renal units) underwent PCNL between 2009 to 2019. A 95% stone clearance rate was achieved collectively. The different techniques used in comparison to adult standard PCNL are described and challenges encountered during these surgeries noted. PCNL in infant renal stone disease is accepted treatment of choice. With adequate precautions, it is a safe option in treating the same.

   A rare complication after lap donor nephrectomy Top

Anil Sharma, Ahmed Kamaal, D. V. Singh

ILBS, New Delhi, India

Introduction: Pyoderma gangrenosum is an uncommon distinctive cutaneous ulceration which is usually idiopathic but may be associated with many systemic disorders. Methods: A case report. Results: The patient eventually improved and recovered completely. Conclusion: Pyoderma gangrenosum is a rare condition , diagnosis of which mainly depends on the recognition of clinical features. Delay in diagnosis may add substantially to patient morbidity.


   Assessment of long-term outcomes with immediate versus delayed surgical repair of penile fractures Top

faizul Haque, Paul Amiya Shankar, Panda Sabyasachi, Hota Datteswar

SCBMCH, Cuttack, Odisha, India

Introduction and Objectives: Penile fracture may leads to erectile dysfunction (ED) and impairs sexual activity and satisfaction. This study aimed to compare the long-term effects of immediate versus delayed surgical repair of penile fractures on postoperative ED, fibrous tunica plaques, and chordee. Methods: This was a prospective observational study conducted between January 2016 and June 2018 which included patients with penile fracture. Details of injury, symptoms, treatment and long-term outcomes (up to 12 months) were collected. Data presented using summary statistics. Results: A total 21 patients (early surgical repair [Group A], n=13; delayed surgical repair [Group B], n=8) were enrolled in this study. The mean age of the patients was 26.5 years. The common cause of penile fracture was masturbation (n=5; n=5) and sexual intercourse (n=7; n=4) in group A and B, respectively. Penile ecchymosis/swelling and pain were present in all the patients of group A (n=13). While, typical pop-up sound heard by eight patients (61.54%) of group A and six patients (75%) of group B. The most common reason for delay in presentation was fear/embarrassment (75.00%). Penile paraesthesia (n=2) and penile curvature (n=3) were observed in Group A; while penile paraesthesia (n=3) was also reported Group B. None of the patients from both groups reported ED. All three patients with urethral injury repaired had mild degree of ventral chordee with a satisfactory erection and good penetration. Conclusion: Results showed that delayed repair did not affect the long-term outcome with no major impact on erectile function and overall sexual satisfaction.

   Inadvertent prolonged cold ischemia time and graft outcome after deceased donor renal transplantation Top

Cherian Dinesh, Saraswathy, R. Govindarajan, K. Saravanan

Madras Medical College, Chennai, Tamil Nadu, India

Introduction: Due to various logistic delays prolonged cold ischemia is the norm . As a result chances of successful graft outcome are contradictory to the actual benefits of a transplant, not forgetting the increased government expenditure, prolonged hospital stay and the limitless use of resources. Objective: We are aware that the least cold ischemia time(CIT) brings the best outcome. The aim of this study is to prospectively analyse graft outcomes that have been transplanted at various unintentional prolonged cold ischemic times.CIT was categorized as 0-6 hours,6-12 hours,and greater than 12 hours. Materials and Methods: Prospective study in 20 patients, who underwent deceased donor renal transplant from October 2017 to July 2018. The impact of prolonged CIT were analysed by (i)Delayed graft function (ii)serum creatinine at 30 days post transplant(iii)acute rejection and (iv)allograft survival. Results: 100% of patients developed Delayed graft function.The mean hospital stay was 29 days across all groups and graft survival was comparable among all categories. Conclusion: This study is not to justify the equitable outcomes of prolonged cold ischemia times,but to make us aware that if there is a possibility of procuring and harvesting a kidney from a distant place, all effort must be made as there is a potential benefit to the recipient despite the time lapse.Every possible potential cadaveric donor must be made useful,as the number of patients awaiting transplant is enormous.

   BK polyoma virus associated urothelial malignancy of the graft kidney posing an immuno-oncological and surgical challenges Top

Ritesh Goel, Amlesh Seth, Siddharth Jain

AIIMS, New Delhi, India

Introduction: With increased renal graft survival, many long term complications are being highlighted. Infection by BK virus and development of Transitional cell cancer of graft kidney is an extremely rare occurrence. Case History: A 57-year-old lady, received live related renal transplant in 2007. IN 2012, she had worsening renal parameters with a creatinine of 2.7mg/dl. Graft biopsy revealed tubular atrophy (IFTA) grade II. Five months later, developed graft failure and started on hemodialysis. Underwent 2nd live unrelated renal transplant in 2015. Patient then noticed swelling and heaviness in the right lower abdomen. CECT revealed a large heterogeneous mass occupying first graft kidney, infiltrating anterior abdominal wall and enlarged pelvic nodes. Graft biopsy showed high-grade urothelial malignancy. Serum BKV was also positive. PET CT showed a pelvic and lung metastasis. 6 cycles of Gemcitabine and cisplatin were given. Follow up CT scan suggestive of resolution of lung lesions and pelvic lesions. Right open radical graft nephroureterectomy was performed. Intra-operatively, dense adhesions between the posterior surface of the kidney with external iliac vessels were present. There were no perioperative complications. Histopathology showed high-grade urothelial malignancy with parenchymal invasion without any lymph node, T3N0. Conclusion: Such cases involve multiple challenges like immunosuppression, optimal chemotherapy with associated surgical challenges and can be managed by multimodal treatment.

   Renal transplant with urinary diversion in pediatric patient with neurogenic bladder Top

Rohit Kapoor, V. P. Sabale, V. Satav

Dr D Y Patil Medical College, Pune, Maharashtra, India

History: 11 year old female low weight ,emanciated,appropriately vaccinated. History of urinary incontinence,nocturnal enuresis and difficulty in walking at the age of 5 years , and was diagnosed as having occult spinal dysraphism, tethered cord and transitional lipoma with sacral agenesis with neurogenic bladder with CKD with h/o multiple surgeries Examination/imaging: Isotope scan revealed eGFR 8 ml/min/1.73 m2, B/l hydronephroureterosis with paper thin cortex due to ? bilateral VUR on USG,with small capacity bladder and significant post void residue on urodynamic study CHALLENGES: Neruogenic dysfunctional bladder ,Compliance for Clean Intermittent Catherisation(CIC) with possible CIC infections post operatively, technical challenges related to vascular anastamotic disparity and kidney size accomadation, and stoma related complications. PLAN/Procedure done: Pre transplant Right nephroureterectomy for VUR,followed by Live Related donor Renal transplantation (grandmother to grand daughter) with urinary diversion using ileal conduit and reimplantion of the left native ureter and allograft ureter into the conduit Discussion : In our case patient was planned for ileal conduit with ureteric reimplantation as patient was non compliant with CIC and had a high risk of recurrent infections Structural urologic abnormalities resulting in dysfunctional lower urinary tract leading to end stage renal disease may constitute up to 20-30% in the pediatric population. Few similar cases have been reported in literature with most extensive multi institutional review being of David A. Hatch that out of 30 pediatric patients with requirement for transplant with urinary diversion/bladder augmentation: 1) 17 had augmented bladder 2)12 had incontinent urinary conduits. 3)1 had continent urinary reservoir.

   Assessment of knowledge, attitudes and practice regarding fistula care Top

Kumar Vikas, Kishore Rishi, Kumar Shashi, Choudhary Apurva, Kumar Ajay

Paras HMRI, Patna, Bihar, India

Objective: Chronic kidney disease is a growing worldwide public health issue. Arteriovenous fistula is the most effective means of hemodialysis. KAP (knowledge, attitude and practice) play vital role in fistula care. Our study aimed to investigate KAP regarding AV fistula in patients on hemodialysis. Methods: This is an ongoing study in Department of Urology Nephrology and Renal Transplant. We have recruited 150 patients till now. Data were collected as per literature review. Results: The most implemented and known rules were not to measure blood pressure and not to draw blood from fistula-arm. Conclusions: Self care forms an integral part for patency of fistula. Repetition by paramedical staffs and written instructions can improve patient's knowledge and compliance about fistula care.

   Surgical management of hypertension in page kidney Top

Prashant Gupta, Bahal Bandhan, Sharma Gaurav, Bhowmik Prosenjit, P. K. Sharma, S. N. Mandal

Calcutta National Medical College, Kolkata, West Bengal, India

Introduction: Hypertension with a normal serum creatinine level is the classic presentation of Page kidney. Page kidney is due to either traumatic or non-traumatic (tumour, lymplocele and urinoma). Diagnosis is mainly based on imaging study. The main therapeutic approach is based on medical management of hypertension and definitive surgical management (percutaneous drainage, open/ laparoscopic hematoma evacuation and nephrectomy in refractory cases). This paper highlights two patients with Page kidney having different aetiology and presentation. Case 1- A 30 years old female presented with pain in right flank and headache 2 weeks after Extracorporeal shock wave lithotripsy (ESWL) treatment for 9 mm right renal calculus. Physical findings was normal except hypertension (172/94 mm Hg), without any prior history of hypertension. Initially patient was managed with antihypertensive medicine followed by open drainage of subcapsular hematoma. Case 2- A 5 year old female presented with pain in abdomen following trivial trauma. On imaging there was large perinephric collection compressing the right kidney. On Surgical exploration there was mass arising from right kidney with large subcapsular hematoma, therefore right nephrectomy was done. Histopathology came out to be Wilms tumour. Conclusion: Page kidney present with symptoms related to hypertension and localised pressure symptoms. These types of cases are managed with early surgical intervention which may prevent persistent hypertension later.

   Assorted therapies for arteriovenous fistula aneurysm - our institutional experience Top

A. P. Pavan, P. Reddy Banu Teja, J. Jayaraju, Reddy Bharagava, P. Reddy Vedamurthy, N. Reddy Mallikarjuna

Narayana Medical College, Nellore, Andhra Pradesh, India

Introduction: Aneurysm in arteriovenous fistula created for chronic kidney disease patients occurs in 8% of patients. Aneurysm is one of the rare complications and it has varied etiologies. Aneurysm either true or pseudo need to be excised and blood flow need to restored. We present our three year experience of treating arteriovenous fistula aneurysms. Materials and Methods: 612 arteriovenous fistulas have been created between 2016 and 2019. Out of which 28 patients developed aneurysms which include both pseudo and true. Standard 1 cm anastomosis for RC AVF and 6 mm BC and BB AVF was done. Standard 6 weeks post surgery cannulation and 6 cm away from anastomosis site cannulation was followed in our institute. Color Doppler was used as standard to diagnose aneurysm with some cases needing CT angiography. Results: 28 cases included with 19 males and 9 females. 24 pseudo and 4 true aneurysms. Radiocephalic- 10; high radiocephalic-4; brachiocephalic-13; brachiobasilic-1. All radiocephalic and high radiocaphalic AVF aneurysms underwent excision of the aneurysm with ligation of the radial artery. In 3 cases end to end reconstruction of brachial artery after excision was done. PTFE graft was used for bridging brachial artery after excision in 3 cases. One case underwent ulnar to basilic AVF after aneurysm take down. Conclusion: Aneurysms needs early identification and surgical intervention to prevent complications. Artery can be reconstructed by various methods depending the length and caliber available. We present our experience of appropriate and successful treatment of aneurysms.

   Safety and efficacy of “on demand” tramadol in patients with premature ejaculation: A systematic review and meta-analysis Top

G. Sharma, A. P. Sharma, S. K. Devana, R. M. Mavuduru, G. S. Bora, A. K. Mandal

PGIMER, Chandigarh, India

Introduction and Objectives: Use of on-demand tramadol has been shown to be efficacious in patients with premature ejaculation (PE) in numerous studies. However, there has been apprehension regarding abuse potential and serious adverse events. Objective of this systematic review was to determine safety and efficacy of tramadol in patients with PE. Methods: Systematic literature review with metanalysis was performed following PRISMA (Preferred reporting items for systematic reviews and meta-analysis) guidelines. Only RCT's (Randomized controlled trials) comparing “on-demand” tramadol with placebo or other drugs were included. Primary outcome measure used for this study was intravaginal ejaculation latency time (IELT) after treatment duration. Results: Ten studies were included in this review. Duration of therapy varied from 4-20 weeks. Various doses of tramadol tested included 25 mg, 50 mg, 62 mg, 89 mg and 100 mg. Studies included were of poor quality due to high risk of bias in various domains of Cochrane risk of bias tool. Tramadol resulted in significant improvement of IELT with mean difference (MD) of 137 sec and confidence interval (CI) 105-169 sec (p<0.00001). Tramadol group had reported significant higher number of adverse events with treatment (15% vs. 5.5%; p=0.03). Although, none of the studies had reported severe side effects due to tramadol. Conclusion: Tramadol appears to be an effective drug for management of PE with low propensity for serious adverse events. Further good quality studies are needed with adequate data on dosage, duration of therapy and side effect profile of tramadol.

   Retroperitoneal gossypiboma mimicking renal tumor in post renal transplant - a diagnostic challenge Top

Shanmugasundaram Rajaian, Pragatheeswarane Murugavaithianathan, Karrthik Krishnamurthy, Lakshman Murugasen

MIOT International, Chennai, Tamil Nadu, India

Introduction and Objectives: Retained surgical sponge also known as gossipyboma. We report a case of retroperitoneal Gossipyboma in a post-renal transplant patient mimicking renal cell carcinoma. Materials and Methods: A 48 year old male had presented with abdominal pain and vomiting of 3 months duration. He underwent deceased donor renal transplantation 9 years ago elsewhere. Examination revealed a 15 x 15 cm size palpable mass in right hypochondium. His renal function was normal. Abdominal CT scan revealed encapsulated hypodense retroperitoneal mass lesion with calcification arising from the lower pole of right native kidney. Retroperitoneal exploration and excision of the mass was done with right nephrectomy. Gross pathology revealed surgical sponge inside the tumor mass. Histopathology of the native kidney was normal. Results and Observations: Pathological evaluation revealed gossipyboma. His renal function was normal and post-operative period was uneventful. Gossipyboma in post renal transplantation scenario can cause diagnostic dilemma by mimicking as renal tumor. Conclusions: Gossipyboma can remain silent for lifetime by encapsulation or can migrate externally to the skin or internally into hollow viscus like rectum, vagina, bladder, or intestine. Gossypiboma in post renal transplant scenario is rare and should be thought of differential diagnosis in post transplant masses.

   External iliac artery versus internal iliac artery anastomosis in renal transplant: Does it really make a difference? Top

Saurabh Kumar Arya, A. Patil, G. Tak, A. Ganpule, A. Singh, R. B. Sabnis, M. R. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

INRODUCTION Most common techniques used for arterial anastomoses is with recipient external(EIA) and internal iliac artery(IIA).Aim of our study was to compare the perioperative and one year follow up outcomes of EIA v/s IIA in kidney transplantation. Materials and Methods: We retrospectively evaluated 150 renal transplant patients admitted from 2017 to 2018, dividing them into two groups (EIA v/s IIA anastomoses).We evaluated preoperative parameters including age, sex, BMI and creatinine of both donor and recipient. Intraoperative parameters like WIT(warm ischemia time),TIT(total ischemia time), prompt diuresis were compared. Postoperative parameters like RI,creatinine at day 1, 1month and 1 year along with vascular complications were compared. Results: Both the groups were comparable with respect to preoperative parameters. WIT was comparable in both groups, while TIT ( P<0.05) and immediate on table dieresis(P-0.037) was statistically significant in IIA group. Postoperative RI, POD 1, one month and one year creatinine was statistically comparable in both groups. There were two vascular complications in both groups. One patient with IIA anastomoses had to be reanastomosed with EIA in view of poor arterial inflow. One patient with IIA had anastomotic aneurysm requiring angioplasty. One patient with EIA had arterial thrombosis requiring graft nephrectomy. Another patient with EIAhad bleeding from anastomotic site requiring re-exploration. Conclusion: The outcomes of IIA were comparable to those of EIA with respect to graft function at one year follow up with similar complication rates.

   UTI in post renal transplant patients: SPC versus PUC, DJS versus no DJS, does it make a difference? Top

Saurabh Kumar Arya, A. Patil, G. Tak, A. Ganpule, A. Singh, R. B. Sabnis, M. R. Desai

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

INRODUCTION Infections are major cause of morbidity and mortality in kidney transplant recipients and rank second as the cause of death in these patients. Early infection (with in first month) like UTI is more likely to be nosocomial. Aim of our study was to compare UTI rate and complications in SPC v/s PUC and DJS v/s no DJS. Materials and Methods: We retrospectively evaluated 75 renal transplant patients admitted during 2018 to 2019.They were divided into those with SPC(n=18) v/s PUC(n=57) and those with DJS (n=33) v/s no DJS (n=42). We evaluated urine culture positivity in SPC v/s PUC.We evaluated urine culture and complications in DJS v/s no DJS. Results: Overall, urine cultures were positive in 17/75 (22%) cases. Tip culture was positive in 14/57(24.5%) in PUC and 2/18 (11.1%) in SPC ,but was not statistically significant. Urine culture was positive in 11/57 (19.2%) in PUC and 6/18(33.3%) in SPC, but was not statistically significant. Epididymo-orchitis and prostatitis was more in PUC than in SPC,but was not statistically significant. Urine culture was positive in 9/42(21.4%) with DJS and 8/33(19%) with no DJS, but was not statistically significant. The complication rates were comparable in both DJS v/s no DJS groups. Conclusion: The type of catheterization (SPC v/s PUC) didn't affect post-renal transplant UTI rates, with similar complications. DJ stenting had similar UTI rates and complications as compared to no DJ.


   Prospective clinical study of grading complications of transurethral resection of prostate using modified clavien classification system Top

R. Prathik, P. Satish Kumar, Ashwin

Sri Sathya Sai Institute of Higher Medical Sciences, Anantapur, Andhra Pradesh, India

Background and Objectives: The absence of a definition and a widely accepted grading system to classify surgical complications has hampered proper interpretation of surgical outcome hence standardized classification is required. The Clavien classification system (CCS) has been proposed to grade complications in most urological procedures. Our aim is to evaluate the applicability of the Modified Clavien Classification System (MCCS) in reporting and grading the severity of complications in patients with BPH submitted to TURP and to discuss its benefits. Methods: This study was done in 260 cases of BPH having Lower Urinary tract Symptoms (LUTS) submitted to TURP during a period from July 2017 to Dec 2018. All complications were evaluated intraoperatively, postoperatively at the end of 48 hours, first week, first and third postoperative month and classified according to the MCCS. Results: Eighty-six complications were seen in 260 patients according to MCCS of which 7 were intraoperative and 79 were post-operative complications. Stricture urethra was the most common complication seen in 17 cases (6.5 % of total cases & 19.8 % of all complications). Other complications included failed voiding trial, UTI, transient hematuria, clot retention, urinary incontinence requiring pharmacological treatment, transient elevation of serum creatinine, balanitis, bleeding requiring blood transfusion, supra ventricular tachycardia, sub trigonal perforation, bladder neck stenosis, myocardial infarction, deep vein thrombosis, chronic obstructive pulmonary disease, TUR syndrome, urosepsis. On analysis of risk factors for complications we found that pre op catheterization, CCI score, duration of operation >60 min were significantly associated with occurrence of complications (statistically significant, p < 0.05). When we applied MCCS grading to our complications grade I complications were 28 (32.55 %), II were 19 (22.09 %) and III were 29 (33.72%) which constituted the main bulk of 76 (88.4%) of total complications while grade IV were less common 10 (11.6 %) and grade V was not reported after TURP. The higher postoperative complication rate in our patients can also be explained by higher preoperative CCI scores. Conclusion: The MCCS provides a validated method that can be successfully adopted by several urological centres for grading complications following major urological procedures. We applied the MCCS to grade complications following TURP and compared it to previous studies which had used the same system. We found MCCS to be a simple tool and effective way to compare data on complications between different studies. Further we found CCI to be a quick, simple and reproducible scoring system to accurately predict the complications after TURP. Despite a few inherent limitations, the MCCS may well serve as a straight forward, standardized platform allowing for sound comparisons, either longitudinally within centres to facilitate audit or among centres using similar or different technologies.

   Miniperc XS in management of renal stone: A review of 100 cases Top

Avreen S. Shah, V. Sabale, P. Pramanik, D. Mane, V. Satav, A. S. Shah

Dr DY Patil Medical College, Pune, Maharashtra, India

Objective: This study was conducted to evaluate the efficacy and safety of Miniperc XS (7.5 Fr) Nephroscope in the treatment of renal stones up to 20 mm. Methods: This was a prospective study that enrolled 100 patients and were treated with Miniperc XS. Primary outcomes included stone free rates, operative time, length of hospital stay, requirement of analgesic post-surgery, decline in hematocrit, stent requirement and requirement of ancillary procedure. Results: The mean preoperative stone size was 17.56mm. The patients who were treated with Miniperc XS had a mean operative time of 38.88 min, 1.84% drop in hematocrit levels post-surgery, 98% stone free rates. Post-operative complications such as fever and nephrostomy leakage occurred in 12 and 2 patients, respectively. Eight cases required some drainage procedure (DJ Stent/ Nephrostomy) post-operatively. In single patient, procedure had to be done in 2 stages due to loss of vision due to bleeding and clots. However, No patient required Blood transfusion. Conclusion: This study showed that Miniperc XS could be considered as an effective treatment option in the treatment of renal stones up to 20 mm as it scores in all the standard parameters used to measure Percutaneous nephrolithotrispy (PCNL) outcomes.

   Urodynamic evaluation of women with stress urinary incontinence - A single centre experience Top

D. N. Gosalia, S. W. Thatte, U. G. Oza, H. Agrawal, V. Gunavanthe, M. Dalvi

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

Introduction and Objective: Stress urinary incontinence (SUI) is involuntary leak of urine during increased intraabdominal pressure in absence of detrusor contraction and reported by 86% of incontinent women. Etiology of SUI is multifactorial. Urodynamic study (UDS) prior to treatment of SUI helps to investigate these factors which include Detrusor overactivity (DO), presence of voiding dysfunction (VD), asymptomatic DO, detrusor underactivity (DU), bladder outlet obstruction (BOO). The objective of our study was to use urodynamic as a tool to identify these factors and plan management in patients presenting with SUI at our centre. Methods: We studied 250 patients at our centre who presented with SUI as their primary complaint. All patients were subjected to detailed history, clinical examination, ultrasonography, urine routine, frequency volume charting and UDS. Results: 37 patients out of 250 (14.8%) had genuine SUI. 134 patients out of 213 (62.9%) had associated mixed urinary incontinence. DO was demonstrated in 86 out of 134 patients (64.1%) and 21 patients had asymptomatic DO on UDS (26.5%). Intrinsic sphincter deficiency (ISD) was demonstrated in 28 patients out of 134 (20.8%) who had associated mixed incontinence. 71 patients had associated VD (33.3%). 22 patients among them demonstrated DU (30.9%) and 12 patients demonstrated BOO (16.9%). 58 patients did not demonstrate stress incontinence on UDS (27.2%). Conclusion: UDS can unveil the function of lower urinary tract regardless of patient's perception of signs and symptoms. UDS has the potential for giving additional information and thus adds dimension of precision to evaluation of SUI.

   A prospective study to asses the value of doppler ultrasound and resistive index in predicting renal graft function after kidney transplantation at our institute Madras medical college Chennai Top

A. Johari, K. Saravanan, P. R. Saravanan

Madras Medical College, Chennai, Tamil Nadu, India

Introduction and Objective: Renal transplant {RT} is choice for patients with end stage renal failure. Detection of early RT complications plays a key role in its success and patient survival. Usg doppler and Serum creatinine measurement are routine investigations for renal function after transplantation and detection of any complications. The aim of my study is to correlate the value of Doppler usg and RI in predicting renal graft function after transplantation. Materials and Methods: This is a prospective study includes 35 recipients who underwent RT from living donor. In all patients Doppler usg was done by single radiologist who measure graft size and resistive index. Serum creatinine was done before RT , POD 7 and 1 year after RT. Exclusion criteria – 1) Pt diagnosed with acute rejection on 1st Doppler 2) Primary graft non function 3) Complications {like perinephric collection , Thrombosis of renal vessels} Results and Observations: Repeated Doppler usg shows sig increase in graft size A] Length {Initial ;100.2 +- 4.8mm, POD 7 ;106.2 +- 3.5mm , p value < 0.0003} B] A.P diameter {I ;45.5 +-4.2mm , POD 7 ; 48.5 +- 3.2mm , p < 0.0002} C] Parenchymal / cortical thickness {I ; 10.2 +- 0.9 mm, POD 7; 11.2+- 0.5 mm p<0.001} The 1 year follow up in increse in graft size on Doppler finding was not significant w.r.t POD 7 Doppler findings. No significant correlation between graft size change and resistive index (RI) or Serum creatinine and RI in early or 1 year post RT. Conclusion: There was sig increase in renal graft size {including Length, A.P diameter and cortical thickness} in early RT period. The increase in graft size correlate significantly with serum creatinine 1 year post RT. No correlation between RI and serum creatinine. Hence Doppler is very effective tool to evaluate graft function at early stage post RT , which help to predict long term outcome of graft.

   Bladder neck obstruction in female: An underdiagnosed manageable entity Top

P. B. Singh, Prashant Kumar Singh, Jigysa Singh, Kuldeep Aggarwal

PBS Urology Varanasi and Yashoda Super specialty Hospital, Kaushambhi, Ghaziabad, Uttar Pradesh, India

Introduction: female with outflow obstruction are often diagnosed as underactive detrusor and managed either by indwelling catheterization or CIC. We managed 11 such females who were diagnosed as underactive detrusor and were on indwelling catheter for periods varying from 9 months to 3 years.After evaluation they were managed by bladder neck incision at 11 and 2 o'clock position. These females are now free of catheter and voiding normally. Materials and Methods: In last 2years 11 females were on indwelling catheter or CIC from 9months to 3 years or. Any obstruction in urethra was ruled out. We did urodynamic study in all case to evaluate maximum Pdet which varied from 12 to 32 cm of water. All these females were subjected to cystoscopy and bladder neck incision (BNI). BNI was done at 11 and 2 o'clock position so that bladder neck falls back from high riding position. Results: These females were given voiding trial after 3 days and all female could void with average to good flow. Ultrasound done after 3 weeks revealed insignificant post void residue. Follow up is ranging from 2 years to one month. All females are free of indwelling catheter or CIC. Conclusion: Bladder Neck Obstruction in female are underdiagnosed and are often taken as under active detrusor. Bladder neck incision in females were avoided due to short urethra and possibility of incontinence. Bladder neck incision in these females is effective to overcome obstruction.

   Post percutaneous nephrolithotomy bleeding requiring angiographic renal angioembolisation. Is lower pole puncture really safe? Top

R. Taori, A. Chawla, A. Kapadia, B. M. Zeeshan

Kasturba Medical College and Kasturba Hospital, Manipal, Karnataka, India

Introduction and Objective: Percutaneous nephrolithotomy (PCNL) is an established procedure for the management of large and complex renal calculi. Severe post-operative bleeding which requires blood transfusion and angioembolisation is a major concern in cases undergoing PCNL. This study aims to identify the risk factors associated with post PCNL angiographic renal embolization. Methods: Case records of 5824 PCNL procedures were retrospectively reviewed and compared with 47(0.80%) PCNL procedures which had severe post PCNL bleed requiring angiographic embolization between January 2006 to May 2019 using chi square univariate and regression multivariate analyses. A detailed evaluation was done including the stone burden, location, calyceal access, number of tracts, Amplantz size, and duration of procedure and patient characteristics like hypertension, Diabetes mellitus, renal failure. Results: Out of 5824 PCNL procedures, 47 patients underwent angiographic embolization (0.80%) for severe bleeding. Among these patients, 41(87.23%) were males and 6(12.77%) were females with the mean age of 50.65+/- 14.13 years. Statistical analysis showed that significant associated factors for severe bleeding were male sex (p=0.018), diabetes (p=0.045), renal failure (p=0.022) and lower calyceal puncture (p=0.016).Factors such as hypertension, stone burden and location, number of tracts, amplatz size were not significant. Conclusion: Male patients, patient with diabetes mellitus, renal failure and who underwent lower calyceal puncture are more prone for post PCNL bleeding which requires renal angioembolisation.

   Our experience in the transplantation of graft kidney with ureter duplication Top

Rohitas Chandora, Pranjal Modi

IKDRC-ITS, Ahmedabad, Gujarat, India

Introduction and Objective: The most effective treatment of chronic renal failure is kidney transplantation. Ureter duplication (UD) is the most common anomaly of the upper urinary tract. There is no consensus on how to perform ureter bladder anastomosis in kidney grafts with double ureters. The aim of this study was to represents our experience and results of renal transplantation with grafts having UD anomaly as well as the long-term graft function. Materials and Methods: Between January 2010 and June2019 , the results of transplantations with kidney grafts which had ureteral duplication were analyzed retrospectively . The distal ends of the ureters were anastomosed to each other and then the modified Lich technique was used for ureteroneocystostomy. Two ureteral stents were placed in the ureters and outcome was studied. Results: Between January 2010 and June 2019, 2039 kidney transplants were performed in our transplantation center. UD was detected in 8 cases (0.3%). The mean age of donors was 43.6 ± 15.5 (24-65). The mean operative time was 80.6 ± 13.4 minutes (65-109). %). Mean serum creatinine at follow up : 1.34 + 0.19 mg/dl. . No urinary complications were observed in the recipients in the mean follow-up period of 6 years. Conclusion: We experienced that modified Lich Gregoir Ureteroneocystostomy method with single-ostium by using 2 Double J stents in the kidney grafts with UD is safer than other method.

   Retroperitoneal ganglioneuroma mimicking right adrenal mass Top

Vipin Sharma, P. Periasamy, G. Sivasankar, A. Senthilvel, Ayesha Shaheen, R. Jayaganesh

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

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 up to 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 neighbouring 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.

   Vesico-vaginal fistula repair by transvaginal route: comparison of resource utilisation and outcome with literature reported population matched minimally invasive cohort Top

Jain Shrey, Kumar Naveen, Kapoor Rohit, Surekha Sanjoy, Srivastava Aneesh, Kapoor Rakesh

SGPGI, Lucknow, Uttar Pradesh, India

Introduction: VVF conventionally repaired by open transvaginal or transabdominal routes. We compared our series of transvaginal VVF repair with literature reported population matched cohort of repair done by laparoscopic or robot assisted techniques. Materials and Methods: 239 VVF repair from 2000-2017, predominantly done transvaginally (n=229, 95.8%). Trans-abdominal route (n=10, 4.2%) considered in complex and recurrent fistulae. Size of fistula, location, operative time, blood loss, major complications, hospital stay and perurethral catheter indwelling time and outcome recorded. Our TV repair cohort (n=229) compared with literature reported cohort of 260 patients undergoing VVF repair by minimally invasive techniques. Results: Overall, success rate in our series was 97% (n=223) vs 96% in LRC. Blood loss in literature was upto 450 ml compared to 80 ml in our cohort. There was significantly shorter operative time 30-100 (mean 55 +/- 9) minutes in our cohort as compared to 70-430 (mean >150) minutes in LRC with hospital stay (3.5 vs 3.2) days in TV as compared to LRC repair. Major complication (Clavien Dindo III or more) was three in our series vs five in reported literature. The cost of surgery at our setup is around 15000 INR for TV repair. The cost by minimally invasive techniques has not been reported but is likely to be at least 5 times higher if it would be done at our setting. Conclusion: Transvaginal VVF repair is comparable to literature reported outcome by minimally invasive approach, however transvaginal performed better as far as resource utilization and postoperative recovery is concerned.

   Bipolar transurethral resection in glands more than 75cc - safety and efficacy Top

Mohammed Taif Bendigeri, C. Mallikarjuna, K. P. C. Reddy, S. M. Ghouse, E. Bhavatej, R. Deepak

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

Introduction and Objectives: Transurethral resection of prostate (TURP) has been the gold standard of endoscopic management of benign prostatic hyperplasia (BPH). Traditionally it was restricted to glands of size less than 75cc. However, with advent of bipolar TURP, the safety of TURP has improved and larger glands can now be done safely. We present our series of bipolar TURP in glands larger than 75cc with a focus on the safety and efficacy of procedure. Materials and Methods: It is a retrospective analysis of prospectively collected data from July 2013 to March 2019. All the patients undergoing bipolar TURP with glands measuring more than 75cc on transrectal ultrasound (TRUS) assessment were included in the study. Preoperative symptoms, demographic details, intra-operative details, post-operative outcomes and complications if any were noted. Patients were followed up with symptom assessment, uroflowmetry and ultrasound examination at 3months and 6 months. Results: Total of 2452 patients were assessed. 327 patients had gland more than 75cc. Mean age was 70.3 years. Mean gland size was 106.5gm. Mean resection time was 95.2 min. Mean drop in haemoglobin was 1.1gm/dl. No incident so TUR syndrome occurred. 2.8% patients had strictures and bladder neck contractures. Conclusion: Bipolar TURP is safe and effective even in glands larger than the conventional limit of 75cc. The upper limit for TURP should be considered for up-scaling and perhaps bipolar TURP can even be considered as size independent gold standard for BPH treatment.

   Retrospective descriptive analysis on the management of genitourinary injuries sustained during laparoscopic hysterectomy in ISO KGH, Triplicane, Chennai Top

Srikala Prasad, Jessima Subahani, B. Amirtha

ISO-KGH, Chennai, Tamil Nadu, India

Purpose: To study the incidence of ureter & bladder injuries detected intra-operatively/post operatively following laparoscopic hysterectomies in the gynecology department of our institution This study describes our experience in the management of ureteric/bladder injuries following laparoscopic pelvic operations and outcome of management of this condition in our local setting. Methods: This is a retrospective descriptive study of patients with iatrogenic injuries to the ureter and bladder following laparoscopic hysterectomies that were managed in our department from March 2016 to March 2019. Analysis of the patient diagnosis, indication for surgery, type of surgery, time at diagnosis of injury, presenting features and the type of management was done. Results: In our study a total of 13 bladder injuries and 8 ureteric injuries were identified out of 511 LAVH procedures performed during the study period. All the bladder injuries were identified intra-operatively and repaired primarily by converting to open TAH with 2 layered bladder rent repair and double continuous bladder drainage in the post-operative period. Among the ureteric injuries only one was identified intra-operatively and treated with stenting, in the follow up period the patient eventually developed a fistula and managed with ureteric reimplantation.Remaining 7 ureteric injuries presented in the post- operative period with involuntary urinary leakage ,and fever as the most common presenting symptoms. Duration of symptoms ranged from immediate post - op to upto 3 months post procedure. All these pateints were evaluated with CT urogram. 5 patients were managed with boari flap repair, 2 patients were treated with ureteric reimplantation and 1 patient with DJ stenting. Most common post operative complication was fever due to UTI. None of the patients had any recurrences and are on regular follow up. Conclusion: Bladder injury is the most common visceral injury following laparoscopic pelvic surgeries with a variable incidence of 0.02-8.3%, as comparable to 2.5 % from our study. Incidence of ureteric injury is <1-2% as comparable to 1.5% from our study. Knowledge of the anatomy of the bladder and thorough understanding of electrocautery are useful in preventing bladder injuries. Meticulous surgical technique as well as identification of the course of the ureter and associated anatomic locations where injury is most likely to occur is important to decrease the risk of ureteric injury. Timely recognition of ureteric injury and its management is associated with good outcome. Treatment of these injuries by experienced team may minimize long term consequences. Keywords: Ureteric and bladder injuries, Iatrogenic, Abdomino-pelvic operations, Management, Outcomes.

   RIRS in paediatric patients - safety, efficacy and technical challenges Top

Mohammed Taif Bendigeri, C. Mallikarjuna, K. P. C. Reddy, R. Deepak, S. M. Ghouse, E. Bhavatej

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

Introduction and Objectives: Management of paediatric stone disease is a very challenging scenario. The usage of RIRS in children has been an option of managing paediatric renal stones recently. We present our series of paediatric RIRS cases with focus on the safety, efficacy and technical challenges. Materials and Methods: It is a retrospective analysis of prospectively collected data from July 2013 to July 2019. All patients less than 14 years of age who underwent RIRS for renal stone disease at out centre were included in the study. Preoperative demographic details, stone parameters, intra-operative details, post-operative outcomes and complications were noted. All patients underwent presenting 2 weeks prior. Stone clearance was assessed at 4 weeks after stent removal with ultrasound abdomen and x-ray. Results: A total of 65 patients were included in the study. The mean age was 5.8years. The youngest child was of 9 months age. Mean duration of procedure was 43min. All patients underwent presenting. 4 patients were stented again after definitive procedure. 4 patients had postoperative fever. Residual fragments were seen in 10 patients (15.4%) at 4weeks. However, at 3 months of follow-up, only 3 patients had residual fragments. All children were evaluated with comprehensive metabolic workup postoperatively. Conclusions: RIRS is safe and efficacious in treating renal stone disease even in children. The benefits of RIRS versus PCNL can be safely extended in children as well. The procedure however is technically demanding and involves higher number of ancillary procedures.

   Dorsal midline incision: A versatile technique for correction of meatal stenosis during hypospadias repair Top

Vibhore Agarwal, S. S. Yadav

SMS Medical College, Jaipur, Rajasthan, India

Introduction: During hypospadias repair meatal narrowing is dealt by ventral midline incision, drawback of this technique is that this incision not only shifted the meatus more proximally but also retubularization of hypo plastic hypo vascular urethra will further hamper the healing process. Here by we are reporting outcome of a technique where instead of ventral urethral incision, dorsal midline incision was made to treat the meatal stenosis during hypospadias repair. STUDY DESIGN Patients having distal hypospadias with meatal stenosis were included in this study.Patients having chordee more than 15 degree, proximal hypospadias, redo cases, glans width less than 14 mm were excluded from the study. Results: 69 hypospadias patients with meatal stenosis were operated by this technique. Mean age of patients was 11.8+/-5.78 yrs. Postoperatively six patients (8.69%) had urethrocutaneous fistula, but none of the patients in coronal hypospadias group had UCF. The uroflowmetry curve was bell shaped in 37(63.7%) boys, interrupted or intermittent in 9(15.5%), slightly flattened in 5 (8.6%). None of the patients in our study developed stricture except one who developed meatal stenosis. DISCUSSION Based on above facts we think treating meatal stenosis by ventral meatotomy is not advisable as it may lead to proximal shift of the meatus, which in turn increases the possibility of UCF. There are several limitations to the present study as there was no comparison with traditional study, relatively short series and all cases were operated by a single surgeon.


   Face and content validity of a novel chicken model for laparoscopic neobladder reconstruction Top

A. G. Singh, Z. Kareem, G. R. Tak, A. G. Ganpule, R. B. Sabnis, M. R. Desai

MPUH, Nadiad, Gujarat, India

Introduction and Objectives: Learning curve of complex urological procedures can be shortened by simulation based training. We present a cadaveric chicken and bovine intestine model for training in laparoscopic neobladder reconstruction. Materials and Methods: It is a prospective observational study. Twenty novice and twenty trained laparoscopic surgeons were included in the study. The relevant chicken anatomy and surgical steps were described to all the surgeons. The culled chicken was placed on its back; evisceration was done and proventriculus was used as urethra and 70 cm of bovine intestine was used to reconstruct the neobladder. The chicken esophagus and trachea were excised and attached to the chicken thigh and mimicked as right and left ureter. This assembly was placed in a self-designed endotrainer. The surgeons were asked to perform the procedure and were asked to fill a nine-point questionnaire comprising of: bowel organization, ability to do urethro neovesical anastomosis, suturing time, suturing similarity, quality of suturing, tissue texture , integrity of anastomosis, realism and usefulness of model. The surgeons scored the questionnaire on a scale of 1-5. Results: All the participants in the study gave a mean score of 3 or more to all the questions asked in the questionnaire. Both the groups rated the usefulness of the model highly with a mean score of 4.6 and 4.4 respectively. The mean score of the questionnaire was 35.9 and 36 respectively for both the groups. Conclusion: The Chicken model for laparoscopic neobladder reconstruction is a useful and effective training tool. This model has Face and Content validity to be used as a teaching and training tool in laparoscopic urology.

   A prospective randomized controlled study of gentamycin irrigation in reducing the postoperative infections following upper tract endoscopy Top

Banu Teja Reddy Patellugari, A. P. Pavan, J. Jayaraju, K. V. Bhargava Reddy, P. Vedamurthy Reddy, N. Mallikarjuna Reddy

Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India

Introduction and Objective: Infection is one of the major complications in URSL and PCNL surgeries, and may range in severity from mild fever to septic shock. Our study is aimed at determining the effect of gentamycin instillation in irrigation fluid during upper tract endoscopic procedures on the rates of post-operative fever. Materials and Methods: A prospective randomised controlled study done from March 2019 to July 2019. 134 cases operated at our institution will be considered. Statistical analysis was done by Chi square test. Inclusion criteria All renal and ureteric calculi patients with preoperative sterile urine culture who underwent PCNL and URSL respectively are included. Exclusion criteria Patients with positive urine culture, fever, UTI or Pyelonephritis and patients on pre operative antibiotics were excluded. Results: A total of 12 patients developed fever among 134 patients. Among the 58 PCNL patients, 7 developed fever and 5 developed fever among 76 URSL patients. P value is 0.658 which is not significant. Among the PCNL patients with stone size >2 cm, using gentamycin irrigation none of the patient developed fever. Duration of fever was less in gentamycin group compared to normal saline group. Conclusion: Single dose of pre-operative IV antibiotic is sufficient for endourological procedures. Though the duration of fever was less with gentamycin irrigation, we need larger numbers to validate this study.

   Factors predicting successful surgical outcome after PCNL: Use of guy's stone score to assess outcomes - A retrospective study Top

Utsav Shah, S. Hariharasudhan, K. Sriram, S. Venkat Ramanan, K. Natarajan

Sriramachandra Medical College, Chennai, Tamil Nadu, India

Introduction and Objectives: PCNL is the gold standard treatment for large and/or complex renal stones. A uniform grading system to categorize stone complexity is the need of the hour. The benefit of using Guy's Stone score will directly extend to predicting the SFR(Stone Free Rates) after PCNL and thus counseling patients preoperatively regarding the same. Materials and Methods: A retrospective study was conducted on 202 patients who underwent PCNL between January 2018 and February 2019. All patients with a stone size of >1cm were included in the study. Those with a stone <1cm, age<16 yrs and having skeletal abnormalities were excluded. Preoperative radiological evaluation with NCCT KUB and postoperatively with USG KUB was carried out in all patients. Results and Observations: The Initial GSS predicted a successful SFR in 95% of cases. On monovariable analyses, variables of amplatz size, access tract location (supra 11th rib in particular), use of multiple access tracts, experience level of the surgeon and GSS were found independently significantly associated with SFR as well as complications. Conclusions: GSS is a valid and reliable score having excellent reliability and good ability to discriminate SFR and complications. Message: GSS can be an answer to the need for institution-specific calibration of outcome standards to better counsel patients undergoing PCNL. GSS could also be useful in referring complex cases to higher centres if uniform calculus complexity grade based outcome databases are established.

   Functional outcome of robotic assisted intracorporeal versus extracorporeal neobladder following radical cystectomy - Initial experience Top

Jeevan Kumar, Altaf Khan, Mujeeburahiman, Nischith D'Souza, Raghu Lavanya Sarath

Yenepoya Medical College, Mangalore, Karnataka, India

Introduction and Objectives: Radical cystectomy is treatment of choice for patients with muscle-invasive and high-risk superficial bladder cancers. With advent of Robotic surgery and increasing expertise Robot-assisted radical cystectomy (RARC)is likely to become the minimally invasive technique of choice. The evolution of robotic surgery, with its three dimensional vision and improved ergonomics has made a new dimension to reconstructive surgery,enabling the surgeon to perform both continent and incontinent urinary diversions intracorporeally. There are so many studies on perioperative outcomes and complications of Extracorporeal Neobladder(ECNB) vs Intracorporeal Neobladder (ICNB) following RARC, But no much studies for comparing functional outcomes of neobladder. So we attempt to study the functional outcomes of neobladder (ECNB vs ICNB). Materials and Methods: All the patients who underwent RARC with neobladder during the period of November 2017 to March 2019 were included in study. All patients were assessed post operatively with USG ,UFM(uroflowmetry), functional bladder studies (urodynamic studies (UDS)), & MCU.Our main outcomes of interest were 1. peak flow rates , 2. Pdet at Qmax , 3. Residual urine , 4. presence or abscence of Reflux, 5. Attainment continence.All the data were tabulated and appropriate statistical analysis applied. Results and Observations: The peak flow rates attained by ICNB & ECNB wer comparable with mean value of 12.3 for ECNB & 12.6 for ICNB . The max Pdet developed in both cases were also comparable with mean value of 32 for ECNB & 34 for ICNB. The residual urine were also comparable in both cases at the end of 2 months. The Attainment of Continence was early in ICNB compared to ECB. Conclusions: Robotic assisted ICNB is Feasible with comparable functional outcome to ECNB and with relatively early attainment of Continence. Also having added advantages of minimal post operative pain ,early recovery and relatively fewer complications

   Effect of a novel technique of posterior reconstruction of pubourethralis on early return of continence after robot assisted radical prostatectomy Top

Malik Abdul Rouf, Rajesh Taneja, Venkatesh Kumar, Anshuman Agarwal, Mahender Sharma, Shrawan kumar, Vaibhaw Sood, Suresh Kumar Rawat

Indraprastha Apollo Hospital, New Delhi, India

Introduction: This is a prospective intervention study to assess the effect a novel method of posterior reconstruction of pubourethralis muscle during robot assisted radical prostatectomy (RARP) on early return of continence. Materials and Methods: Thirty nine patients who underwent RARP for localized adenocarcinoma of prostate were part of this study which had a due ethics committee clearance. After standard excision of the specimen, the posterior reconstruction in the form of Rocco stitch was done. The pubourethralis was approximated posteriorly in midline at the proposed site of vesicourethral anastomosis. The patients continence was assessed by making a note of number of pads used, continence being defined as the need to use 0-1 pads in 24 hours. The data was collected on Day 0,3,7,15,30,90 and 180 after removal of catheter. Results: Out of 39 patients, 7 patients (17.9%) 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 (23%) were continent (no pad in 6 patients) ,on day7 of catheter removal 23 patients (58.9%) were continent (no pad in 10 patients). On day 15, 29 patients (74.3%) were continent (no pad in 16 patients), while 38 patients (97.4%) were continent at 1 month (no pad in 31 patients and 1 pad in 7 patients). At 3 and 6 months, 39 patients (100%) were pad free . Conclusion: Despite a small number of patients in this study and lack of a control group, posterior midline approximation of pubourethralis appears to be enhancing the chances of early return of continence after RARP. However it is necessary to further validate the efficacy of this procedure through multicenteric controlled trials.

   Programmed death ligand-1 receptor status in urothelial cancers and its association with chemoresponsiveness Top

Subhajit Mandal, Shrawan kumar Singh, Ravimohan Suryanarayan Mavuduru, Nandita Kakkar, Arup Kumar Mandal, Girdhar Bora, Santosh Kumar

PGIMER , Chandigarh, India

Introduction and Objective: PD-L1 as a marker of aggressiveness is in investigational stage for urothelial cancer. We evaluated the expression of PD-L1 in urothelial cancer and its association with chemoresponsiveness. Methods: Bladder tumour tissue samples were evaluated for expression of PD-L1 (membrane, immune cells and overall positivity) by immunohistochemistry (Ventana 263 kit) in this observational prospective study between January 2018 and June 2019. In muscle invasive bladder cancer (MIBC) patients, following 3 cycles of neo-adjuvant chemotherapy (NACT), PD-L1 status was reassessed in tissue samples of radical cystectomy. Chemoresponsiveness (complete or partial response, according to RECISTv1.1) was correlated with PD-L1 expression status. Results: Seventy-two patients with bladder tumour (Non-MIBC=39, MIBC=33) were included. Overall PD-L1 expression was positive in 48.6% of patients. PD-L1 expression was significantly higher in MIBC than non-MIBC (66.6% vs. 38.2%; p=0.001) and High-grade tumors versus low-grade tumors (62% vs. 22.2%; p=0.001). Twenty of 33 MIBC patients underwent post NACT radical cystectomy. No change in PD-L1 expression was observed following NACT. Three out of 10 patients in PD-L1 positive group and 8 out of 10 patients in PD-L1 negative group showed response following NACT. There was no statistically significant association between PD-L1 positivity and chemoresponsiveness (p=0.07). Conclusion: High expression of PD-L1 in urothelial cancer may be regarded as a marker of aggressiveness and invasiveness. A larger study is necessary to evaluate the effect of tumoral PD-L1 expression and chemoresponsiveness.

   Retrograde intrarenal surgery in children less than 5-year Top

P. M. Siddalinga Swamy, V. Chandra Mohan, P. Ramakrishna, Manas Babu, G. Soundarya

Preeti Urology and Kidney Hospital, Hyderabad, Telangana, India

Introduction: Percutaneous nephrolithotomy (PCNL) and shock wave lithotripsy (SWL) are established standard forms of treatment in children with renal stones, according to EAU guidelines. Owing to the less invasiveness and rapid clearance, Flexible Ureterorenoscopy (FURS) is an attractive option for upper tract calculi, especially in children. There are very few studies in literature which have described RIRS in preschool children. We have evaluated the outcomes of RIRS in children less than 5 years done at our hospital. Objective: To analyse the feasibility, stone free rate and complications of RIRS in children less than 5 years of age. Materials and Methods: A retrospective analysis was done on all children less than 5 years of age, who underwent RIRS in our hospital, for renal/proximal ureteric stones, from Feb 2010 to Feb 2019. Ureteral access sheath 9/11 Fr (Cook, USA) was used whenever feasible, If any resistance encountered, flexible ureterorenoscope (Flex X2, or P7) was backloaded over the guide wire, Laser lithotripsy done. Results: A total of 62 pediatric patients, 67 renal units. Mean age was 3.95 +/- 1.06 years. Mean stone size was 12.42+/-8mm. 4 cases (5.9%) required conversion to miniPCNL in the same sitting, due to access failure. At the end of 2 months, 54 patients revealed stone free rate of 83.3%. Complications were seen in 38.01% comprising mainly grade 1 28.5%. Conclusion: Pediatric RIRS is feasible and is a promising option in young children as it offers non compromising stone free rates and a less incidence of major complications.

   Transrectal ultrasound elastrography: A diagnostic tool to differentiate between benign and malignant lesion of prostate Top

Shah Darshil, R. Neelakandan, T. Chandru, K. Sriram, S. Venkatramanan, K. Natarajan

Sri Ramachandra Medical College, Chennai, Tamil Nadu, India

Introduction and Objective: Elastography is a non-invasive imaging to depict relative tissue stiffness or displacement(strain) in response to impacted force, Ca-prostate is stiffer than normal tissue. Transrectal-elastosonography has been established to be feasible in guiding biopsies and for improving the detection of prostate lesions. Shear wave elastography(SWE) is a modified real-time imaging technique that represents a substantial advance in ultrasound elastography. The present study aimed to determine cut off value to differentiate between benign and malignant lesions of prostate and to test sensitivity, specificity and positive predictive value of SWE. Methods: Prospective observational study, period of 6 months in a single tertiary care centre. Study included 30 patients. All patients underwent 6or 12 core prostate biopsies. Elastography of the involved segment compared with histopathology of core biopsy from the same segment. Results: Mean age 66.77years. Serum PSA range 3.8-698 ng/dl. Out of 30, 15 patients had Ca-Prostate, 15 patients had benign histology. Elasticity in Ca-Prostate group: 76.5-161.7kPa, mean 109.39kPa. Elasticity in benign group: 19.7-134.1kPa, mean 69.94kPa. Based on these, we can conclude 90kPa as cut off value to differentiate between benign and malignant lesions. Sensitivity calculated based on this cut off value is 73.91%, specificity- 76%, positive predictive value- 75.49% and negative predictive value- 74.44%. Conclusions: This study concludes that 90kPa on SWE can be used as cut-off between benign and malignant prostate lesions with high sensitivity(73.91%) and specificity(76%) and positive predictive value of 75.49%. Thus, SWE can improve guiding capability and reduce unnecessary core biopsies required for diagnosis.

   Evaluation of ultrasound guided abdominal wall block for post-operative analgesia in laproscopic donor nephrectomy: A single center study Top

T. M. Mistry, M. Pahwa, V. Tyagi, P. Laddha, S. Chadha, H. Jauhari

Sir Ganga Ram Hospital, New Delhi, India

Introduction and Objective: Ultrasound guided abdominal wall nerve block is a novel technique of analgesia as a part of multimodality regimen. Significant component of pain in abdominal surgery is related to the incision. Current study was undertaken to evaluate the efficacy of these blocks in pain management after laproscopic donor nephrectomy. Materials and Methods: Total 106 donors (age 18-60) had undergone laproscopic donor nephrectomy at our center from October 2018 to April 2019. Donors were randomized using computer-generated random numbers into test group who received the block (n=41) & control group who received only routine analgesics in form of paracetamol & tramadol (n=65). Pain was assessed at 1, 6 & 24 hours following the surgery using Numeric rating scale (NRS). Rescue analgesics were given in form of tramadol & paracetamol for NRS more than or equal to 6. Statistical analysis was done. Results: Mean NRS observed among the test group at 1hr, 6hrs & 24hrs were 3.48, 3.36 & 3.45 respectively. Mean NRS observed in control group at 1hr, 6hrs & 24hrs were 4.5, 4.09 & 3.90 respectively. Difference between mean NRS was found to be statistically significant (p=0. 0034, p=0.04 & p=0.04 respectively) .Total 8 patients required rescue analgesics (19.51%) in test group. 30 out of 65 patients in control group (46.15%) required additional analgesics. No significant complication was observed after the block. Conclusion: Ultrasound guided abdominal nerve block is a promising option for post-operative analgesia after laproscopic donor nephrectomy. However, large multi-centric trials are required for its extrapolation.

   Blue light cystoscopy - A golden opportunity to optimise the program for bladder cancer! Top

Ashwin Sunil Tamhankar, Siya Lodhia, Alexander Hampson, Beverely Aldwinkle, Sheena Cleaver, Nikhil Vasdev

East and North Hertfordshire NHS trust, Lister Hospital, Stevenage, United Kingdom

Introduction: Blue light cystoscopy (BLC) is the diagnostic and therapeutic tool for non muscle invasive bladder cancer (NMIBC), unfortunately not been used too often in majority centers across the globe. Methods: We analysed the data of 47 BLC adjunct procedures, either biopsy or transurethral resections (TURBT) from September 2016 to November 2018. Patient pool was the NMIBC without any intravesical therapy in past, who were on surveillance cystoscopy or were the candidates for restaging TURBT or the suspected malignancy on the initial flexible cystoscopy. The outcomes were assessed in terms of evaluation of muscle representation in pathology and probable upstaging of grade or T stage of the tumor in resection. Results: Out of 47 patients, 33 underwent formal TURBT in blue light and 14 underwent biopsy of suspicious lesions. 20 amongst these 47 had previous history of bladder cancer. Malignancy was picked up in total 12 of them (1 after the biopsy and 11 after TURBT). Six of them were primarily diagnosed (6/27 = 22.2%) whereas 6 were known cases of bladder cancer. 97% cases of TURBT had muscle representation. Out of the previous known bladder cancer patients, one (16.66 %) patient had upstaging of grade (G2 to G3), one (16.66%) patient had upstaging of T stage (Ta to T1) and two patients (33.33 %) had detection of carcinoma in situ (CIS) in the background of malignancy. In a long term follow up, total 8 patients recurred with three of them having at least T2 histology. Conclusion: Blue light cystoscopy guided procedure has higher propensity for representing muscle for exact pathological staging along with higher probability of detecting concomitant CIS in NMIBC. Previous pathology Pathology on BLC Upstaging 1 G2pTa G3 pTa + CIS G2----G3, CIS 2 G1pTa G1pTa 3 G3pT1 G3pT1 Ta----T1 4 G3pTa + CIS G3pT1 5 G3pT1 CIS CIS 6 G2pT1 G2pTa.

   Intra-urethral flora and post-cystoscopy urinary tract infection in males - A clinical study Top

Rohit Dadhwal, Rishi Nayyar, Arti Kapil, R. M. Pandey

AIIMS, New Delhi, India

Introduction and Objective: Role of distal urethral flora in post-cystoscopy urinary tract infection (UTI) is unclear. Office cystoscopy (OC) is associated with UTI in 10-15% of patients. We conducted this study to isolate and define the role of distal urethral bacterial microflora in post-procedural UTI in males undergoing OC. Additionally we sought to determine whether irrigation of urethra with betadine reduces UTI's compared to standard surgical preparation. Materials and Methods: It was a prospective, single centre, double blind randomised study on healthy males (age: 15-75) with sterile urine culture, undergoing OC. Distal urethral culture was taken after standard part preparation with betadine 5% just before OC using sterile cotton swab. The operating surgeon and the microbiologist were blinded to each other's findings of pre-operative flora. Patients were randomised into two groups, with or without an additional urethral 2% betadine instillation. No post procedural antibiotics were given. Urine cultures were obtained in all cases at 48 hours and 1 week or as clinically indicated. Results: 192 patients were included with mean age of 56.5 years (31- 74). Growths on distal urethral swab were seen in 188. Most common organisms were  Staphylococcus epidermidis Scientific Name Search 2 (21.8%). UTI occurred in 28 (14.5%) patients, E coli being most common isolate in 18 (64%). In control group UTI episode was seen in 21 (22%) as compared to 7 (7.2%) in intervention group (p = 0.007). Conclusion: Distal urethral commensal flora is diverse but has got limited role in causing UTI. Irrigating distal urethra with betadine caused significant decrease in post procedural UTI and need for antibiotic therapy.


   Laparoscopic pyeloplasty in triple moiety horseshoe kidney Top

A. Ghanghoria, D. Sarma, T. P. Rajeev, S. J. Baruah, S. K. Barua, P. K. Bagchi, M. Phukan

Gauhati Medical College and Hospital, Guwahati, Assam, India

Introduction and Objective: Horseshoe kidney is common fusion anomaly of the kidney, with an incidence of approximately 0.25%. Horseshoe kidney is renal fusion anomaly characterized by renal malrotation and a propensity for uretero-pelvic junction (UPJ) obstruction in one third of cases. Minimal access surgery laparoscopic pyeloplasty has become standard of care in case of horseshoe kidney. The objective of this video is to show that laparoscopic surgery in incidentally detected anomalies in case of horseshoe kidney can be performed safely and efficiently in experienced hands with reduced patient morbidity and early recovery. We are hereby presenting a video of a case of UPJ obstruction in triple moiety horse shoe kidney in a 14 years old female child. Methods: It is a videographic presentation of a single patient. Surgery was done on JAN, 2019. Our patient was a 14 years female child, presented with intermittent dull aching left flank pain. Contrast enhanced computed tomography revealed malrotated left and right renal moeity with fusion of lower pole with multiple caliectation on left side Triple moiety and pelviureteric junction obstruction in lower moiety of left kidney. Patient was planned for laparoscopic pyeloplasty. Results: Operative time was 80 minutes with blood loss of approximately 100 ml. Patient had uneventful post-operative recovery and discharged on 3rd post-operative day. Conclusion: Laparoscopic pyeloplasty in case of UPJ obstruction associated with triple moiety horseshoe kidney is very safe in experienced hands with early patient recovery.

   Laparoscopic upper pole heminephroureterectomy for non functioning dilated upper pole moiety in a female child with duplex kidney having ectopic ureter Top

Priyank Kothari, Hemant Pathak, Mukund Andankar, Amit Sharma, Tarun Jain

Topiwala National Medical College, Mumbai, Maharashtra, India

Duplex ureter is an uncommon malformations of the urinary tract, which occurs 1 in 125 cases with female to male ratio of 1.6:1. Upper moiety is frequently obstructed, poorly functioning and is associated with UTI and reflux. We videographically present a case of laparoscopic upper pole heminephroureterectomy in a 5 yr old female child. 5 year old female child presented with continuous dribbling of urine since birth with multiple episodes of UTI. On evaluation was found to have ectopic ureter on urethroscopy. Further evaluation on CT IVU showed left duplex kidney with non functioning dilated upper pole renal unit with ureter. Renal scan(DTPA) confirmed that the upper pole was non functional. We performed a left sided laparoscopic upper pole heminephrectomy with 145 mins operative time and estimated blood loss of 50 ml. Patient was discharged on post op day 4. Isolation and low ligation of ureter was performed as in our past experience leaving behind the ureter had lead to ureteric abscesses and cutaneous sinus formation. Patient recovered well with no post op complications. Laparoscopic transperitoneal upper pole heminephroureterectomy is the treatment of choice for non functioning dilated lower segments of duplicated kidneys. Use of laparoscopic approach offers good working space, good ergonomics, good visual control of hilar vessels and allows very low isolation of ureteral stump which justifies peritoneal violation. Though other approaches have been described we prefer the laparoscopic approach.

   Laparoscopic transvesical common sheath ureteric reimplantation for vesicoureteric reflux disease Top

Raj Kumar Sharma, Reddy P. Banuteja, A. P. Pavan, J. Jayaraju, Reddy K. V. Bhargava, Reddy P. Vedamurthy, Reddy N. Mallikarjuna

Narayana Medical College, Nellore, Andhra Pradesh, India

Introduction and Objectives: To report our technique of Laparoscopic Transvesical common sheath ureteric reimplantation for Vesicoureteric reflux disease. Vesicoureteric reflux is common entity in female for upper tract deterioration. Diagnosing it early and treating it, is best way to safeguard the upper tracts. Transvesical approach is one of the safe and better ways of ureteric reimplantation . We present our experience with this technique for grade IV reflux in a left duplex system. Materials and Methods: A 30 year old lady presented with pain abdomen since 1 month ,associated with fever and vomiting. On MCUG, grade IV vesicoureteric reflux was visualized on the left side and on IVP, patient was diagnosed to have a left duplex moiety . Planned for left ureteric reimplantation. Cystoscopy revealed both ureter in a common sheath at VUJ, planned for a laparoscopic transvesical common sheath urteric reimplant. Results and Observations: Patient recovered well, operating time was 90 mins with minimal blood loss and post operative MCU showed resolution of reflux. Conclusions: We report our technique of Transvesical Laparoscopic Common Sheath Ureteric Reimplantation.

   Surgical nuances in the management of peri-hilar/para-aortic masses Top

Sanjoy Kumar Sureka, Naveen Kumar, Kumar Madhavan, R. Kapoor

SGPGIMS, Lucknow, Uttar Pradesh, India

Introduction: Para aortic or peri hilar masses are uncommon masses, which present a unique surgical challenge with no pre defined surgical management or technique. They are also heterogeneous in nature in terms of their origin, nature (benign or malignant), location, anatomic relations and need for removal of additional organs. We have discussed our experience in their management and present our surgical technique. Methods: We operated on 9 such patients between January 2018 and May 2019. We maintained a prospective database of their baseline demographic parameters, operative time, and blood loss, post op stay, histopathology and follow up. Results: Out of the 9 patients, 7 were gentlemen and 2 were ladies. They had a median age of 49 years (21 - 68). Median operating time was 165 minutes (135 - 381). The median blood loss was 80 cc (50 - 300). There were 4 paraganglioma (2 were functional), 2 seminomas, 1 leiomyosarcoma, 1 schwannoma and 1 lymphatic cyst. Caution was important, especially when dissecting the mass off the ureter and iliac vessels. We placed ureteric catheter in 7 patients and had to do nephrectomy in 1. Conclusion: Para aortic masses are technically challenging to manage, and should be attempted by surgeons with experience in laparoscopy after a good pre op imaging study. Consent should be taken for additional procedures.


   Mini-perc for renal calculi in pediatric patients: does size matter? A prospective randomised study Top

Jain Shrey, Mani Anil, Syal Sarita, Yadav Priyank, M. S. Ansari

SGPGI, Lucknow, Uttar Pradesh, India

Objective: To assess the safety, efficacy, and stone-free rate (SFR) of Mini percutaneous nephrolithotomy (mPCNL) and compare it with conventional PCNL (cPCNL) for management of renal calculi in pediatric patients under 18 years age. Patients and Methods: 50 paediatric patients with renal calculi were prospectively randomised into two groups. Group A, 28 patients managed by mPCNL. Group B, 22 patients who underwent cPCNL. The basic demographic profile and the stone characteristics were recorded for both the groups. The mean operating time, complications and SFR were compared between the two groups. Results: Both groups were comparable for preoperative parameters. The mean operating time was statistically significantly longer in Group A than Group B (p=0.04). On first session of PCNL the SFR for m-PCNL was 93.31% and for cPCNL, 94.2%, which was not significantly different. On re-look, SFR improved to 96.2% and 97.3% respectively. Episodes of haematuria and drop in Hb were more in cPCNL as compared to mPCNL[p=0.03]. Likewise, pain score on POD and POD1(p = 0.02 and 0.039), need of analgesia - intravenous acetaminophen(p = 0.017), perinephric extravasation(p = 0.034) and nephrostomy site leak (p-0.03) were all higher in cPCNL as compared to mPCNL. Although the hospital stay was longer in cPCNL as compared to mPCNL this was not statistically significant(p-0.244). Conclusion: Mini-Perc offers good outcomes with lower complications rates compared to the conventional technique even for larger stones. The size of tract influences the nature of complications such as higher rates of haematuria, lumbar pain and perinephric extravasation.

   Bleeding following standard vs mini percutaneous nephrolithotomy: A randomized controlled trial Top

A. Thakur, S. K. Devana, K. M. Parmar, R. S. Mavuduru, A. K. Mandal

PGIMER, Chandigarh, India

Introduction: Miniaturization of percutaneous nephrolithotomy (PCNL) was developed with the aim of reducing tissue trauma. Previous randomized controlled studies(RCT) comparing standard(SPCNL) and mini PCNL(mPCNL) have shown conflicting results. Materials and Methods: Prospective RCT was done from January 2018 to July 2019. Sample size was calculated with an alpha error of 0.05 and a beta error of 0.2. At a sample size of 60, power of the study was 86%. 400 patients were assessed and 60 patients were included with renal stone disease (size 1-3cms). Patients with active urinary tract infection, renal malformation, uncorrected coagulopathy, requiring more than one puncture were excluded. Patients undergoing PCNL were randomized into two groups, SPCNL (24Fr) vs. mPCNL (17.5 Fr). Blood loss was evaluated by measuring fall in haemoglobin and haematocrit on postoperative day(POD)1. Post-operative pain was evaluated by visual analogue score (VAS). Results: All the baseline preoperative variables were comparable in both the groups. SPCNL patients had significantly higher drop in hematocrit level as compared to mPCNL (4.6 vs. 3.1, p=0.02). Two patients in mPCNL group required blood transfusion. Mini PCNL patients had significantly less VAS scores at 6 hours (4.4 vs. 3.27, p=0.002) and POD 1 (2.83 vs. 2.10, p=0.001). Post op analgesic requirement was comparable in both the groups (33mg vs. 18mg morphine, p=0.22). Conclusion: Mini PCNL is associated with less post-operative bleeding and pain. However smaller tract size in mini PCNL doesn't guarantee safety from severe bleeding.

   Our experience with adult exstrophy-epispadias repair using a novel osteotomy technique Top

Katiyar Varun, Sharma Umesh, Goel Hemant, Jangira Vivek, Sood Rajeev

PGIMER Dr. RML Hospital, Delhi, India1

Introduction and Objectives: We present experience of our modified one-stage reconstruction of bladder exstrophy using a novel osteotomy technique which obviates the need for external fixation after classical osteotomy and minimizes the related morbidity. Methods: A total of 6 patients (5 males and 1 female) between ages 13 to 25 years, presenting with classic exstrophy of bladder and complete epispadias underwent detailed evaluation followed by single stage repair by a multispecialty team of orthopedic and urologic surgeons between September 2015 to December 2018. Bilateral superior and inferior Pubic osteotomy for closure of pelvis followed by single stage bladder closure, bladder neck reconstruction and epispadias repair was done in all patients. They were later discharged and followed up on outpatient basis for 6 months. All intraoperative complications, postoperative coarse and complications were followed and studied. Results: The mean age of patients was 18.6 years, mean hospital stay was 10 days. 2 patients developed minor surgical site infection which resolved with wound care One patient developed vesicocutaneous fistula which healed on prolonged catheter drainage. All except one female subject attained continence. All others have been doing well with good bladder function and urine flow (mean Qmax 20.7 ml/s) and low PVR (mean 20 ml) at 6 months follow up. Patients were up and about just 7 days after surgery, contrary to the prolonged immobilization needed after classical osteotomies. Conclusions: Surgical correction in bladder exstrophy subjects with bilateral superior and inferior pubectomy is a promising technique which achieves good results with decreased morbidity.



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