Use of penile skin flap in complex anterior urethral stricture repair: our experience

Objective: To present our experience of treatment of complex anterior urethral strictures using penile skin flap

Study Design: Descriptive, case series

Place and Duration of Study: Department of urology Combined Military Hospital Malir Cantonment, Karachi and Armed Forces Institute of Urology, Rawalpindi from Jan 2012 to Feb 2014

Material and Methods: Total 18 patients with complex anterior urethral strictures and combined anterior and bulborurethral strictures were included. Patients underwent repair using Orandi or circularfacio-cutaneous penile skin flap depending upon the size and site of stricture. First dressing was changed after two days and an in dwelling silicone two way foleycatheter was kept in place for three weeks. Graft was assessed with regards to local infection, fistula formation and restricturing. Re-stricture was assessed by performing uroflowmetery at 6 months and 1 year. Ascending urethrogram was reserved for cases with less than 10 ml/sec Q max on uroflowmetery. Repair failure was considered whenthere was a need for any subsequent urethral procedure asurethral dilatation, dorsal visual internal urethrotomy, or urethroplasty

Results: Overall success rate was 83.3%. Of all the patients operated 1[5.6%] had infection with loss of flap, 3[16.7%] had urethral fistula and none had re stricture confirmed by uroflowmetery

Conclusion: In our study the excellent results of the penile skin flap both in anterior urethral strictures and combined anterior and bulbar urethral strictures are quite encouraging. It is easy to harvest and seems anatomically more logical

Forgotten ureteral stents: an avoidable morbidity

Objective: To assess the clinical presentation of forgotten ureteral stents and highlight the etiological factors resulting in the retention of these stents. Study Design: Observational study. Place and Duration of Study: Department of Urology, Armed Forces Institute of Urology, Rawalpindi, from January 2010 to June 2011

Methodology: Thirty-eight patients, with forgotten ureteral stents, retained for more than 6 months duration, were enrolled. A detailed evaluation was performed, along with the questions regarding the patients' opinion about the ureteral stents. They were specially asked whether they knew about the stents or were they formally informed regarding the stents. Subsequently, the patients were managed according to their clinical condition

Results: The male to female ratio was 2.1:1 aged 23 - 69 years, mean being 40.24 +/- 12.59 years. The time of presentation after the ureteral stenting was 7 - 180 months [mean = 28.89 +/- 33.435 years]. Seven patients [18.4%] reported with chronic kidney disease, including ESRD in two cases. Recurrent UTI was seen in 28 cases [73.6%], calculus formed over the stents in 20 cases [52.6%], and stent fragmented in 5 patients [13.1%]. Majority of patients, [n = 23, 60.5%], were not even aware of the placement of these stents while 8 [21.0%] knew but were reluctant about its removal. In 3 cases [7.8%], the relatives knew about the stent but never informed the patients. The stent had been removed in 2 cases [5.2%], but the other broken fragment was missed. One case [2.6%] each had a misconception about the permanent placement of the stents like cardiac stents and regarding degradation of the stents in situ

Conclusion: Forgotten ureteral stents produce clinical features ranging from recurrent UTI to ESRD. This preventable urological complication is primarily due to the unawareness or ignorance of the patients and their relatives regarding the stent

Comparison of circumcision by plastibell versus open method

Objective: The objective of the study is to compare circumcision by plastibell and open method in terms of bleeding, infection and cosmesis

Study Design: Randomized clinical trial

Place and Duration of Study: Surgical ward, Combined Military Hospital, Kharian from Aug 2011 to Sep 2012

Material and Methods: All individuals fulfilling inclusion criteria underwent circumcision in the operation theatre of CMH Kharian as indoor patients, under local anaesthesia and aseptic measures. In group 1, circumcision was done using plastibell where as in group 2, circumcision was done by open method

Results: Mean age in plastibell group was 3.37 months [SD=1.77] and in open group was 3.12 months [SD=1.33] [p=0.100]

In plastibell group 18% had bleeding however in open group 4% had bleeding [p<0.001]. In plastibell group 4% patients had infection. However in open group 15% had infection [p<0.001]

In plastibell group 82% parents were satisfied whereas 18% had extra skin, whereas in open group 96% parents were satisfied, 1% had extra skin and 3% had less skin [p<0.001]

Conclusion: Circumcision being a commonest surgical procedure demands careful selection of the operative procedure because plastibell method is superior in terms of post-operative infection whereas open method is better in terms of cosmesis and post-operative bleeding

Vesico-vaginal fistula: interposition flap, a key to success

Vesico-vaginal Fistula [VVF] is an abnormal communication between bladder and vagina that causes continuous discharge of urine into vaginal vault. The objective of this study is to describe current trends of aetiology and repair of Vesico-vaginal Fistulae. This is a Descriptive Study, conducted at Armed Forces Institute of Urology, Rawalpindi and Combined Military Hospital, Kharian between May 2001 and May 2007. All patients diagnosed as cases of vesico-vaginal fistulae were included in the study. Their demographic profile and repair success was determined. A total of 86 patients were included in the study. The mean age of the patients was 35.5 years [range 25-46]. Total abdominal hysterectomy was the most common cause [53% of the cases] followed by obstetric causes [43.92% of the cases]. Success rate of the surgery in the study was 97.5%. The common causes of vesico-vaginal fistula in this study were total abdominal hysterectomy and obstetric causes. The success rate was high, yet the attempt should be made to prevent this socially distressing condition

Role of urodynamic studies in evaluation of lower urinary tract symptoms

To emphasize the role of urodynamic studies in the evaluation of lower urinary tract symptoms and to describe the technique and report results of tracings from a urodynamic center in a tertiary care settings. Descriptive Study. This study was carried out at Armed Forces Institute of Urology, Rawalpindi, over thirty months from January 2003 to June 2005. sixty seven patients referred to the urodynamic centre of AFIU, Rawalpindi with complaints of urinary incontinence or voiding disorders were evaluated with conventional urodynamic tests. During cystometry, the detrusor activity, bladder sensation, bladder capacity and bladder compliance were measured with simultaneous urinary flow measurement in those who were able to void. Results were grouped into eight different types of urodynamic diagnoses. There were 51 females [76%] and 16 males [24%] patients. Majority of patients [48%] were in age group of 20-50 years. Ages ranged from 5-84 with a mean of 41.3 +/- 17.3 years. Majority of the patients found to have neuropathic bladder [25.3%] followed by patients with pure stress incontinence [23.9%]. In 38 female patients who presented with urinary incontinence, majority of them i.e. 16 [42.1%] were found to have pure stress incontinence on urodynamic evaluation while 11 [28.9%] patients had normal cystometric findings and 5 patients [13.1%] had hypersensitive cystometrogram signifying sensory urge incontinence while motor urge incontinence implying detrusor instability occurred in 1 patient [2.7%]. Urodynamic studies are useful in evaluation of lower urinary tract symptoms not responding to conventional medical treatment as they help clinician in identifying the underlying causes for the symptoms, and to quantify the related pathophysiological processes. Treatment of the underlying pathophysiology facilitates better treatment of symptoms

Obturator nerve block; transurethral resection of lateral bladder wall tumours [TUR-BT]

To evaluate the efficacy of obturator nerve block combined with spinal anaesthesia for prevention of adductor muscle spasm and its associated complications during transurethral resection of bladder tumours located at its lateral and inferolateral wall. A prospective study. At AFIU Rawalpindi. From January 2005 to December 2006. Material and method Fifty patients who had tumours at their lateral / inferolateral bladder wall of physical status ASA I - IV received spinal anaesthesia at 3rd or 4th lumbar space followed by obturator nerve block with a view to preventing adductor jerk during resection of tumour. There was complete suppression of adductor jerk in 45 [90%] patients and surgery was completed smoothly. Two patients [4%] had mild adductor jerk and additional sedation was required. The block failed to work in 3 [6%] cases and required conversion to general anaesthesia. Thus the procedure was successful in 94% [complete and partial suppression of jerk. We conclude that spinal anaesthesia combined with obturator nerve block is an effective technique for preventing adductor jerk during TUR-BT, thus avoiding intra-operative and post operative complication

Metastatic malignant Pheochromocytoma of adrenal gland

Malignant pheochromocytoma is a rare disease with a high mortality. Surgical removal is usually curative while chemotherapy and radiotherapy are palliative treatments. A case of metastatic malignant pheochromocytoma of the right adrenal gland is presented who had fluctuating blood pressure with episodic headache and raised urinary VMA levels. Thoraco-abdominal resection of the tumour resulted in control of blood pressure and patient was asymptomatic at 4 months follow-up

Tubularized incised plate urethroplasty for various types of hypospadias

To report out short term results of hypospadias repair using Tubularised Incised Plate [TIP] Urethroplasty as described by Snodgrass for various types of hypospadias. A cohort of 62 patients comprising various types of hypospadias [62% distal penile, 30% mid penile and 8% proximal penile] underwent Snodgrass repair by one surgeon [F.A.] from June 2001 to November 2005. Age of the patients ranged from 1 to 20 years, the modal age being 3.2 years. There was no chordee in 90% of the cases whereas mild to moderate chordee was present in the remaining 10%. Urethroplasty was done by tubularization of the incised urethral plate as described by Snodgrass with coverage of the suture line by vasclarized dartos layer for water proofing. Chordee, if persisted after degloving of the penis, was corrected by dorsal placation. Patients were followed postoperatively on day 5, one month and subsequently on three monthly basis for a year. On the mean follow up of six months 46 patients [74%] achieved good functional and cosmetic results, with normal looking penis and ability to void urine with good forwardly directed stream. Complications were observed in 16 patients [26%]. The most common complication was urethrocutaneous fistula in 14 [22%]. Out of these 8 patients had minor leak which closed without requiring any further surgical intervention by regular urethral dilatation. The remaining 6 patients required re-operation for closure of the fistula. 2 patients had glans dehiscence which required re-operation 6 months later. Another 2 patients developed meatal stenosis which settled with regular post-op dilatation. So, the complications requiring surgical intervention was seen in 8 patients only. TIP Urethroplasty is a simple single stage procedure applicable for the majority of the hypospadias including mid and proximal hypospadias and redo cases where urethral plate is intact. It provides excellent functional neo-urethra, cosmetically normal looking glans and vertically oriented slit like meatus with lesser complication as compared to other single stage procedures