Outcome analysis of tumors in undescended testes--a single center experience of 15 years.

OBJECTIVE: To present our experience in managing tumors in undescended testes (UDT) in the last 15 years at our institute, in an attempt to understand the tumor behavior and the optimum approach to management in these patients. METHODS: This is a retrospective review of all patients with tumors in UDT who had registered and undergone treatment at our institute in the last 15 years. The available records of 50 of these patients were reviewed with respect to the presentation, pathologic type, treatment schedule followed, and the survival and recurrence statistics. RESULTS: There were 23 patients with seminomatous and 27 with nonseminomatous germ cell tumors. The median follow-up was 21 months (range, 4-180). The 5-year recurrence-free survival was 77.5% in patients receiving chemotherapy first and 59.5% in patients being operated first. There were 4 disease-related deaths in our patients. The 5-year overall survival estimates were 100% for stage I disease, 93.75% for stage II disease, and 76.10% for stage III disease. CONCLUSION: Most patients with UDT still presented at a higher stage, that is, stage II or stage III disease. Patients receiving chemotherapy first had lesser recurrences than those being operated first. Overall survival was dependent on the stage at presentation and comparable with the rates commonly seen for germ cell tumors in the normally descended testes.

A rare case of adult diphallus with anorectal malformation.

We present the case of a 24 year old man who presented with acute urinary retention and found to have diphallus with vertical duplication of penis. Superior phallus was well developed without any urethral meatus whereas inferior phallus was rudimentary but with patent urethra. History of erection was present in superior phallus only whereas patient was voiding urine from inferior phallus. It was associated with anorectal malformation and bilateral pelvic ectopic kidneys. Patient was managed by suprapubic catheter placement and planned for penile and urethral reconstructive surgery. Diphallus very rarely present in adulthood and vertical duplication is very unusual.

Perioperative outcome of initial 190 cases of robot-assisted laparoscopic radical prostatectomy - A single-center experience.

OBJECTIVE: To analyze the perioperative outcome of the first 190 cases of robot-assisted laparoscopic radical prostatectomy performed at our center from July 2006 to December 2010. MATERIALS AND METHODS: Operative and recovery data for men with localized prostate cancer undergoing robot-assisted radical prostatectomy at our center were reviewed. All surgeries were performed using the 4-arm da Vinci-S surgical robot. Preoperative data included age, body mass index (BMI), prostate specific antigen (PSA) level, prostate weight, biopsy Gleason score and TNM staging, while operative and recovery data included total operative time, estimated blood loss, complications, hospital stay and catheter time. These parameters were evaluated for the safety and efficacy of this procedure in our center. RESULTS: The mean age of our patients was 65 ± 1.2 years. The mean BMI was 25.20 ± 2.88 and the median PSA was 14.8 ng/ml. Majority of our patients belonged to clinical stage T2 (51.58%). The mean total operative time was 166.44 ± 11.5 min. Six patients required conversion to open procedure and there was one rectal injury. The median estimated blood loss was 302 ± 14.45 ml and the median duration of hospital stay was 4 days. The overall margin positivity rate was 12.63%. CONCLUSION: Despite our limited robotic surgery experience, our perioperative outcome and complication rate is comparable to most contemporary series. Robot-assisted laparoscopic prostatectomy (RALP) is easy to learn and provides the patient with the benefits of minimally invasive surgery with minimal perioperative morbidity.

Hybrid minimally invasive urethroplasty for pan-anterior urethral strictures: initial results.

INTRODUCTION: To describe our minimally invasive hybrid technique for treating pan-anterior urethral stricture. PATIENTS AND METHODS: From February 2009 through November 2011, 12 patients with pan-anterior urethral stricture were operated on in our unit. The bulbospongiosus muscle was mobilized on one side, and a 2.5-cm dorsolateral bulbar urethrotomy was made. A full-thickness cold knife optical internal urethrotomy was made to reach the corpus cavernosum as graft bed. A 14- to 16-cm-long, 15- to 16-mm-wide buccal/lingual mucosa graft was harvested and sutured dorsally at the site of urethrotomy, and then distally at the meatus along with meatoplasty. RESULTS: The mean operating time was 91.66 min. The average hospital stay was 2.4 days. The Foley catheter was removed after 3 weeks. The mean Q(max) preoperatively and postoperatively was 5.5 ± 1.87 and 18.83 ± 2.04 ml/s, respectively. Our mean follow-up was 18.5 ± 6.92 (6-32) months. CONCLUSIONS: Our hybrid technique provides good short-term results while promoting minimal urethral mobilization and graft vascularity.

Robotic-assisted inguinal lymph node dissection: A preliminary report.

Penile cancer with inguinal lymph node metastasis is a common cancer in India. Open inguinal lymphadenectomy is the gold standard treatment of metastatic inguinal lymph nodes. We report our experience and technique of robotic assisted inguinal lymph node dissection in two patients presented with palpable inguinal lymph nodes, which to our knowledge is the first reported case series from India.

Primary tuberculosis of glans penis after intravesical Bacillus Calmette Guerin immunotherapy.

A 55-year-old male with carcinoma in situ of urinary bladder was treated with weekly intravesical injections of Bacillus Calmette Guerin (BCG) vaccine. Three days after the sixth injection, he developed low grade fever and multiple grouped punched out, 2-3 mm ulcers around meatus and corona glandis. In addition, multiple, firm, indurated, nontender papules and few deeper nodules were present on the proximal part of glans penis, along with bilateral enlarged, matted and nontender inguinal lymph nodes. There was no history suggestive of sexually transmitted diseases and high risk behavior. Chest X-ray was within normal limits, and Mantoux, Venereal Disease Research Laboratory (VDRL) and HIV antibody tests were negative. The biopsy from the penile ulcer revealed epithelioid cell granuloma with Langhans giant cells. Fine needle aspiration cytology from the lymph node also revealed epithelioid cell granuloma and acid fast bacilli on Ziehl Neelsen's stain. The tissue biopsy grew Mycobacterium tuberculosis. The BCG immunotherapy was stopped and patient was treated with four drug antitubercular therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide in standard daily doses along with pyridoxine. The edema resolved and the ulcers started healing within 2 weeks, and at 6 weeks after starting antitubercular therapy almost complete healing occurred. To the best of our knowledge, we describe the first case of an Indian patient with BCG induced primary tuberculosis of penis after immunotherapy for carcinoma urinary bladder and review the previously described cases to increase awareness of this condition in dermatologists and venereologists.

Correlation between the preoperative serum prostate specific antigen, Gleason score, and clinical staging with pathological outcome following robot-assisted radical prostatectomy: an Indian experience.

OBJECTIVES: To correlate the preoperative serum prostate specific antigen (PSA), Gleason score, and clinical staging with pathological outcome following robot-assisted radical prostatectomy (RARP) in Indian men with clinically localized cancer prostate. MATERIALS AND METHODS: A prospective study analysis was done for 166 consecutive patients of prostate cancer who underwent RARP at our center from June 2006 to October 2009. Preoperative workup included serum PSA, biopsy Gleason score, and clinical staging. The preoperative parameters were correlated with final Gleason score, capsular penetration, seminal vesicle involvement, and lymph node status on final histopathology. RESULTS: The mean age was 64 years (range: 50-76 years) with mean and median PSA of 17.98 ng/ml (range: 0.3-68.3 ng/ml) and 12.1 ng/ml, respectively. With increase in preoperative Gleason score, chance of organ confinement decreases (P=0.002) and capsular penetration increases (P=0.004) linearly. With increasing serum PSA, there is linear decrease in trend of organ-confined disease (P=0.03) and increased chances of seminal vesicle involvement (P=0.02). Patients with higher clinical stage have less probability of localized disease (P=0.007) and more chances of capsular penetration (P=0.04) and seminal vesicle involvement (P=0.004). CONCLUSION: Our data suggest that patients with higher preoperative serum PSA, Gleason score, and clinical stage have more chances of advanced pathological stage following RARP.

Renal tumors presentation: changing trends over two decades.

PURPOSE: We have analyzed the changing trends in surgical treatment of renal tumors over the last 2 decades with regard to age incidence, presentation, incidental detection, and histopathology. MATERIALS AND METHODS: Records of renal tumors were analyzed from January 1, 1988 to December 31, 2007. Data were split into 4 parts based on a 5-year time period, 1 for each cohort of patients: cohort 1 (1988-1992)-103 patients, cohort 2 (1993-1997)-161 patients, cohort 3 (1998-2002)-243 patients, and cohort 4 (2003-2007)-304 patients. A comparative study was performed with regard to age incidence, presentation, incidentallomas, histopathology, and management with statistical analysis. RESULTS: Out of 811 renal tumors, 17.63% cases were benign and 82.37% were malignant. In the first cohort, 34.95% cases were detected in the seventh decade as compared with cohort 4 in which these were detected in the sixth (34.86%) and fifth decades (21.38%). Incidentallomas increased from 11 (10.67%) in cohort 1 to 84 (27.63%) in cohort 4 (P = 0.001). The cases of surgically treated tumors increased in number from 103 to 304 in cohort 4. Among the presenting features, incidence of weight loss, flank pain, and lump decreased while other clinical syndromes were constant. Only open radical nephrectomy was performed in the first 2 consecutive timeperiods. Laparoscopic radical nephrectomy was increasingly used in cohort 4 as compared with cohort 3 (121 vs 32, respectively). Similarly, open nephron sparing surgery (NSS) was increasingly used in cohort 4 as compared with cohort 3. Among the histopathologies, clear cell carcinoma was most common (73.35 %), but Fuhrman grading showed a trend toward more cases detected with grade 1 and 2 in cohort 4; 23.73% and 61.86%, respectively, as compared with 15.85% and 45.12% in cohort 1 (P = 0.001); more T1 tumors were detected (63.42% in cohort 4 as compared with 41.46% in cohort 1). CONCLUSIONS: A majority of renal tumors presented as symptomatic tumors. Recently, tumors are being detected at an early stage and grade; in the younger patients, with an increasing trend of laparoscopic and open NSS.

Transpubic urethroplasty for complex posterior urethral strictures: a single center experience.

AIM: To review our experience and outcome of transpubic urethroplasty for complex posterior urethral strictures. PATIENTS AND METHODS: 19 patients, mean age 17.8 (6-35) years, were treated with transpubic urethroplasty over the last 6 years. All had traumatic etiology (15 due to road traffic accidents and 4 due to falls from height). Mean stricture length was 4.4 (3.0-6.0) cm. All had a history of some intervention earlier. Three had rectourethral fistula, and 2 sinus tract in perineum which was connected to the periurethral cavity. One had a long fistulous tract connected through the anus to the anterior abdominal wall. One patient each had urethrocutaneous fistula, periurethral cavity and osteomyelitis of the pubic bone. RESULTS: 16 of 19 (84.2%) patients had excellent outcomes with no evidence of stricture. Three had acceptable outcomes with some evidence of stricture. The mean operative time was 3.2 (2.5-4.0) h and average blood loss was 650 (500-900) ml. The mean hospital stay was 7.6 (6-12) days and average follow-up was 30 (7-66) months. Two patients developed mild wound infection. One patient each developed epididymoorchitis, perineal hematoma, fecal fistula and urine leak. One patient failed to void, and one patient developed erectile dysfunction. CONCLUSION: Transpubic urethroplasty is an excellent approach for patients with complex posterior urethral strictures.

Outcome of end-to-end urethroplasty: single-center experience.

OBJECTIVE: We review our experience of end-to-end urethroplasty for urethral strictures performed during the last 6 years. MATERIAL AND METHODS: From September 2001 to December 2006, 138 male patients underwent anastomotic urethroplasty at our center. Mean age was 28.1 years (range 6-71), average stricture length was 2.2 cm (range 0.7-6.0). One hundred and one patients (73.2%) had obliterative stricture while 37 (26.8%) still had some urethral passage. Ninety (65.2%) had a history of previous intervention. Sixty patients (43.5%) had associated complicating factors like urethrocutaneous fistula, rectourethral fistula, vesical calculus, blind tract and cavities, bony deformity, or urinary tract infection. RESULTS: The mean operative time was 92 min (range 60-240). Average follow-up was 26.7 months (range 6-60). One hundred and fourteen (82.6%) had excellent outcome, 18 (13%) had acceptable outcome and 6 (4.3%) failed to respond. Seventeen patients developed complications: 5 developed wound infection, 3 epididymorchitis, 2 failed to void, 2 each had incontinence and perineal hematoma, and 1 each had erectile dysfunction, accidentally pulled his catheter out and had urethrocutaneous fistula. CONCLUSION: End-to-end urethroplasty is an ideal procedure for managing strictures of bulbous and posterior urethra in properly selected cases.

Midline intraprostatic cyst: An unusual cause of lower urinary tract symptoms.

Symptomatic prostatic cyst presenting as obstructive lower urinary tract symptoms (LUTS) is an infrequent diagnosis in males. Midline cysts are much more likely to obstruct the bladder outlet. We report our experience with four such cases in the last one year, along with a short review of the literature. Two of these cases had additional presenting symptoms besides LUTS - febrile Urinary tract infection (UTI) with perinephric abscess and primary infertility. One case had an anterior midline prostatic cyst which is an extremely rare entity. The remaining three had midline posterior cysts. All cases were treated with transurethral marsupialization, had good relief of symptoms and no adverse effects.

Purple urine bag syndrome: a rare clinical entity in patients with long term indwelling catheters.

An elderly gentleman, on urinary drainage catheter for 3 months developed a purple discoloration of the urinary bag with the urine inside remaining clear. He was found to have a urinary tract infection with a strain of E. coli manifesting as a rare clinical entity reported in literature as the "Purple urine bag syndrome".

Retroperitoneoscopic adrenalectomy for phaeochromocytoma in a morbidly obese patient: a case report.

A 38-year-old morbidly obese lady (BMI-46 kg/m(2)) was diagnosed with a right adrenal phaeochromocytoma. She successfully underwent retroperitoneoscopic adrenalectomy using a 3-port technique incurring a blood loss of 110 ml. Postoperatively her recovery was rapid and uneventful with stabilisation of blood pressure and relief of symptoms, thereby emphasising the safety and efficacy of retroperitoneoscopic adrenalectomy in morbidly obese patients.

Management of an unusual case of atypical Mayer-Rokitansky-Kuster-Hauser syndrome, with unilateral gonadal agenesis, solitary ectopic pelvic kidney, and pelviureteric junction obstruction.

Congenital absence of uterus and vagina, Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, is mullerian agenesis and is the second most frequent cause of primary amenorrhea. Only atypical form of MRKH (type B) is associated with renal skeletal and ovarian abnormalities. We report the management of an unusual case of atypical MRKH, unilateral gonadal agenesis, and solitary ectopic pelvic kidney with pelviureteric junction obstruction (PUJO). After doing thorough Medline search, to the best of our knowledge, this is the first case reported with this combination.

Unilateral renal lymphangiectasia: imaging appearance on sonography, CT and MRI.

Lymphangiomas are benign tumors of unknown etiology often seen in children, involving the neck (75%), and axillary (20%) region, but rarely the kidney [Zapzalka et al. (2002) Lymphangioma of the renal capsule. J Urol 168:220.]. We report a case of unilateral renal lymphangiectasia, where the diagnosis was made on imaging.

Open nephron-sparing surgery in renal tumors with normal contralateral kidney: A single centre experience of 8 years.

INTRODUCTION: We present our eight-year experience with open nephron-sparing surgery (NSS) in renal tumors with contralateral normal kidney to assess its oncological efficacy and safety. MATERIALS AND METHODS: Thirty-six patients undergoing open NSS for small localized renal tumors with normal contralateral kidney from January 1998 to August 2006 were studied regarding demographic, clinical and pathological characteristics along with long-term follow-up. RESULTS: The mean age was 48.28 +/- 9.5 years. The mean tumor size was 3.72 cm (range 1.5-6). The following surgeries were performed: Wedge resection-13, partial polar nephrectomy-15, segmental resection-eight. The following techniques were used for vascular control: clamping and cooling-eight, warm ischemia-12, a novel technique of serial encirclage-16. The mean warm ischemia time was 23.2 +/- 3.2 min. The mean operating time was 190.07 +/- 11.3 min. The mean estimated blood loss was 331 +/- 17.4 ml. The majority of renal tumors were renal cell carcinoma (97.22%). There were no positive surgical margins. There were no major intraoperative and postoperative complications. The mean follow up was 52.1 months (range 4-80) with no case showing progression to renal insufficiency (defined as serum creatinine > 2 mg/dl). There was only one local recurrence. However, four distant metastases were reported. The five-year cancer-specific survival, recurrence-free survival and overall survival were 94.4%, 88.88% and 86.11% respectively. CONCLUSIONS: In patients with solitary, small localized, unilateral renal tumors with normal contralateral kidney, elective open NSS is feasible, safe and provides excellent long-term local control and oncological efficacy with functional benefits.

Reconstructive surgery for the management of genitourinary tuberculosis: a single center experience.

PURPOSE: We evaluated the role of surgery for genitourinary tuberculosis with special emphasis on reconstructive procedures. MATERIALS AND METHODS: Case records of 241 patients with genitourinary tuberculosis who underwent surgery at our center during a period of 17 years were reviewed. Clinical features, organ involvement, investigations, treatment and outcome of therapy were studied. RESULTS: There were 129 males and 112 females with a mean age of 34.6 years. The most common presentation was irritative voiding symptoms. Azotemia was seen in 54 (22.4%) cases. The most commonly involved organ was the kidney in 130 (53.94%) cases. Preoperative bacteriologic diagnosis was confirmed in 70 (29%) cases. All patients received antitubercular drug therapy for 9 months. A total of 248 procedures, including 33 endoscopic, 87 ablative and 128 reconstructive, were performed with some patients requiring more than 1 procedure. Early complications, which mainly involved the bowel, were seen in 19 (7.88%) cases. Bacteriologic cure was achieved in all culture positive cases. Renal functional parameters stabilized or improved in 44 of 54 patients (81.5%) in whom they were deranged at presentation. CONCLUSIONS: Genitourinary tuberculosis is common in developing countries. Diagnosis is often delayed because of late presentation and many patients present with cicatrization sequelae. A combination of antitubercular drug therapy and judicious surgery achieves satisfactory results in the majority of cases. With improved antitubercular drug therapy and experience with the use of bowel segments in the urinary tract, more reconstructive procedures are being performed with satisfactory outcomes. In patients who undergo reconstructive procedures, a rigorous and prolonged followup is necessary.

Suture foreign body granuloma masquerading as renal neoplasm.

Foreign body granulomas and pseudotumors due to retained surgical linen are well known in surgical practice. These lesions usually correspond to the actual size of residual foreign body and have characteristic presentation according to the anatomy involved. Renal suture granuloma is a rare postoperative complication of renal surgery due to persistence of sutures used to close the pelvicalyceal system/nephrotomy incisions and usually present as incidentally detected small mass lesions. This case of a suture foreign body granuloma presenting with hematuria, large peripheral mass lesion and characteristic computed tomography picture of renal cell carcinoma confounded the diagnosis and underwent laparoscopic radical nephrectomy. In retrospect, such lesions warrant the use of selective needle biopsy and intraoperative frozen section confirmation to clinch diagnosis. Mass lesions occurring in a previously operated kidney should have granuloma as a differential diagnosis.