Robot-assisted complex urinary tract reconstruction using intestinal segments: redefining the paradigm.

Complex urinary tract reconstruction has significantly advanced with the increasing use of robot-assisted procedures. Robotic surgery aims to achieve the same outcomes as open surgery while minimizing morbidity by causing less blood loss, faster postoperative recovery, and reducing complications. This article shares our technique, challenges encountered, and experience of robot-assisted complex urinary tract reconstruction using intestinal segments. Between January 2020 to March 2022, 6 patients who underwent robot-assisted complex urinary tract reconstruction using intestinal segments at our centre were retrospectively reviewed. Demographic, clinical, and operative data were recorded. Patients underwent renal function tests, blood gas analysis, and radiographic imaging in the follow-up. Symptomatic and radiologic relief were the criteria for success. Out of 6 cases, three patients underwent ileal ureter replacement, two combined ileal ureter with augmentation ileo-cystoplasty and one augmentation ileo-cystoplasty alone. The mean age, estimated blood loss, length of hospital stay, and follow-up period were 32.6 years, 110 ± 13.1 mL, 7.0 ± 1.1 days, and 11.3 months, respectively. The indications for surgery were either benign ureteral stricture following lithotripsy or sequelae of genitourinary tuberculosis. No intra-operative complications were found. Clavien-Dindo grade-II and Grade-IIIa were found in three and one patient, respectively. During follow-up, none had compromised renal function or acidosis. Robot-assisted complex urinary tract reconstruction using intestinal segments is safe and offers the advantages of minimally invasive techniques. Techniques demonstrated in this article make these reconstructions feasible with good surgical and clinical outcomes.

Eosinophilic Leukemoid Reaction with Eosinophilic Tumor Tissue Infiltration as an Extermely Poor Prognostic Factor in Urinary Bladder Cancer- a Known Entity Revisited.

Eosinophilia can be a manifestation of a variety of causes such as infections, allergic reactions and autoimmune processes. Also, it is described in various solid malignancies in the presence of tumour eosinophilic infiltration. We report a patient of high-grade urinary bladder cancer with eosinophilic leukemoid reaction and tumour histopathology demonstrated diffuse infiltration of eosinophils. Though the entity is described to carry a good prognosis in literature, our experience is totally different as the patient deteriorated rapidly in a matter of days, was deemed inoperable in view of worsening performance status and was referred for palliative management.

Prospective audit of complications after ultrasonography-guided percutaneous nephrostomy for upper urinary tract obstruction using modified Clavien classification system.

INTRODUCTION: Percutaneous nephrostomy (PCN) is a commonly performed intervention in urology for various benign and malignant conditions causing upper urinary tract obstruction. We present a prospective audit of complications of ultrasonography (USG) guided PCN using modified Clavien classification system (mCCS). METHODS: The data were prospectively collected for 368 PCN performed in 344 patients from June 2015 to January 2017, for various benign and malignant diseases causing upper urinary tract obstruction. Patients were followed for 1 month, and complications arisen of PCN were noted. RESULTS: PCN was successful in 356 renal units. The 12 patients in which PCN failed was due to minimal pelvicalyceal dilatation and PCN was successfully performed after 48 h by a senior urologist. 207 patients had malignant disease and 161 patients had benign condition. Most common malignant disease was carcinoma cervix. 238 were noninfected while 130 had infected renal units. 62 (16.84%) patients had Grade I (self-limiting hematuria/cot/debris/fever). 37 (10.0%) patients had Grade II (7 - transfusion and 30 - urinary tract infection). 34 (9.2%) had Grade III a (repositioning/change/reinsertion of PCN tube under local anesthesia) and 4 (1.1%) had Grade III b (repositioning under anesthesia). 8 (2.2%) Grade IV a (Sepsis), 0 Grade IV b, and 0 Grade V complications were observed. CONCLUSION: USG-guided PCN is a safe, minimally invasive, and effective procedure for upper urinary tract diversion with a low rate of morbidity. Individual complications are within the threshold limits set by the American College of Radiology, the Society of Interventional Radiology. mCCS is well applicable and easily reproducible tool for reporting the complications of PCN.

Recurrent leiomyoma of the vulva mimicking peripheral nerve sheath tumour.

Leiomyoma, a benign monoclonal tumour, is very rarely found in extrauterine sites, especially in the vulval region. Histopathology of the soft tissue tumours affecting this region is similar and immunohistochemistry (IHC) may be essential to confirm the diagnosis. We report a case of a 63-year-old postmenopausal woman who presented with a recurrent vulval mass involving the clitoris and left labia majora with suspected urethral involvement. Although the wedge biopsy was reported as peripheral nerve sheath tumour, staining with smooth muscle actin clinched the diagnosis of leiomyoma, highlighting the importance of IHC for diagnosis.

In vitro effect of fosfomycin on multi-drug resistant gram-negative bacteria causing urinary tract infections.

BACKGROUND: Rising rates of resistance to antimicrobial drugs among Enterobacteriaceae limit the choice of therapeutic agents to treat urinary tract infections. In this context we assessed the in-vitro effect of fosfomycin against extended-spectrum beta-lactamases, AmpC beta-lactamases and carbapenemase-producing strains of Escherichia coli, Klebsiella pneumoniae, Enterobacter spp, and P seudomonas aeruginosa isolated from the patients with urinary tract infection (UTI) and also studied the effect of fosfomycin on their biofilm formation. MATERIALS AND METHODS: A total of 326 multidrug-resistant (MDR) isolates comprising of Escherichia coli, Klebsiella pneumoniae, Enterobacter spp, and P seudomonas aeruginosa from the urine samples of the patients with a diagnosis of UTI were included in the study. MIC 50 and MIC 90 were detected by agar dilution method and the capacity to form biofilm in the presence of fosfomycin by these MDR isolates was assessed by the tissue culture plate method. RESULTS: The MIC50 for meropenem (0.5 µgm/mL) and nitrofurantoin (32 µgm/mL) was within the susceptible range only for E. coli. Fosfomycin was the only antibiotic that inhibited 100% E.coli, 70% Klebsiella spp, and 50% Pseudomonas spp and 40% Enterobacter spp which included the extended-spectrum beta-lactamases producers. It showed a similar effect on carbapenemase producers and AmpC producers. Fosfomycin disrupted biofilm in 67% (n=141) E.coli, 74% (n=50) Klebsiella spp, 88% (n=27) Pseudomonas spp and 36% (n=23) Enterobacter spp at 24 hrs of incubation with a concentration of 2 fold dilution lower than that of the MIC. CONCLUSION: Fosfomycin showed a good inhibitory effect on the biofilms produced by the MDR organisms studied here.

Testicular and Epididymal Metastasis from Prostate Carcinoma: A Rare Manifestation of Common Disease.

Carcinoma prostate secondary metastasis to testicle and epididymis is rare. We report a case of metastatic carcinoma prostate in which testicular and epididymal metastasis were diagnosed incidentally in bilateral orchiectomy specimen. Testicular and para testicular structure should be properly evaluated for accurate staging of carcinoma prostate. Epididymis should always be included in bilateral orchidectomy specimen.

Hypoadiponectinemia, elevated iron and high-sensitivity C-reactive protein levels and their relation with prostate size in benign prostatic hyperplasia.

Elevated iron, high-sensitivity C-reactive protein (CRP) and hypoadiponectinemia are known to initiate tumour development. There is paucity of data regarding the above-mentioned parameters and their relation with prostate size in benign prostatic hyperplasia (BPH). The present study was designed to assess the levels of iron, hs-CRP and adiponectin levels and their association with prostate size in BPH patients. A total of 37 BPH cases and 36 controls were enrolled in the study. Iron, hs-CRP and adiponectin were estimated in both the groups. Iron and hs-CRP were significantly increased and adiponectin was significantly reduced in BPH cases when compared with controls. Iron (r = .397, p = .015), hs-CRP (r = .341, p = .039) and adiponectin (r = -.464, p = .004) were significantly associated with prostate size in BPH cases. Multivariate linear regression analysis showed that iron acts as predictor of prostate size in BPH (R2  = 0.395, ß = 0.526, p = .001). We conclude that iron and hs-CRP are elevated and adiponectin is reduced in BPH cases and associated with prostate size.

Sporadic bilateral synchronous multicentric papillary renal cell carcinoma masquerading as bilateral multifocal pyelonephritis.

Pyelonephritis is defined as an inflammation of the kidney and renal pelvis. The diagnosis is usually clinical. Acute multifocal bacterial nephritis is a rare form of pyelonephritis that is more severe and sepsis is more common. We report a patient who presented with fever and right-sided abdominal pain associated with right flank tenderness, suggesting right acute pyelonephritis. Bilateral multifocal pyelonephritis was diagnosed on ultrasonography, radionuclide renal scintigraphy and computed tomography. However, owing to non-resolution of symptoms, a biopsy was performed, which showed bilateral papillary renal cell carcinoma (PRCC). PRCC is known to exhibit multicentricity. To our knowledge, a case of bilateral multicentric PRCC masquerading as bilateral multifocal pyelonephritis has not been reported in the English literature. This case highlights the need to be vigilant while treating patients with focal lesions of the kidney as an inflammatory condition lest a malignancy should be missed.

Penile nodule with inguinal lymphadenopathy: Prostatic adenocarcinoma masquerading as penile cancer.

Although anatomically the penis is closely related to the prostate, penile metastasis from prostate cancer is an uncommon phenomenon. These patients usually present late in the course of the disease with wide spread metastasis. We report a patient who presented with a penile mass and inguinal lymphadenopathy. He was clinically diagnosed as a case of penile cancer but the penile mass as well as the inguinal lymphadenopathy was subsequently diagnosed to be metastases from carcinoma of the prostate.

Successful timely minimally invasive management of grade 4 renal injury in children: a report of two cases.

Expectant management of renal injuries has become the standard of care but most of such experience has been with adult patients. Although some recent reports suggest equally comparable results in pediatric populations too, there is a paucity of data. We report our experience with two children who sustained grade 4 renal injury due to blunt trauma, which was managed successfully by endourological intervention facilitating preservation of renal units and review the current literature.

Single-stage correction of urinary incontinence and vaginoplasty in a case of urethral coitus with vaginal agenesis.

Urethral coitus is a very rare entity which usually presents as urethral incontinence during intercourse and is most commonly seen with intact vagina. Only about 24 cases have been reported in the literature. A presentation in vaginal agenesis is exceedingly rare and poses the surgical challenge of restoring continence without interfering with sex life. Here we report a case of urethral intercourse with vaginal agenesis presenting with incontinence that we treated with McIndoe's vaginoplasty and urethral plication in a single stage, with satisfactory result. To the best of our knowledge, this method of reconstruction has not yet been reported for this condition.

Osseous metaplasia in renal cell carcinoma: report of a rare case.

Focal calcifications are frequently seen in renal masses including renal cell carcinoma (RCC). Osseous metaplasia, on the other hand, is a rare finding in RCC. We report a case of RCC with radiological evidence of speckled calcification that showed osseous metaplasia on histopathological examination. The clinical and pathologic differential diagnosis for this tumor is discussed along with a review of the literature on this unusual phenomenon.

Altered insulin sensitivity, insulin secretion and lipid profile in non-diabetic prostate carcinoma.

Insulin can influence cancer risk through its effect on cell proliferation, differentiation and apoptosis. Although hyperinsulinemia is considered as a risk factor in the pathogenesis of various cancers, the data related to insulin sensitivity, insulin secretion and lipid profile is lacking in non-diabetic prostate carcinoma cases. The present study was undertaken to evaluate lipid profile parameters and insulin sensitivity and secretion using surrogate markers derived from the measurements of fasting glucose and fasting insulin. The study group comprises 27 prostate carcinoma cases and 27 controls having similar age. Fasting serum insulin, glucose and lipid profile parameters were estimated in both the groups. Insulin sensitivity was assessed by Homeostasis model assessment of insulin sensitivity and Quantitative insulin sensitivity check index. Insulin secretion was assessed by insulinogenic index. Fasting serum insulin, insulinogenic index and LDL-cholesterol were significantly increased (p < 0.05) and HOMA-IS, QUICKI and HDL-cholesterol was significantly decreased (p < 0.05) in carcinoma cases compared to controls. PSA level was significantly associated with fasting insulin (R2 = 0.150, beta = 0.387, p = 0.046) and QUICKI (R2 = 0.173, beta = -0.416, p = 0.031). Fasting insulin was significantly correlated with triglyceride (r = 0.404, p = 0.037) and HDL-cholesterol (r = -0.474, p = 0.013). The present study concludes that hyperinsulinemia associated with reduced insulin sensitivity may play a role in the pathogenesis of prostate carcinoma.

Renal adenocarcinoma presenting as a groin swelling: a case report.

Renal cell carcinoma (RCC) is known to have myriad presentations due to the extremely vascular nature of the organ. RCC are known to metastasize extensively to various organs of the body. We report a case of a 70-years-old male who presented with multiple inguinal lymph node enlargements which on excision biopsy showed metastatic adenocarcinomatous deposit. Search for the primary revealed a RCC arising from the left kidney. Inguinal lymph nodal metastasis, an uncommon site of distant metastasis in renal neoplasm, as a fi rst clinical sign leading to the diagnosis is not yet reported in literature.

Adult Wilms' tumor masquerading as pyonephrosis: a diagnostic dilemma.

In the era of modern imaging, modalities like ultrasonography, computed tomography and magnetic resonance imaging diagnosis of renal mass lesions has become more accurate. Nevertheless, rare cases of renal adenocarcinoma and other primary renal tumors have been rarely reported to mimic pyonephrosis, renal abscess, perinephric abscess or tuberculosis. We report, for the first time in literature, a case of Wilms' tumor mimicking as a case of pyonephrosis. The incidence, possible causes and implications of such a misdiagnosis and the measures to avoid the same are discussed.

Application of evidence-based urology in improving quality of care.

Evidence-based medicine requires use of the best available evidence for optimal patient care. Increasingly scarce resources and escalating demands on time have led to emphasis on effective treatment. Opinion is slowly yielding to high-quality existent evidence. It is important that urologists adapt to these changes for them to deliver optimum care to the patients. This article discusses the levels of evidence, the nature of desirable evidence, means of assessing quality of clinical trials and meta-analysis and finally the practice of evidence-based urology with special reference to bedside evidence-based urology.