Evaluating efficacy of various operative procedures done in anterior urethral stricture using urethral stricture score.

CONTEXT: Scoring systems have been an important tool of clinical decision making in medicine. As scoring systems like Glasgow Coma scale have made a revolutionary change in stratifying the patient, in particular, clinical scenario. Wiegand et al. in 2012 proposed UREThRAL Score a novel method to quantify anterior urethral stricture. AIMS: The aim was to validate urethral stricture score (USS) for evaluating the efficacy of operative procedures. SETTINGS AND DESIGN: Study was done in a retrospective manner and includes patients operated for anterior urethral stricture by a single surgeon in tertiary care center over the period of 2008-2014. SUBJECTS AND METHODS: A total of 57 cases were included in this study who met the inclusion criteria, of these cases 7 underwent excision and primary anastomosis (EPA), 20 underwent preputial flap urethroplasty (PFUP), 22 underwent tunica albuginea urethroplasty (TAU), and rest 8 underwent scrotal flap urethroplasty (SFUP). Procedures were assigned different complexity level, and USS was compared with the particular procedure to see the relation between both. STATISTICAL ANALYSIS USED: Data were analyzed using ANOVA on SPSS software. RESULTS: Mean USS for EPA, PFUP, TAU, and SFUP in our study group was found to be 6.57, 8.95, 9.00, and 10.00, respectively, with an overall USS of 9.03, with a standard deviation of 1.56. USS was significantly associated with complexity. CONCLUSIONS: Mean USS increased with increase in surgical complexity indicating that higher USS correlates with more complex surgery. Strongest association between complexity and the individual parameter was found with location and length.

Desmoid tumour: a rare etiology of intestinal obstruction.

Intestinal obstruction is a frequently encountered entity in surgical practice. The signs & symptoms, many a times, are suggestive of the level of obstruction, making the diagnosis of obstruction evident. There are various causes of intestinal obstruction which diversify to an enormous extent, stamping on the famous paradigm for the mysterious nature of the abdomen being referred to as the Pandora's Box. In accordance with the above saying, we report a rare case of a desmoid tumour, presenting as intestinal obstruction, which entices us to strongly believe the same.

Evaluation of digital infra-red thermal imaging as an adjunctive screening method for breast carcinoma: a pilot study.

BACKGROUND: Early screening plays a pivotal role in management of breast cancer. Given the socio-economic situation in India, there is a strong felt need for a screening tool which reaches the masses rather than waiting for the masses to reach tertiary centers to be screened. Digital infra-red thermal imaging (DITI) or breast thermography as a screening test offers this possibility and needs to be carefully assessed in Indian scenario. METHODS: The study involved 1008 female patients of age 20-60 years that had not been diagnosed of cancer of breast earlier. All the subjects in this population were screened for both the breasts using DITI. Based on the measured temperature gradients (ΔT) in thermograms, the subjects were classified in one of the three groups, normal (ΔT ≤ 2.5), abnormal (ΔT > 2.5, <3) and potentially having breast cancer (ΔT ≥ 3). All those having (ΔT > 2.5) underwent triple assessment that consisted of clinical examination, radiological and histopathological examination. Those with normal thermograms were subjected to only clinical examination. RESULTS: Forty nine female breasts had thermograms with temperature gradients exceeding 2.5 and were subjected to triple assessment. Forty one of these which had ΔT ≥ 3 were proven to be having cancer of breast and were offered suitable treatment. Eight thermograms had temperature gradients exceeding 2.5 but less than 3. Most of these were lactating mothers or had fibrocystic breast diseases. As a screening modality, DITI showed sensitivity of 97.6%, specificity of 99.17%, positive predictive value 83.67% and negative predictive value 99.89%. CONCLUSION: Based on the results of this study involving 1008 subjects for screening of breast cancer, thermography turns out to be a very useful tool for screening. Because it is non-contact, pain-free, radiation free and comparatively portable it can be used in as a proactive technique for detection of breast carcinoma.

A prospective comparison of topical feracrylum citrate versus adrenaline as haemostatic agent in hypospadias surgery in children.

BACKGROUND: A comparative study of topical feracrylum citrate versus adrenaline to minimise haemorrhage-related complications in paediatric hypospadiac patients. PATIENTS AND METHODS: A total of 108 consecutive paediatric hypospadiac patients (48 in the study group and 60 control - random allocation) were studied. In the study group, 1% feracrylum citrate solution was used and adrenaline (1:100,000) in controls. RESULTS: Among the study group, average number of blood-soaked gauge pieces were 2.95/patient, correlating with average intraoperative blood loss of 14.74 ml. In controls, average blood-soaked gauge pieces were 4.83/patient corresponding to an average blood loss of 24.13 ml. The average amount of blood loss during surgery in the <5 years was 13.70 ml/patient in the feracrylum group, while the same in the adrenaline group was 23.45 ml. Average duration of surgery was 79 min in the study group, while the same in controls was 94 min/patient. Average number of cauterisations was 0.255/patient in the study group and 0.583/patient among controls. Postoperative haematoma was seen in 8% study group compared with 18% controls. Wound oedema appeared in 4.17% study group and 11.67% controls. Postoperative complications were higher among controls. CONCLUSIONS: Feracrylum is more efficient and safer topical haemostatic agent than adrenaline. It reduced the frequency of cauterisation and tissue damage, intraoperative blood loss, and postoperative complications.

Postmyomectomy gossypiboma: A surgical mishap.

Gossypibomas or retained surgical foreign bodies, although uncommon causes of abdominal lumps, still remain a major cause of concern for surgeons worldwide. Their early identification and treatment are mandatory to prevent morbidity as well as mortality. The major diagnostic dilemma still remains in the vagueness of presentation of this callous entity. We present a similar situation in which a 30-year-old lady, previously operated for a uterine myoma, reported to us with an intra-abdominal lump which on exploration turned out to be a surgical sponge.

A retrospective analysis of delayed complications of urethroplasty at a tertiary care centre.

Urethroplasty is commonly performed worldwide by reconstructive urologists and such a large scale practice is often faced with numerous complications, yet "complication based analysis" still persists as a gray area. Our study aims to provide an evaluation of long-term post-urethroplasty complications, after the five commonly practiced procedures, at our centre. 302 male patients with urethral strictures due to various etiologies were assessed preoperatively via retrograde urethrogram, urethrosonogram, and uroflowmetry. They were then subjected to different urethroplasty techniques viz. tunica albuginea urethroplasty (TAU), U-shaped prostato-bulbar anastomosis (USPBA), dorsal buccal mucosa graft urethroplasty, skin substitution urethroplasty and Dartos flap urethroplasty. Postoperatively, patients were assessed at regular intervals, regarding the occurrence of complications. The overall complication rate was 21% at 5 years follow-up, with the majority during the initial 2 years. Infection and restenosis were the major long-term complications (12%). Maximum complications were seen in patients, who underwent TAU and USPBA simultaneously followed by Dartos flap urethroplasty and minimum were seen with TAU. In conclusion, a meticulous post-urethroplasty follow-up reveals a wide range of long-term complications. The complication rate differs in accordance with the etiology, site and length of stricture as well as the reconstructive technique.

Comprehensive analysis of etiology on the prognosis of urethral strictures.

INTRODUCTION: Urethral strictures remain a reconstructive dilemma, due to high incidence of recurrence and less than satisfactory outcomes. Even experienced surgeons following strict surgical principles have not achieved optimal results, leading us to think whether the etiology of strictures dictate the outcome . We evaluated this "cause-effect" relationship highlighting the significance of the etiology on the overall prognosis of urethral strictures. MATERIALS AND METHODS: A total of 302 males with urethral strictures were assessed (both retrospectively and prospectively) over a period of ten years. The preoperative evaluation was performed by retrograde urethrogram, urethrosonogram, and uroflowmetry and categorized, based on etiology: a) as post traumatic, b) post infective, c) iatrogenic or d) unknown. Traumatic strictures were subjected to pelvic X-ray and sub-categorized into grades A, B and C, following the TILE classification. Patients were operated; with tunica albuginea urethroplasty for anterior strictures and U shape prostato-bulbar anastomosis for posterior strictures. RESULTS: Traumatic strictures accounted for 54% of cases. 127 of the 302 patients were treated using Tunica Albuginea Urethroplasty, while U shaped Prostatobulbar Anastomosis was performed on others. Post traumatic strictures had best outcome whereas post infective strictures had the worse outcome. Among strictures following pelvic fractures, TILE grades A and B had a better post operative course as compared to TILE C. Overall complication rate was 13.24%. CONCLUSION: Our study demonstrated that etiology of urethral strictures may play a vital role for the overall prognosis of urethral strictures.

Comprehensive analysis of etiology on the prognosis of urethral strictures

INTRODUCTION: Urethral strictures remain a reconstructive dilemma, due to high incidence of recurrence and less than satisfactory outcomes. Even experienced surgeons following strict surgical principles have not achieved optimal results, leading us to think whether the etiology of strictures dictate the outcome . We evaluated this "cause-effect" relationship highlighting the significance of the etiology on the overall prognosis of urethral strictures. MATERIALS AND METHODS: A total of 302 males with urethral strictures were assessed (both retrospectively and prospectively) over a period of ten years. The preoperative evaluation was performed by retrograde urethrogram, urethrosonogram, and uroflowmetry and categorized, based on etiology: a) as post traumatic, b) post infective, c) iatrogenic or d) unknown. Traumatic strictures were subjected to pelvic X-ray and sub-categorized into grades A, B and C, following the TILE classification. Patients were operated; with tunica albuginea urethroplasty for anterior strictures and U shape prostato-bulbar anastomosis for posterior strictures. RESULTS: Traumatic strictures accounted for 54 percent of cases. 127 of the 302 patients were treated using Tunica Albuginea Urethroplasty, while U shaped Prostatobulbar Anastomosis was performed on others. Post traumatic strictures had best outcome whereas post infective strictures had the worse outcome. Among strictures following pelvic fractures, TILE grades A and B had a better post operative course as compared to TILE C. Overall complication rate was 13.24 percent. CONCLUSION: Our study demonstrated that etiology of urethral strictures may play a vital role for the overall prognosis of urethral strictures.

Prognosis of urethral strictures following pelvic fracture urethral distraction defects--a single centre study.

INTRODUCTION: Urethral strictures remain a reconstructive dilemma due to high incidence of recurrence and unsatisfactory outcomes. Pelvic trauma remains the foremost etiology leading to morbidity. We evaluated this "cause-effect" relationship of pelvic trauma to stricture outcome, to replenish our understanding of contemporary urethral strictures and highlight significance of type, degree and influence of primary management of pelvic trauma on the overall prognosis of urethral strictures. MATERIALS AND METHOD: 163 male patients with urethral strictures, primary etiology being pelvic trauma, were assessed preoperatively followed by retrograde urethrogram, urethrosonogram, uroflowmetry, and then subjected to pelvic radiographs to identify presence and type of pelvic fracture, and further sub-categorize them into grades A, B and C, of TILE classification. Thereafter, 6 weeks later, these patients underwent urethroplasty. RESULTS: Of 163 patients having pelvic trauma, 80 fell under category A of TILE grading, whereas 55 were under TILE B and 28 under TILE C. Most common stricture location was membranous urethra. Success rates were 96-98% till 1 year follow up, but after two years, they declined to 93%. TILE A and B had a better post operative course as compared to TILE C. Overall complication rate was 20.25%. CONCLUSION: The magnitude of the impact of the type of pelvic fracture and its management has remained unexplored. Our representative study enunciates that these parameters play a vital role in the overall prognosis of urethral strictures and command due importance, to bridge the rift in this "cause-effect" relationship.

Urogenital fistulae: A prospective study of 50 cases at a tertiary care hospital.

INTRODUCTION: The misfortunate incident of formation of a urogenital fistula remains a major challenge for surgical urologists worldwide. Such fistulae may not be a life-threatening problem, but surely the women face demoralization, social boycott and even divorce and separation. The fistula may be vaginal, recto-vaginal or a combination of the two. The World Health Organization (WHO) has estimated that in the developing nations, nearly 5 million women annually suffer severe morbidity with obstetric fistulae being the foremost on the list. The objective of our study was to enunciate the patient demography, patient profile, incidence, type of surgery, as well as the long-term outcomes encountered in the management of all types of genital fistulae at a tertiary care centre. MATERIALS AND METHODS: 50 consecutive patients, attending the outpatient department with urogenital fistulae, were studied during the period of 5 years from July 2005 to July 2009. All female patients with complaints of urinary incontinence and fecal incontinence and dribbling, patients having a history of obstructed labor, radiotherapy, instrumental delivery, foreign body or trauma and with a history of hysterectomy (abdominal/ vaginal) and lower segment caesarean section (LSCS) were included. A thorough urological examination included a dye study using methylene blue, Renal function tests, X-ray KUB and intravenous urography (IVU). Cystoscopy along with examination under anaesthesia (EUA) were done to assess the actual extent of injury. All patients were subjected to appropriate surgical interventions via the same combination of surgeons . Post operatively, prophylactic antibiotics were administered to all patients and patients were managed till discharge and followed thereafter via regular outpatient visits for a period of 3 years. RESULTS: Age of patients ranged from 21 to 40 years. 64% patients hailed from rural areas, 76% were from the lower socio-economic strata, 40% illiterate and 69% were short Statured. Vesico vaginal fistulae (VVF) was seen in 64% cases of which 50% were due to obstructed labor, 19% cases post LSCS and 31% cases post total abdominal hysterectomy (TAH). 68% of urogenital fistulae were between 1 to 3 cms. We obtained a 75% cure rate in UVF, 87.5% cure rate in RVF while a 93.75% cure rate was observed in patients with VVF. 76% of all patients were cured while 8% had a recurrence, probably due to the large size of fistula. CONCLUSION: Genital fistula is preventable, yet it remains a significant cause of morbidity among females of reproductive age group. Despite facilities available, certain conditions like physical, social, economic, illiteracy, and a very casual attitude towards maternal health and children birth practices limit utilization of services for women. It is important that the modern health care providers should be aware of these aspects, so that they can recognize services that are appropriate and acceptable to the people. Thus, one must agree that in cases of urogenital fistulae, "prevention is better than cure".

Solo extracorporeal shock wave lithotripsy for management of upper ureteral calculi with hydronephrosis.

INTRODUCTION: The aim of this study was to evaluate extracorporeal shock wave lithotripsy (SWL) outcomes as a solo therapy in patients with upper ureteral calculi and varying degrees of hydronephrosis. MATERIALS AND METHODS: Eighty patients with upper ureteral calculi and a body mass index between 19.5 kg/m2 and 22.5 kg/m2 were included. They were categorized into 4 groups according to the severity of hydronephrosis as seen on ultrasonography and intravenous urography: group 1, no dilatation; group 2, mild dilatation; group 3, moderate dilatation; and group 4, severe dilatation of the pyelocaliceal system. The size of calculi, time to calculus clearance, success rate of solo SWL, and the need for additional therapeutic methods were recorded and compared between the four groups of patients. RESULTS: The median size of the calculi was 13.5 mm, and the mean time to calculus clearance was 56.0 +/- 24.2 days. In 71.3% of the patients, solo SWL was successful in the treatment of the calculi. Twenty-three patients required other therapies including double-J stenting, ureteroscopy, and nephrolithotomy. The patients without hydronephrosis and those with severe hydronephrosis (groups 1 and 4) showed a significant difference in the days to clearance of the calculus (mean, 31.7 days versus 85.6 days; P < .001). CONCLUSION: Patients with upper ureteral calculi and mild hydronephrosis can be effectively treated with solo SWL therapy. In those with moderate hydronephrosis, clearance takes longer or requires secondary interventions. In patients with severe hydronephrosis, we recommend alternative/adjunctive procedures.