Comparison of mean operative time in patients undergoing Ho: YAG laser lithotripsy and pneumatic lithotripsy in ureterorenoscopy for ureteric calculus.

OBJECTIVE: To compare the mean operative time (MOT) in patients undergoing Ho: YAG laser lithotripsy (LL) and pneumatic lithotripsy (PL) for ureteric stones. METHODS: This randomized study was conducted at Armed Forces Institute of Urology (AFIU) Rawalpindi, Pakistan from July 2016 to November 2018. Non probability consecutive sampling technique utilized to enroll 60 patients of both gender aged 18-60 years, having ureteric calculus ≤1.5cm. Randomization was done into group I (LL) and II (PL) via computer generated number tables. Six Consultant Urologists performed surgeries under spinal anesthesia utilizing Swiss Lithoclast® Master (EMS+ S.A. Switzerland) in group II and holmium laser fiber (365µm, 8-10Hz, 9.6-16W, 2100nm wavelength) in group I respectively. MOT was noted from insertion of cystoscope till removal out of meatus. Data obtained was analyzed through IBM SPSS 24.0. RESULTS: Analysis involved 60 patients (30 each group) having similar baseline characteristics (age, gender, laterality, location). There was statistically significant different MOT between LL & PL (25.48±6.99 vs 34.83± 7.47 minutes, p < 0.001). Data stratification with respect to age, gender, laterality and stone location revealed similar trend. Lithotripsy technique significantly affected MOT (p < 0.001) on Multiple Linear Regression Analysis. CONCLUSIONS: Ho: YAG LL is an efficient technique when compared with PL in terms of MOT for ureteric stones.

Mini PCNL: A viable single stage treatment for pediatric nephrolithiasis in resource limited countries.

INTRODUCTION: There is increasing enthusiasm for the value of mini PCNL for pediatric stone clearance. In developing countries, it is important to arrange a single stage treatment as a significant proportion of patients do not comply with repeated treatments, such as SWL. OBJECTIVE: To assess the safety, feasibility and outcomes of Mini PCNL in a pediatric cohort. MATERIALS AND METHODS: Retrospective analysis was performed of all paediatric patients undergoing Mini-PCNL at our institute between December 2016 and December 2019. Data was collected on stone size, stone clearance rate, complications, fluoroscopic exposure, mean procedural time and length of hospital stay. Follow up data included imaging to assess stone free status at 1 and 3 months postoperatively. RESULTS: Mini PCNL was performed in 113 pediatric patients, a total of 135 procedures, accounting for bilateral disease in 22. The age range was from 1 to 14 years with a mean age of 8.45 ± 3.14 years. The mean stone burden was 2.1 ± 0.4 cm. Partial and complete staghorn stones were observed in 7 and 3 patients, respectively. The mean operative time was 63.8 ± 13.2 min (range: 25 min to 116min) and mean length of stay was 4.3 ± 2.2 days. Primary stone clearance was achieved in 91.1% (123 patients). Ancillary procedures were undertaken in 10 patients resulting in a secondary clearance rate of 97.0% (131 patients) at 3 months. Complications occurred in 16.3% (22 patients) using the modified Clavien Classification. Metabolic abnormalities were seen in 56.7% of patients with hypocitraturia and hypercalciuria being the most common abnormalities. DISCUSSION: Our study reports a clearance rate of 91.1%, whereas, Zeng et al. documented a stone clearance rate of 80.4%. This contrast may be attributed to the difference in followup imaging protocols of the two studies and the energy source used for fragmentation. The incidence of complications with PCNL ranges from 10.6% to 36.3%, we found complications in 16.3% of our cohort. Our study is limited due to its retrospective design with a short follow-up protocol. Computed tomography being gold standard for qualitative and quantitative assessment of stone burden was not used in all patients to assess the preoperative stone size. Furthermore, postoperatively stone clearance was determined on the basis of ultrasound and x-ray films that could limit the accuracy of our stone clearance rate. CONCLUSION: Our study suggests that mini PNCL in pediatrics patients is an effective single stage treatment for definitive stone clearance with an acceptable complication risk.

Pure xanthine pediatric urolithiasis: A cause of acute renal failure.

Xanthine urolithiasis is usually a benign condition, easy to prevent or cure by appropriate alkalinization, forced hydration and restriction of dietary purines if diagnosed early. When unrecognized, xanthinuria can lead to end-stage renal failure or nephrectomy.

Renal endometriosis mimicking a renal tumor in a pregnant patient.

Renal endometriosis, if progressed is a serious localization of disease burden that can lead to urinary tract obstruction, with subsequent hydronephrosis leading to potential kidney loss. Diagnosis is elusive and relies heavily on clinical suspicion as endometriosis can occur with both minimal and extensive disease. Management technique varies but the goal is to salvage renal function and disease burden.

Classical prone percutaneous nephrolithotomy in a solitary functioning kidney with severe kyphoscoliosis.

Percutaneous nephrolithotomy (PCNL) is one of the important options in the management of large (>2 cms) and complex renal calculi. Traditionally the prone position has been used to access the pelvicaliceal system. It has its advantages and disadvantages as well. Several modifications to this position have been suggested and reported by several urologists. We had performed PCNL in an elderly female in classical prone position with severe kyphoscoliosis and solitary functioning kidney.

Left renal mass with venous extension in hemi-azygous vein.

Extension of renal mass (RM) along venous drainage pathways is a well-recognized entity. All previously reported cases of RM show inferior vena cava (IVC), left renal vein and azygous vein involvement. We report a 55-year-old man who had left RM arising from the upper pole with invasion in left renal vein, IVC and hemi-azygous vein. To our knowledge, we report the first case of RM with venous extension in hemi-azygous vein.

Are we performing a lot of simple nephrectomies?

OBJECTIVE: To assess the frequency of simple nephrectomies for benign diseases and compare it with the frequency of nephrectomies for malignant diseases. METHODS: The observational study was conducted at the Armed Forces Institute of Urology, Rawalpindi, Pakistan, from October 2008 to September 2011, and comprised patients undergoing simple nephrectomy for benign disease who were followed up for one year. This was compared to all the other urological procedures performed during the study period, including nephrectomies for malignant diseases. Indications and the post-operative sequel of simple nephrectomies were documented. SPSS 16 was used for data analysis. RESULTS: Of the total 7518 procedures, 1995(26.5%) were open cases. A total of 295 nephrectomies were performed during this period, out of which 203 (68.8%) were simple nephrectomies for benign disease and 92 (31.1%) were radical nephrectomies for malignant causes. Simple nephrectomy (203 cases) represented 2.7% of the total and 26.5% of the open procedures. In contrast, the radical nephrectomies for malignant disease (92 cases) represented 1.2% and 4.6% respectively. Among the 203 cases of simple nephrectomy, the male-to-female ratio was 2.27:1 with 141(69.5%) males and 62(30.5%) females. The mean age was 40.21 + 17.243 years (range: 4-84 years) The most common indication of simple nephrectomy was non-functional kidney due to renal calculus disease 101(49.7%). This was followed by pelvi-ureteric junction obstruction causing renal damage 31(15.2%), chronic pyelonephritis 24(11.2%) and pyonephrosis 15(7.38%). Two (0.98%) patients had a fatal outcome.. CONCLUSIONS: The percentage of nephrectomies for benign diseases was more than the malignant diseases. Simple nephrectomies are being performed in a large percentage, indicating the advanced stage of benign diseases at the time of presentation.

Examination of CK2α and NF-κB p65 expression in human benign prostatic hyperplasia and prostate cancer tissues.

Protein kinase CK2 plays a critical role in cell growth, proliferation, and suppression of cell death. CK2 is overexpressed, especially in the nuclear compartment, in the majority of cancers, including prostate cancer (PCa). CK2-mediated activation of transcription factor nuclear factor kappa B (NF-κB) p65 is a key step in cellular proliferation, resulting in translocation of NF-κB p65 from the cytoplasm to the nucleus. As CK2 expression and activity are also elevated in benign prostatic hyperplasia (BPH), we sought to increase the knowledge of CK2 function in benign and malignant prostate by examination of the relationships between nuclear CK2 and nuclear NF-κB p65 protein expression. The expression level and localization of CK2α and NF-κB p65 proteins in PCa and BPH tissue specimens was determined. Nuclear CK2α and NF-κB p65 protein levels are significantly higher in PCa compared with BPH, and these proteins are positively correlated with each other in both diseases. Nuclear NF-κB p65 levels correlated with Ki-67 or with cytoplasmic NF-κB p65 expression in BPH, but not in PCa. The findings provide information that combined analysis of CK2α and NF-κB p65 expression in prostate specimens relates to the disease status. Increased nuclear NF-κB p65 expression levels in PCa specifically related to nuclear CK2α levels, indicating a possible CK2-dependent relationship in malignancy. In contrast, nuclear NF-κB p65 protein levels related to both Ki-67 and cytoplasmic NF-κB p65 levels exclusively in BPH, suggesting a potential separate impact for NF-κB p65 function in proliferation for benign disease as opposed to malignant disease.

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.

MEDICAL EXPULSIVE TREATMENT OF DISTAL URETERAL STONE USING TAMSULOSIN.

BACKGROUND: Many minimally invasive interventional techniques as well as expectant treatment exist for the management of lower ureteric calculi. This study was conducted to evaluate th efficacy of tamsulosin as an expulsive pharmacologic therapy for the treatment of distal uretern stone. METHODS: This randomized control trial included 100 patients over 18 years of age wit stone Size > or = mm in distal 1/3 of ureter. Patients were randomly assigned into two groups (A & B Group A Patients were given Capsule Tamsulosin 0.4 mg, 1 daily up to 4 weeks while group B patients were given placebo, 1 Capsule daily up to 4 weeks. The primary endpoint was expulsio rate. A written informed consent was taken from all the patients. Expulsion time, need for analgesics, need for hospitalization and drug side effects were secondary endpoints. RESULTS: A total of 49 patients in group A and 48 patients in group B reported back, therefore 97 out of 10 patients were evaluated. Mean age of the patients was 36.34 years (range 18-57 years). Mea stone size was 5.78 mm (range 4-8 mm) in greatest dimension. A stone expulsion rate of 85.71C (42 patients) was noted in group A and 54.20% (26 patients) in group B. Group A revealed statistically significant advantage in term of stone expulsion rate (p=0.032). Considering expulsio time in days group A showed statistically significant advantage (p=0.015). Regarding age, se) stone size and stone lateralization (right/left), there was no significant difference between th group A and B. No drug side effects were noted in both the groups. CONCLUSION: By usin tamsulosin a higher stone expulsion rates can be achieved in a shorter time. More randomize control trials are required to establish tamsulosin as a standard medical expulsive treatment fc

Vesicouterine fistula.

A 41 years lady presented with 13 years history of urinary incontinence alongwith menouria, which had developed after the first vaginal delivery. However, she had four normal vaginal deliveries later. Intravenous urography showed normal flow on both sides but there was spillage of contrast from the urinary bladder into the uterus, in the cystographic phase. Cystoscopy showed a fistulous opening in the posterior wall of bladder above the trigone. She was subjected to total abdominal hysterectomy with repair of the fistulous bladder opening. Postoperative recovery was smooth and the patient became asymptomatic.

Transitional cell carcinoma of ureter in a solitary functioning kidney.

We present a 60 years old male with transitional cell carcinoma of the left ureter. The right kidney was non excretory while the left one was the solitary functioning kidney with multiple renal cysts. He had presented with significantly deranged renal profile and left obstructed ureter. The ureterorenoscope could not be negotiated so exploration of the left ureter was done. This showed a growth in left ureter, confirmed as transitional cell carcinoma (TCC) on histopathology. Subsequently excision of the distal left ureter along with the tumour and the cuff of bladder (segmental ureterectomy) was contemplated. Proximally transureteroureterostomy was performed. Postoperative recovery was smooth and the renal profile became normal within 3 months.

Inverted papilloma of ureter: a rare cause of hydronephrosis.

A case of hydronephrosis with a rare underlying cause in a 35 years old male is described. He reported with pain in the left lumbar region with a past history of left ureterolithotomy. The ultrasound and IVU studies were suggestive of left hydronephroureter. CT Scan showed left hydronephroureter with narrowing at the lower end of left ureter. Ureterorenoscopy (URS) confirmed polypoidal lesions in the left lower ureter, completely obliterating the lumen and involving the whole circumferential wall of the lower ureter. The biopsy of the lesion revealed an inflammatory polyp. Accordingly open surgical intervention was planned. Excision of the lower third of left ureter with ureteric reimplantation was done with a Boari flap. The histopathology report of the lower third of ureter confirmed inverted papilloma of ureter. The patient made a smooth postoperative recovery.

Ureterovaginal fistula--etiological factors and outcome.

OBJECTIVE: To assess the etiological factors and the outcome of ureterovaginal fistula in an urban setting. METHODS: The observational study was conducted at the Armed Forces Institute of Urology, Military Hospital, Rawalpindi, from January 2009 to January 2011. All the patients of uretero-vaginal fistula at the centre were included on the basis of non-probability purposive sampling. The etiology, clinical presentation and the investigative procedures were recorded. The operative modality contemplated was noted and post-operative results were evaluated. The data was entered in a structured proforma and analysed for descriptive statistics using SPSS version 14.0. RESULTS: Seventeen cases of ureterovaginal fistula were recorded. Amongst these 10 (58.8%) were post-hysterectomy, while 7 (41.1%) cases post-caesarean section. The emergency procedures performed by the residents/junior registrars contributed 12 (70.2%) of the cases. All these patients were treated surgically; 14 (82.3%) were managed with ureteroneocystostomy, 2 (11.7%) required Boari Flap reconstruction, and in psoas hitch was performed in 1 (5.8%) case. The time of intervention was 4 - 12 weeks (9.76 +/- 2.223). Post-operatively, only 1 (5.8%) case had superficial wound infection and 1 (5.8%) urinary tract infection. All the patients remained dry with a follow-up period of 3 - 24 months (mean 12.24 +/- 6.879). CONCLUSION: Ureterovaginal fistula is one of the complications of emergency procedures, especially in the hands of inexperienced surgeons. Prompt diagnosis and surgical intervention produce excellent results. Intervention can be done safely as early as 4 weeks after the initiation of the condition.

Bladder outlet obstruction in a 5 years boy.

We report a 5 years old boy with bladder outlet obstruction secondary to a fibroepithelial polyp of prostatic urethra. The micturating cystourethrogram showed a filling defect in the posterior urethra. Cystourethroscopy revealed a polyp in the prostatic urethra proximal to the verumontanum. Transurethral resection was done and histopathology confirmed fibroepithelial polyp of the urethra.

Bulbar uretheral stricture repair with buccal mucosa graft urethroplasty.

OBJECTIVE: To evaluate the use of buccal mucosa graft in single stage urethral reconstruction of bulbar urethral stricture. METHODS: In Armed Forces Institute of Urology Rawalpindi, from Jan 2008 to Oct 2009, 56 patients underwent single stage dorsal onlay urethroplasty using buccal mucosa graft for long bulbar urethral strictures (> 2cm). Urethra was incised along the strictured segment in the 12 o'clock (dorsal) position starting from the distal end. A buccal mucosa graft of required length was harvested. The graft was anchored in a spread fixed fashion to the corporal bodies opposing the dorsally incised strictured urethra. The urethra was rotated back to the normal anatomic position. The margins of urethral incision were sutured to the fixed graft edge and corporal body using interrupted 4-0 vicryl. After completion of right margin's stitches, a 16 Fr silicon catheter was placed and then left margin stitches were completed. RESULTS: Only 54 out of 56 patients could be evaluated because 2 patients were lost to follow up. Mean age of the patients was 48 +/- 11.32 years (range 19-67 yrs). Mean length of the buccal mucosa graft was 3.4 +/- 0.6 cm (range 2.6 - 5.5 cm). Duration of follow up was 4-20 months, mean 16.3 +/- 3.65 months. In 47 (87%) patients, the procedure was successful, 7 (13%) patients developed recurrence, out of these 7 patients, 2 (3.7%) required optical urethrotomy and 5 (9.25%) patients responded to urethral dilatation. Mean operative time was 92 +/- 13.22 minutes. CONCLUSION: Buccal mucosa graft urethroplasty produces encouraging results in long bulbar urethral strictures. Longer follow up is required.

A rare complication of forgotten ureteral stent.

A 35 years old lady presented with history of something coming out of the genitalia for the last 5 days. She also had history of pain in the left lumbar region which was initially investigated but the patient did not follow-up. About 15 years ago she also underwent left ureteric reimplantation. On examination, a stick like tube was protruding out of the urethral meatus which was fixed to the underlying vesical calculus. The calculus was evident radiologically and on ultrasound. The projecting portion of the stick like tube was cut and the vesical calculus with the inner portion of the tube was removed by open procedure. On evaluation of the specimen, it was found that the vesical calculus was fixed to the plastic tube which had concretions around it. This plastic tube had been placed after the ureteric reimplantation done 15 years ago and the patient was not aware of it.

Pattern of malignant renal tumours using 2004 WHO classification of renal tumours on radical nephrectomy.

OBJECTIVE: To determine the type of malignant renal tumours subjected to radical nephrectomy at a tertiary care urology unit using the 2004 WHO classification for renal tumours. METHODS: It was an observational study conducted at Department of Urology, AFIU Rawalpindi, from October 2008 to September 2010. The study included 92 patients with malignant renal tumours of both genders aged above 15 years. The histopathological types and grades were recorded along with the gross tumour presentation. The data was entered in structured proforma and analysed for descriptive statistics using SPSS-14. RESULTS: Over the span of 24 months study, 92 cases of malignant renal tumours were subjected to radical nephrectomy. The age was 16-82 (57.23 +/- 14.61) Years and male to female ratio was 2.1:1. The lesions were mostly unifocal (96.7%) and 58.6% affecting the right side. The commonest malignant renal tumour encountered was the conventional clear cell renal carcinoma (78.2%). The other tumours in descending order were the transitional cell carcinoma (7.6%), papillary (chromphilic) renal cell carcinoma (6.5%), renal cell carcinoma unclassified (3.2%), chromophobe renal cell carcinoma (2.1%), Wilm's tumour and oncocytoma (1.7%). T1 lesions were found in 42 cases (45.6%), T2 lesions in 25 cases (27.1%), T3a lesions in 17 cases (18.4%) each, while 8 cases (8.6%) had T3b lesions. Four cases had high and 3 had low grade lesions in transitional cell carcinoma. Wilm's tumour had favourable prognosis, 1 case had oncocytoma limited to kidney. Among the rest, 26 (28.2%) were G1, 35 (38%) were G2, 16 (17.3%) were G3, and 6 (6.5) were G4. CONCLUSION: The commonest type of the malignant renal neoplasm remains the clear cell (conventional) renal cell carcinoma. The lesions from T1 to T3 are amenable to radical nephrectomy and may not include the ipsilateral adrenalectomy as well. The grade may range from G1 to G4.

Allergic broncho-pulmonary aspergillosis presenting as flitting opacities on chest radiograph.

Allergic broncho-pulmonary aspergillosis (ABPA) is hypersensitivity reaction to Aspergillus fumigatus in the bronchial tree of young asthmatic patients. A 28 years old female patient presented with one year history of fever with generalised body aches and pains and had already received treatment for pulmonary tuberculosis. Her chest radiograph showed flitting opacities in both lung fields with a TLC of 13.2 x 109/L having 25% eosinophils and ESR of 87 mm at first hour. Her serum IgE were markedly raised and CT scan of the chest showed dilated large and medium sized bronchi forming mucocoeles, finger in glove appearance and nodular shadowing in the lung parenchyma. Sputum also showed fungal hyphae by direct microscopy. All the findings were consistent with the diagnosis of ABPA, which responded to oral Itraconazole and Prednisolone. ABPA is a potentially destructive lung disease requiring high index of suspicion for an early diagnosis to prevent irreversible lung damage.

Modified midline abdominal wound closure technique in complicated/high risk laparotomies.

OBJECTIVE: To assess the local wound complications in complicated/ high risk laparotomies in terms of wound dehiscence and incisional hernia formation with a modified technique of midline abdominal wound closure. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of General Surgery, Combined Military Hospital, Bahawal Nagar Cantonment, May 2006 to June 2008. METHODOLOGY: Cases of complicated/high risk abdominal conditions, which required laparotomy, were included in the study. A modified midline abdominal wound closure technique was used. Interrupted Smead-Jones sutures with prolene, a non-absorbable suture material for closure of linea alba was combined with mass closure involving all the layers (also with prolene) and drains were placed. Patients were followed-up for 3-23 months. The postoperative wound dehiscence and incisional hernia formation were noted. Other local wound complications were also recorded. RESULTS: Out of the 36 patients undergoing this surgical technique, 20 (55.55%) had inflammatory/intra-abdominal sepsis, 8 (22.22%) had trauma, 7 (19.44%) had neoplasia and 1 (2.77%) had vascular aetiology. Only 1 (2.77%) had partial wound dehiscence and 1 (2.77%) developed incisional hernia. Wound infection was noted in 12 (33.33%) cases; 4 (11.11%) experienced pain over the subcutaneous palpable knots and 3 (8.33%) developed sinus due to the knots. The average follow-up period was 12.47+7.17 months. CONCLUSION: Patients with extensive widespread generalized peritonitis and metastatic abdominal tumours need special attention regarding wound closure. This modified technique of midline abdominal wound closure is associated with low incidence of wound dehiscence and incisional hernia formation.