Müllerianosis of the urinary bladder with unilateral complete renal agenesis: a rare coincidental finding causing delayed presentation.

Müllerianosis is a rare benign lesion of the urinary bladder, which is constituted by two or more of the Müllerian-duct-derived tissues. We report a 45-year-old perimenopausal multiparous woman presenting with occasional episodes of dysuria and lower abdominal discomfort of recent duration. Ultrasound examination revealed a well-defined lesion in urinary bladder and the absence of left kidney. Contrast-enhanced CT of the abdomen confirmed the findings. During diagnostic cystoscopy, haemorrhagic polypoidal lesions were noted in the left side of the posterolateral wall and dome of urinary bladder along with the absence of left ureteric orifice. Transurethral resection of the bladder lesions was done and histology examination confirmed the diagnosis of Müllerianosis. She was administered Luteinizing hormone-releasing hormone (LHRH) agonist monthly. At 1 year of follow-up, cystoscopy showed only scar tissue. The case was reported for the rarity of Müllerianosis noted in a patient with unilateral agenesis of kidney, a possible cause of delayed presentation.

Giant pancreatic mucinous cystadenoma masquerading as renal hydatid disease.

Mucinous cystic neoplasms of the pancreas are the most common pancreatic cystic neoplasms. A 54-year-old female presented with an abdominal mass and was diagnosed to have a multilocular hydatid cyst from the left kidney by imaging. During surgery, a large thick-walled cyst with multiple loculi was seen arising from the upper pole of the left kidney and adherent to the distal pancreas and splenic vessels. The cyst was completely excised without hilar clamping. Histopathological examination confirmed mucinous cystadenoma arising from the pancreas. In conclusion, imaging can be unreliable in differentiating benign renal cysts from tumors of adjacent organs, raising a diagnostic dilemma. Surgical excision only would be able to differentiate the conditions as in our case.

Extended Boari-flap reconstruction in isolated tuberculous pan-ureteral stricture.

A 53-year-old female presented with left loin pain and imaging showed left pan-ureteral stricture secondary to tuberculosis. The renal unit was salvaged by percutaneous nephrostomy. She was planned for ileal ureteric replacement. An extended Boari flap was constructed for her as the bladder capacity was good and Boari bladder flap reached the renal pelvis without tension. Follow-up nephrostogram revealed wide pyelovesical junction with prompt drainage. She completed antituberculous treatment. Extended Boari flap is rarely used for upper ureteric reconstruction. It should be considered as an option for complete ureteric reconstruction in the unilateral pan-ureteral stricture in selected cases.

High rectourethral fistula following TURP: repair possible only after transvesical prostatectomy.

We report a case of iatrogenic rectourethral fistula (RUF) in an elderly man with benign prostatic enlargement and acute urinary retention, following a transurethral resection of prostate (TURP). This patient presented a unique challenge of tackling the RUF in the presence of a large residual prostate gland and urinary tract infection. RUF was repaired only after getting the access to the fistula following transvesical prostatectomy. Follow-up imaging showed well-healed repair of RUF. Transvesical prostatectomy is a useful adjunctive procedure in repair of RUF when associated with a large prostate. This case also highlights the importance of technique selection while planning for surgery on large prostate glands. TURP is not the preferred first modality of choice for larger glands as noted in this case.

Diagnostic Accuracy of Prebiopsy Ga-68 PSMA PET/CT in Detecting Primary Prostate Carcinomas with Prostate-Specific Antigen <50 ng/ml.

BACKGROUND AND AIM: Serum prostate-specific-antigen (PSA) guided systematic transrectal ultrasound (TRUS)-guided biopsies are known to have a low predictive value in detection of primary prostate carcinomas (PCa). Our aim was to evaluate the accuracy of gallium-68 (Ga-68) prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) for the detection of PCa with serum PSA <50 ng/ml. PATIENTS AND METHODS: We retrospective analyzed prebiopsy Ga-68 PSMA PET/CT's of all patients with suspected PCa from October 2019 to March 2020. Several quantitative clinical and PET/CT variables were compared in benign and malignant groups and assessed for significance using an independent t-test. Diagnostic performance of PSMA PET/CT for detection of cancer was evaluated and compared with the diagnostic performance of cancer risk predicting calculator (European Randomized Study for Screening of Prostate Cancer [ERSPC3]). The standard of reference was 12-core TRUS-guided biopsies. RESULTS: Sixty-four patients were included with mean age 70 years (range 48-94 years); mean PSA 15.67 ng/ml (range 1.74-44), mean PSA density 0.32 ng/ml2 (range 0.01-0.99) and mean prostate volume 54.55 cc (range 16.5-182). 64% (n = 41/64) patients had benign histology and 36% (n = 23/64) had carcinoma. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of PSMA PET/CT for detecting PCa reported using the prostate cancer molecular imaging standardized evaluation (PROMISE) was 74%, 92%, 85%, 86%, and 86%, respectively. Mean prostate maximum standardized uptake value (SUVmax) was significantly higher in PCa versus Benign lesions (19.56 ± 18.11 vs. 4.21 ± 1.5, P = 0.00001), in patients with PSA >20 ng/ml versus PSA <20 ng/ml (19.1 ± 20.6 vs. 6.01 ± 5.4, P-0.0052), and in patients with Gleason's score (GS) score >7 versus GS ≤7 (28.1 ± 20.3 vs. 10.2 ± 8.9, P-0.010). SUVmax cutoff value of 5.6 on PSMA PET/CT showed a sensitivity of 95% and specificity of 90.9% (area under the curve 0.990, P < 0.0001). CONCLUSION: Ga-68 PSMA PET/CT can differentiate benign and malignant lesions of the prostate with very high accuracy and when used alongside with ERSPC3 calculator and magnetic resonance imaging, could potentially reduce painful and often unnecessary prostate biopsies.

Vesicovaginal fistula: Review and recent trends.

Vesicovaginal fistula (VVF) is an abnormal communication between the bladder and the vagina. Prompt diagnosis and timely repair are essential for successful management of these cases. As the clinical scenario is variable, it is difficult to frame uniform guidelines for the management of VVF. Hence, the management protocol is dependent on the treating surgeon and the available resources. Conservative methods should be used in carefully selected patients. Delayed repair is better than the early repair of VVF. Transvaginal route for repair is preferred as it has low morbidity, higher success rates, and minimal complications. Anticholinergics should be used in the postoperative period for better chance of bladder healing. When facilities are available, all the patients may be referred to a tertiary care center where expertise and advanced resources are available. Trained surgeons adapting the new trends should refine the art of VVF repair.

Non Transecting Dorsal Onlay and Ventral Inlay Buccal Mucosal Substitution Urethroplasty for Obliterative Bulbar Urethral Strictures.

BACKGROUND: Dorsal or ventral single layer repair can be impractical when there is an inadequate strip of urethra. Staged urethroplasty and non-transecting bilayer substitution urethroplasty are the other alternatives. OBJECTIVES: To assess the safety and outcome of non-transecting dorsal onlay and ventral inlay buccal mucosal substitution urethroplasty technique. METHOD: Between January 2014 and December 2018, 21 patients underwent non-transecting, double-layer, buccal mucosal urethroplasty for inflammatory bulbar urethral strictures. Four weeks after surgery, foley catheters were removed and voiding trial was given. Clinical examination and uroflowmetry (UFM) were done at 1, 3, and 6 months after surgery. Annual follow-up with flow rate and post-void residual assessment were also recorded. Failure was defined as a condition when there was flow rate deterioration (<15 mL/s) or when there is stricture recurrence (<20 Fr). RESULTS: The mean age was 49.5 years. There was no significant difference in comorbidities among the patients. The mean duration of operative time was 259 min. The mean blood loss was 190 mL. The follow-up duration ranged from 12 to 66 months. The average length of stricture was 3.9 cm. The mean diameter of stricture segment was 1.96 mm. Comparison of UFM trend during follow-up was statistically significant (p = 0.05). One patient had Clavien-dindo grade 1, while 2 patients had grade 3b complications. Two patients had soft anastomotic site stricture and were treated successfully with endoscopic internal urethrotomy. The success rate was 90.47%. CONCLUSIONS: Non-transecting bilayer substitution urethroplasty is safe and has better short-term outcome in case of obliterative inflammatory urethral strictures.

Primitive neuroectodermal tumour of the kidney presenting as diplopia secondary to skull metastasis.

A 20-year-old man presented to the department of neurology with diplopia, occipital headache and right flank pain for 1-week duration. CT of the brain revealed skull metastasis with heterogeneously enhancing dural-based mass lesion at the occipital region. Positron emission tomography revealed tracer avid soft tissue mass involving the upper pole of the right kidney with loss of fat planes with the inferior surface of the liver. Multidisciplinary team approach was discussed. He underwent palliative nephrectomy with lymph nodal mass excision. Biopsy from the renal mass was suggestive of primitive neuroectodermal tumour. He developed progressive liver metastases in spite of adjuvant chemotherapy denoting very aggressive disease.

Retrograde Pyelogram during intended Cystogram: A Rare complication of a common procedure.

Inadvertent placement of the urinary catheter into the ureter can cause several complications. We describe a rare complication during cystogram due to unrecognized inadvertently placed urinary catheter in ureter, resulting in a life-threatening situation. A 47-year-old multiparous female underwent total laparoscopic hysterectomy for adenomyosis. During early postoperative period, she developed vesicovaginal fistula and transvaginal repair of fistula was done. During filling cystography done at 2 weeks, she developed right loin pain and urosepsis. Contrast extravasation was seen in the right renal subcapsular space with Foley's catheter inside the right ureter. Subsequently, she recovered well.

Traumatic rectourethral fistula repair: A potential application of porcine small intestinal submucosa.

Rectourethral fistula is an uncommon but devastating condition. Traumatic rectourethral fistula is still uncommon and repair of traumatic rectourethral fistula involves a complex procedure. Most of the urologists would prefer to repair the fistula through perineal route especially when urethral reconstruction is also required. The repaired ends of the fistula are separated with various interposition flaps and grafts in order to prevent recurrence. Gracilis interposition muscle flap is commonly used. We describe the first case of traumatic rectourethral fistula repair in a 45-year-old man using interposition of a porcine small intestinal submucosal (Biodesign™ (Surgisis(®)) graft.

Large bifid ureteric calculus in a patient with an ileal conduit.

Urinary diversion after extirpative surgery of the bladder is done by various methods. Conduit urinary diversion is the most commonly practiced method of urinary diversion. It is relatively easy to perform and has a lower complication rate than other forms of diversion, e.g., orthotopic neobladder and continent cutaneous urinary diversion. Urolithiasis is a known and common complication of urinary diversion. Upper tract calculi in these cases often manifest symptomatically as occurs in the general population. Stones in the conduit can have a variable clinical presentation. Asymptomatic presentation is also noted in a few cases. We report a case of a large silent bifid ureteric calculus within an ileal conduit in a woman who had undergone urinary diversion 32 years earlier. Plain X-ray of the abdomen is the only investigation necessary to rule out urinary lithiasis in those who have had urinary diversion for a long time. This simple tool can diagnose the condition well in advance and aid in planning the management of this condition.

Impacted calculus within a urethral stent: A rare cause of urinary retention.

An elderly male presented to the emergency department with acute urinary retention. He had poor flow of urine associated with serosanguinous discharge per urethra for 3 days duration. Earlier he underwent permanent metallic urethral stenting for post TURP bulbar urethral stricture. Plain X-ray of Pelvis showed an impacted calculus within the urethral stent in bulbar urethra. Urethrolitholapaxy was done with semirigid ureteroscope. Urethral stent was patent and well covered. Subsequently he had an uneventful recovery. We describe a unique case of acute urinary retention due to calculus impaction within a urethral stent.