Ureterovesical Leak Following Renal Transplant and Effects of Acute Rejection and Antirejection Therapy: A Nested Case-Control Analysis and Outcome of 1102 Consecutive Renal Transplant Recipients.

OBJECTIVES: Studies on nontechnical risk factors for ureterovesical leak after renal transplant are scarce. This study aimed to report the possible pre- and postoperative risk factors and the role of acute rejection and antirejection therapies for urine leak after transplant and its effect on graft and patient survival. MATERIALS AND METHODS: We conducted a retrospective analysis of 13 patients (1.17%) with urine leak (case group) and 52 patients without leak (control group) (case-to-control ratio of 1:4) from 1102 living related (first degree) renal transplant recipients seen between January 2012 and December 2021. We analyzed demographic and clinical details and biochemical and outcome parameters using a nested case-control design. RESULTS: Cases were olderthan controls (P = .018), were more ABO incompatible (P = .009), and had more 6/6 HLA mismatch transplants (P = .047). Donors of cases were older than donors of controls (P = .049). The rate of postoperative hypoalbuminemia was greaterin the case group (P = .050). Rates of acute rejection (P = .012) and plasmapheresis (P = .003) were greaterin the case group than in the control group. On multivariate logistic regression analysis, recipient age, 6/6 HLA mismatch, and plasmapheresis were found to independently associated with urine leak. None ofthe patient required surgical repair, as all responded to conservative therapy. Urine leak did not affect graft outcomes (P = .324), but overall survival was less in cases than in controls. CONCLUSIONS: Nontechnical risk factors that cause posttransplant ureteric leak include older donor and recipient age and ABO incompatible and 6/6 HLA mismatch transplants. Acute rejection and plasmapheresis predispose leak, and an indwelling double J stent can allow adequate healing of the anastomosis. High index of suspicion and prompt management are imperative to preserve graft and patient outcome.

Is systematic prostate biopsy an overkill in metastatic prostate carcinoma ? A prospective validation.

PURPOSE: To assess the efficacy of 2-core prostate biopsy in advanced prostate cancer patients. This included a retrospective analysis of 12-core prostate biopsies and a prospective validation that a reduced number of cores are sufficient for histopathological diagnosis. METHODS: The first phase analyzed retrospective data from 12-core prostate biopsies between January 2013 and 2018. In the second phase, from January 2018 to January 2022, in a prospective setting, patients with PSA > 75 ng/dl underwent bone scans first. Those with positive bone scans underwent a 2-core biopsy. Cancer detection rate and complications were analyzed to validate the findings of the first phase. RESULTS: In the retrospective analysis, the number of positive cores in metastatic disease was 12 in 93 (73.8%), 11 in 14 (11.1%), and 10 in 7 (5.6%) patients. Using probability analysis, 94% of patients with metastasis could be detected with a single core and 97.8% with a 2-core biopsy. In the prospective analysis, 52 patients with PSA > 75 were enrolled. 3/52 (5.7%) patients had a negative bone scan. 49 were assigned for 2-core biopsy, out of which 48 (97.9%) had a positive result. One patient underwent a repeat 12-core biopsy. The prospective cohort's complications (p = 0.003) and pain score (p = 0.03) were lower compared to patients who underwent standard 12-core biopsies during phase one of the study period. CONCLUSION: A 2-core biopsy is adequate in almost all patients with metastatic prostate cancer with PSA > 75, and this avoids excess complications and morbidity associated with a systematic 12-core prostate biopsy.

Comparing T2-T3 staging of penile cancer according to the American Joint Committee on cancer 8th edition with two modified staging systems in predicting survival outcome: A single-center experience.

Introduction: Penile cancer is a rare malignancy of the genitourinary tract. We aimed to validate the recent changes in the T2 and T3 stages of penile cancer in the American Joint Committee on Cancer (AJCC) 8th edition and to compare its predictive ability with two other modified staging systems for survival outcomes. Methods: This is a retrospective study of patients diagnosed with penile cancer from June 2015 to March 2020. The AJCC 8th edition and two other newly proposed systems by Li et al. and Sali et al. were used for staging the tumor. All variables were categorized and correlated with lymph node (LN) metastases and overall survival (OS). Results: Fifty-four patients were eligible for this study. The mean age was 58 years (range 46-72 years). The tumor stage (P = 0.016), clinical LN stage (P = 0.001), the involvement of the spongiosa (P = 0.015) and the cavernosa (P = 0.002), lymphovascular invasion (LVI) (P = 0.000), and PNI (P = 0.021) were found to be the significant predictors of LN metastases. When the 5 year OS was compared between the T2 and T3 stages of the AJCC 8th edition, Li staging and the Sali staging systems, it was 91% and 50.1% (P = 0.001), 97.5% and 10.3% (P = 0.000), 94.4% and 14.7% (P = 0.000), respectively. The presence of LVI (P = 0.001) was the most significant independent predictor of OS. Conclusions: The recent changes in the AJCC 8th edition pertaining to the T2-T3 stage are relevant, although the other two newly proposed staging systems were more precise in predicting the survival outcomes.

Vesicovaginal Fistula Repair by Transvaginal Route: Comparison of Resource Utilisation and Outcome with Literature Reported Population Matched Cohort of Patients Operated by Minimally Invasive Route.

Introduction and Objectives: VVF is conventionally repaired by open transvaginal or transabdominal routes. In last few decades, minimally invasive techniques (laparoscopic/robotic) for VVF repair have gained popularity. We have reported our experience of transvaginal vesicovaginal fistula (VVF) repair and compared it with the literature reported population matched cohort of VVF repair done by laparoscopic or robot-assisted techniques. Material and Methods: Intraoperative and post-operative parameters including aetiology of fistula, location, operative time, blood loss, major complications, hospital stay and success rate of 202 patients with simple VVF undergoing transvaginal repair at a tertiary care hospital from 1999 to 2019 were recorded. We also compared our transvaginal repair cohort (n = 202) with the literature reported cohort of 260 patients undergoing VVF repair by minimally invasive (laparoscopic and robot assisted) techniques in the systematic review by Miklos et al. Results: Most common aetiology of VVF in our series was post hysterectomy in 122 (60.39%) cases followed by trauma during emergency caesareans section in 80 (39.60%) cases. Transvaginal route had higher success rate than minimally invasive approach (99.50 vs. 96.50%, respectively). Mean operative time was lesser in transvaginal group than the minimally invasive group (63 ± 16 min vs. 161.56 ± 41.02 min, p < 0.01) with shorter mean hospital stay in transvaginal group (3 ± 1 days vs. 3.5 ± 1.16 days, respectively, p < 0.01). Mean estimated blood loss was significantly lesser in transvaginal repair (p < 0.01). 62% patients were sexually active at last follow-up. The cost of transvaginal VVF repair is significantly lower compared to repair by minimally invasive approach. Conclusion: Transvaginal VVF repair is comparable to minimally invasive approach in terms of post-operative outcomes and morbidity; however, transvaginal repair performs better in terms of cost and resource utilization.

Percutaneous nephrostomy in Ureteropelvic junction obstruction with poorly functioning kidney: Is it still pertinent in adults?

OBJECTIVE: To determine the pertinence of percutaneous nephrostomy drainage in adult patients of primary ureteropelvic junction obstruction with poorly functioning kidneys (<20% split renal function). MATERIAL AND METHODS: Clinical records of all patients with primary ureteropelvic junction obstruction with poorly functioning kidneys who underwent percutaneous nephrostomy drainage in our institute between February 2015 and January 2020 were retrospectively reviewed. The patients were divided into 4 groups according to their split renal function obtained from the Tc-99m ethylenedicysteine diuretic renogram. Group I consisted of all patients having split renal function ≤5%, group II with split renal function 6-10%, groupIII with split renal function 11-15%, and finally group IV with split renal function 16-20%. Those patients inwhom split renal function was improved by >10% and had daily percutaneous nephrostomy output >400 mL, underwent pyeloplasty and the rest underwent nephrectomy. RESULTS: Seventy-two patients were studied, out of which 5 were in group I, 20 in groups II and III each, and27 in group IV. The mean age of presentation was 34.4 ± 14 years. The split renal function improvement of>10% was seen in 55 patients (76.4%) after percutaneous nephrostomy drainage (P < .05). Pyeloplasty wasdone in 40 patients (55.6%) and nephrectomy was done in 32 patients (44.4%). CONCLUSION: In conclusion, we recommend the use of a Tc-99m ethylenedicysteine scan for estimation of split renal function during the initial presentation in every patient followed by reconstructive surgery if split renal function is above 15% and nephrectomy if it is below 5%. The trial of percutaneous nephrostomy is pertinent if split renal function is between 6% and 15%.

Experience with management of renal cell carcinoma with inferior vena cava/right atrial tumor thrombus.

INTRODUCTION: We aimed to present our experience in managing renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus. METHODS: Records of all patients aged 18 years and older, with a diagnosis of primary renal masses with IVC thrombus, presenting to our institute from January 2012 to August 2020 were retrospectively reviewed. Patients with tumor thrombus limited only to renal vein were excluded from the analysis. Their hospital course and outcomes were recorded and evaluated for predictors of survival. RESULTS: During the study period, we treated 61 patients with a renal mass and concurrent IVC thrombus and 56 of these underwent surgery. 7 of them had level III and 6 had level IV thrombus. A total of six patients received neoadjuvant tyrosine kinase inhibitor (TKI) therapy and all of them showed a decrease in size and level of tumor thrombus and cardiopulmonary bypass was safely avoided. Fourteen patients had distant metastasis and underwent cytoreductive surgery and of these 12 patients received TKI therapy after surgery with a mean survival of 26.8 months. The overall survival at 2 and 5 years of nonmetastatic group was 81.1% and 47.5% respectively and in metastatic group was 35.1% and 0%, respectively. Poor performance status, distant metastasis, higher T stage, higher thrombus levels, and positive surgical margins were all predictors of decreased survival. CONCLUSIONS: Complete surgical resection in both nonmetastatic and metastatic RCC with IVC thrombus has long-term survival benefits. Neoadjuvant TKI therapy, with adequate preoperative planning, helps in decreasing the size of the thrombus and in safely avoiding bypass in level III and IV IVC thrombi.

A prospective randomized study to define the role of low dose continuous prophylactic antibiotics and anti-adherence agents in altering the microbial colonization related to indwelling double-J stents.

OBJECTIVE: Despite conflicting evidence, it is common practice to use continuous antibiotic prophylaxis (CAP) in patients with indwelling double-J (DJ) stents. Cranberry extracts and d-mannose have been shown to prevent colonization of the urinary tract. We evaluated their role in this setting. METHODS: We conducted a prospective randomized study to evaluate patients with indwelling DJ stents following urological procedures. They were randomized into three groups. Group A (n=46) received CAP (nitrofurantoin 100 mg once daily [OD]). Group B (n=48) received cranberry extract 300 mg and d-mannose 600 mg twice daily (BD). Group C (n=40) received no prophylaxis. The stents were removed between 15 days and 45 days after surgery. Three groups were compared in terms of colonization of stent and urine, stent related symptoms and febrile urinary tract infections (UTIs) during the period of indwelling stent and until 1 week after removal. RESULTS: In Group A, 9 (19.5%) patients had significant bacterial growth on the stents. This was 8 (16.7%) in the Group B and 5 (12.5%) in Group C (p-value: 0.743). However, the culture positivity rate of urine specimens showed a significant difference (p-value: 0.023) with Group B showing least colonization of urine compared to groups A and C. There was no statistically significant difference in the frequency of stent related symptoms (p-value: 0.242) or febrile UTIs (p-value: 0.399) among the groups. CONCLUSION: Prophylactic agents have no role in altering bacterial growth on temporary indwelling DJ stent, stent related symptoms or febrile UTIs. Cranberry extract may reduce the colonization of urinary tract, but its clinical significance needs further evaluation.

Upper tract transitional cell carcinoma clinically mimicking inflammatory renal pathology: A report of three cases.

Upper tract urothelial carcinoma (UTUC) of the renal pelvis and the ureter is incidentally detected in a small proportion of cases. However, the majority of UTUC cases present with hematuria, flank pain, and clot colic. Typical imaging features include hydronephrosis of the kidney (s) due to obstruction by the mass with a soft-tissue lesion that typically shows low-grade enhancement with or without a filling defect. Rarely, such a tumor may present with signs and symptoms mimicking an inflammatory or infective pathology of the kidney and is diagnosed only on biopsy or on nephrectomy. We present three such patients and cite another similar case we have published earlier. All three of these patients presented with signs and symptoms of an obstructed infected kidney with long-standing renal calculi and a forgotten DJ stent in one instance. Nephrectomy for the presumed infected kidney in all three cases revealed high-grade UTUC. In patients presenting with equivocal findings on cross-sectional imaging with a history of renal calculi or foreign bodies, we should have a high index of suspicion for malignancy.

Role of MRI in staging and surgical planning and its clinicopathological correlation in patients with renal cell carcinoma.

BACKGROUND AND AIMS: Radiological evaluation of renal cell carcinoma (RCC) is used for non-invasive staging for better surgical planning. However, the correlation of radiological staging using magnetic resonance imaging (MRI) with histopathological findings has not been done so far. The aim of this study is to assess the role of MRI in pre-operative staging of RCC in patients undergoing radical nephrectomy and nephron sparing surgery (NSS) and correlate it with histopathological findings. SETTINGS AND DESIGN: This prospective observational study was conducted from February 2015 to October 2016 at a tertiary care hospital in northern India. METHODS: MR imaging was done on 3 Tesla MR scanner (Signa Hdxt General Electrics, Milwaukee, USA). Preoperative staging was based on 2010 TNM staging system. The preoperative parameters in MRI were tumor size, detection/breach of pseudocapsule, tumor extension into perirenal fat and detection of tumor venous thrombus. The staging on MRI was compared with surgical and pathological staging. STATISTICAL ANALYSIS USED: The agreement between these three staging methods was determined using the kappa statistics (0.0-0.2, poor; 0.2-0.4, fair; 0.4-0.6, moderate; 0.6-0.8, good; 0.8-1.0, excellent). RESULTS: 30 patients with suspected RCC underwent NSS (n = 10) and radical nephrectomy (n = 20). Mean tumor size was 9.66 ± 2.99 cm in the radical nephrectomy group and 4.06 ± 1.16 cm in the NSS group. There was perfect agreement between MRI, surgical and pathological staging for breach of pseudocapsule (κ =1.0, Percentage of Agreement = 100%, P < 0.05). In none of the patients, MRI missed extension beyond the Gerota's fascia or presence of venous thrombus. CONCLUSION: MRI staging of RCC is an accurate predictor of the surgical and pathological stage and has the potential to become a useful tool for preoperative identification of patients with RCC who can undergo NSS.

Xanthogranulomatous prostatitis mimicking prostatic adenocarcinoma: a diagnostic dilemma.

We report a case of xanthogranulomatous prostatitis confirmed on histological examination of resected prostate which was initially suspected to be carcinoma on clinical, biochemical and radiological evaluation and also misdiagnosed as high-grade prostatic adenocarcinoma on core biopsy specimen.

Safety and outcome of percutaneous nephrolithotomy in patients with solitary kidney: A tertiary care center experience.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) for stones in solitary kidney poses a significant challenge and potential threat for acute kidney injury or progression of chronic kidney disease (CKD). We present our experience of PCNL in solitary functioning kidney (SFK) to evaluate the safety, efficacy, and postoperative complications and highlight the differences between these outcomes with respect to the stage of CKD. METHODS: We carried out a retrospective study of patients with SFK, who underwent PCNL at our center from April 2010 to March 2018. Patients who had a minimum of 6 months of follow-up were included. Patients were classified into CKD groups based on the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative. Group 1 included Stages 1, 2, and 3A and Group 2 included Stages 3B, 4, and 5. Postoperative complications and stone-free rate were recorded and graded according to the Clavien-Dindo classification and compared between the two groups. RESULTS: We had a total of 128 patients (Group 1 - 84 and Group 2 - 44). Stone-free rate after the first PCNL was higher in Group 1 as compared to Group 2 (88.1% [n = 74] vs. 50% [n = 22], P = 0.02). Overall, 48 patients (37.5%) had postoperative complications, but most were minor. Clavien Grade 1 and 2 complications were seen in 34 patients (Group 1, n = 18 and Group 2, n = 16, P = 0.069), whereas Grade 3 and 4 complications were seen in 14 patients (Group 1, n = 2 and Group 2, n = 12, P < 0.001), respectively. Need for postoperative (number of sessions) dialysis was seen with increased frequency in patients with higher chronic kidney stages (Group 1 vs. Group 2; 6 vs. 22 sessions, P < 0.001). CONCLUSION: PCNL in SFK is safe, with satisfactory outcome, but patients with advanced CKD stage have higher risk of complications including need for dialysis and may require multiple sessions for complete stone clearance. Hence, they should be managed at high output tertiary centers.

Spontaneous renoalimentary fistula as a complication of upper tract urothelial carcinoma: unknown complication of a rare disease.

Fistulae of the upper urinary tract with the alimentary tract are rare. Most cases of renoalimentary fistulae are secondary to penetrating trauma, which may be iatrogenic or due to locally invasive benign infective processes or complicated nephrolithiasis, or following surgical procedures. Spontaneous renoalimentary fistulae developing secondary to locally advanced malignancies, namely renal cell carcinoma, are very rare, and unknown due to upper tract transitional cell carcinoma. We present a case where a 60-year-old man, presented with clinical symptoms suggestive of upper gastrointestinal tract pathology, with no urological complaints and was diagnosed to have a renoalimentary fistula on cross-sectional imaging and upper gastrointestinal endoscopy with histopathology of duodenal growth biopsy showing high-grade transitional cell carcinoma. Due to unresectable nature of this mass, this patient had a gastric and biliary diversion and was started on palliative chemotherapy. Renoalimentary fistulae due to benign inflammatory causes may be treated by nephrectomy with or without resection of the involved bowel segment. However, all malignant fistulae have to be treated as locally advanced tumours and en bloc resection should be attempted whenever feasible.

A modified cutaneous ureterostomy provides satisfactory short and midterm outcomes in select cases.

OBJECTIVE: We present the outcomes of modification of cutaneous ureterostomy by extreme lateralization of the stoma and use of skin flap for formation of ureterostomy. MATERIAL AND METHODS: Between June 2012 and June 2016, 36 patients had modified cutaneous ureterostomy for ureteral obstruction due to pelvic malignancy or genitourinary tuberculosis. Transureteroureterostomy was made with cutaneous stoma at anterior axillary line between iliac crest and lower rib cage, instead of spinoumbilical line. To prevent stenosis a 'V' shaped skin was fed into the stoma. Double J stents were used in all patients for 6 weeks. Perioperative morbidity and mortality were evaluated. All patients were followed up at 3 month intervals. RESULTS: Of 36 patients, 22 had radical cystoprostatectomy (including nephroureterectomy in 2 patients) and 7 had palliative cystectomy. Others had locally advanced prostate cancer (n=1), locally advanced cervical cancer (n=3), ovarian cancer (n=1) and genitourinary tuberculosis with small capacity bladder along with a large vesicovaginal fistula (n=1). One patient developed ureteral necrosis requiring conversion to ileal conduit. Three patients developed stomal stenosis: two were managed by self-dilatation while one required revision of stoma. Thirteen patients died of the disease at a median follow up of 6 months with functioning stoma. Remaining 19 patients survived without any complications at a median follow-up of 20.5 months (5.5-43.5 months). None of the patients had any problem related to ureterostomy bag application. CONCLUSION: Modified lateral cutaneous ureterostomy provides relatively straighter and shorter retroperitoneal course of ureter with acceptable morbidity and avoids use of bowel in selected patients.

A rare case of extra-adrenal bilateral perirenal and periureteric myelolipoma.

A 30-year-old immunocompetent female presented with right flank pain since 3 years. MRI revealed a large well-defined T1 and T2 hypointense mildly enhancing lesion in the right anterior pararenal space displacing the right kidney and encasing the right ureter with T2 hyperintense wall thickening of the left renal pelvis and ureter. A provisional diagnosis of solitary fibrous tumour was kept. Bilateral double J stenting was done for hydronephrosis. Surgical debulking of the lesion was done with biopsy from the left periureteral wall thickening and was found to be myelolipoma on histopathological examination. This case is a novel variety of myelolipoma which is lipid poor, extra-adrenal and in bilateral perirenal and periureteric location.

Large Multicystic Dysplastic Kidney Mimicking a Large Cystic Renal Neoplasm.

Multicystic Dysplastic Kidney (MCDK) is one of the most common renal conditions seen in paediatric population. The natural history typically involves involution and many of the patients with unilateral disease may actually never become symptomatic. The initial evaluation is usually done on Ultrasonography (USG) while cross-sectional imaging and nuclear scan are reserved for diagnostic dilemmas. Management is conservative and surgery is done for selected patients with symptomatic cysts or suspicion of neoplasm. We present an interesting case of MCDK in a nine-month-old female hypertensive child presenting with a large abdominal mass increasing in size with imaging features similar to cystic neoplasm and managed with nephrectomy.

An audit of early complications of radical cystectomy using Clavien-Dindo classification.

INTRODUCTION: Despite the major improvements in surgical technique and perioperative care, radical cystectomy (RC) remains a major operative procedure with a significant morbidity and mortality. The present study analyzes the early complications of RC and urinary diversion using a standardized reporting system. MATERIALS AND METHODS: Modified Clavien-Dindo classification was used to retrospectively assess the peri-operative course of 212 patients who had RC with urinary diversion between October 2003 and October 2014 at a single institution. The indications for surgery were muscle invasive urothelial carcinoma, high-grade nonmuscle invasive bladder cancer (BC), and Bacillus Calmette-Guerin-resistant nonmuscle invasive BCs. Data on age, sex, comorbidities, smoking history, American Society of Anaesthesiologists score, and peri-operative complications (up to 90 days) were captured. Statistical analysis was performed using SPSS 20.0 software (Chicago, USA). RESULTS: The mean age was 56.15 ± 10.82. Orthotopic neobladder was created in 113 patients, ileal conduit in 88 patients, and cutaneous ureterostomy in 11 patients. A total of 292 complications were recorded in 136/212 patients. 242 complications (81.16%) occurred in the first 30 days, with the remaining 50 complications (18.83%) occurring thereafter. The rates for overall complication were 64.1%. The most common complications were hematologic (21.6%). Most of the complications were of Grade I and II (22.9% and 48.9%, respectively). Grade IIIa, IIIb, IVa, IVb, and V complications were observed in 10.2%, 8.9%, 3.4%, 2.7%, and 2.7% of the patients, respectively. CONCLUSIONS: RC and urinary diversion are associated with significant morbidity. This audit would help in setting a benchmark for further improvement in the outcome.

Predictors for progression of metastatic prostate cancer to castration-resistant prostate cancer in Indians.

BACKGROUND & OBJECTIVES: There is lack of data on natural history and progression of prostate cancer (PC) which have implications in the management of the disease. We undertook this retrospective study to analyze factors predicting progression of metastatic PC to castration-resistant prostate cancer (CRPC) in Indian men. METHODS: Complete records of 223 of the 489 patients with metastatic PC were obtained from computerized data based system in a tertiary care hospital in north India between January 2000 to June 2012. Patients with follow up of < 6 months were excluded. Age (≤ and > 65 yr), baseline PSA (< and ≥ 50 ng/ml), bone scan and Gleason score (≤7 and >7) were recorded. Extent of bone disease (EOD) was stratified according to the number of bone lesions i.e., < 5, 5-10, > 10. CRPC was defined as two consecutive PSA rise of > 50 per cent from nadir or an absolute value of > 5 ng/ml. RESULTS: Mean age of patients was 61.5 ± 12.45 yr and their PSA level was 325.6 ± 631.35 ng/dl. Of the 223 patients, 193 (86%) progressed to CRPC at median time of 10.7 (4-124) months. Median follow up was 24 (6-137) months. On univariate and multivariate analyses EOD on bone scan was found to be a significant predictor ( P=0.006) for time to CRPC. Median time to CRPC was 10 months (CI 95%, 7.5-12.48) with >10 lesions or super scan versus 16 months (CI 95%, 10.3-21.6) with <10 bone lesion (P=0.01). Ninety (46.6 %) patients of CRPC died with median time to death from time of CRPC 21 (10-120) months. INTERPRETATION & CONCLUSIONS: Median time for progression of metastatic PC to CRPC ranged from 10-16 months depending on the extent of the bone involvement. In Indians, the aggressive course of advanced prostate cancer warrants further clinical trials to explore the need for additional treatment along with initial castration.

Impact of changing trends in technique and learning curve on outcome of hypospadias repair: An experience from tertiary care center.

INTRODUCTION: Apart from numerous clinical factors, surgical experience and technique are important determinants of hypospadias repair outcome. This study was aimed to evaluate the learning curve of hypospadias repair and the impact of changing trends in surgical techniques on the success of primary hypospadias repair. MATERIALS AND METHODS: We retrospectively analyzed of data of 324 patients who underwent primary repair of hypospadias between January 1997 and December 2013 at our center. During the initial 8 years, repairs were performed by multiple 5 different urologists. From 2005 onwards, all procedures were performed by a single urologist. The study cohorts was categorized into three groups; Group I, surgeries performed between 1997-2004 by multiple surgeons, Group II, between 2005-2006 during the initial learning curve of a single surgeon, and Group III, from 2007 onwards after completion of the learning curve of the single surgeon. The groups were compared in respect to surgical techniques, overall success and complications. RESULTS: Overall 296 patients fulfilled the inclusion criterion, 93 (31.4%), 50 (16.9%), and 153 (51.7%) in Group I, II, and III, respectively. Overall success was achieved in 60 (64.5%), 32 (64%), and 128 (83.7%) patients among the three groups respectively (P < 0.01). Nineteen (20.4%), 20 (40%), and 96 (62.7%) patients underwent tubularized incised plate repair in Group I, II, and III, with successful outcome in 12 (63.2%), 15 (75%), and 91 (94.8%) patients, respectively (P < 0.01). The most common complication among all groups was urethrocutaneous fistula, 20 (21.5%) in Group I, 11 (22%) in Group II, and 17 (11.1%) in Group III. CONCLUSION: There is a learning curve for attaining surgical skills in hypospadias surgery. Surgeons dedicated for this surgery provide better results. Tubularized incised plate urethroplasty appear promising in both distal and proximal type hypospadias.