Microbiome studies in urology- where do we stand and where can we reach?

The role of microbiome milieu in the urinary tract, their interplay in diverse urological conditions and their therapeutic implications are not completely understood. The microbiome has contributed towards urinary tract infections, urolithiasis and urological cancers. The possibility of manipulating microbiome for diagnosis and treatment is evolving. Probiotics might help in overcoming the problems of recurrent infection and antibiotic resistance. Novel applications like stents and catheters coated with non-pathogenic organisms are being developed. Research in the urinary microbiome has progressed from using mouse models to the presently available three- dimensional cultured organoids, thus making it more feasible. As our knowledge regarding the urinary microbiome increases, justice can be done to many patients in whom the advancements can be used for prophylaxis, diagnosis, treatment and even in improving their quality of life. The growing amount of antibiotic resistance is also a matter of concern and probiotics might be the answer to this upcoming calamity. In this review, we have discussed the role of the urinary microbiome in pathogenesis, diagnosis and treatment of urological conditions and pondered upon its future prospects.

Predictors for severe hemorrhage requiring angioembolization post percutaneous nephrolithotomy: A single-center experience over 3 years.

CONTEXT AND AIM: About 1% of the patients undergoing percutaneous nephrolithotomy (PCNL) have bleeding severe enough to require angioembolization. We identified factors which could predict severe bleeding post-PCNL and reviewed patients who underwent angioembolization for the same. SETTINGS AND DESIGN: This is a single-institutional, retrospective study over a period of 3 years. SUBJECTS AND METHODS: We retrospectively studied 583 patients undergoing PCNL at our institute from 2013 to 2016. We analyzed nine patients (three from our institute and six referred patients) who underwent angioembolization for severe bleeding post-PCNL. We analyzed the preoperative characteristics, intraoperative findings, and postoperative course of these patients and compared this with those patients who did not have a severe post-PCNL bleeding. STATISTICAL ANALYSIS USED: Fischer's exact test and Chi-square test were used in univariate analysis. Logistic regression analysis was used in multivariate analysis with a value of P < 0.05 considered statistically significant. RESULTS: Three of the 583 patients (0.51%) who underwent PCNL at our institute required embolization to control bleeding. Preoperative characteristics that were significant risk factors for severe bleeding were a history of ipsilateral renal surgery (P = 0.0025) and increased stone complexity (P = 0.006), while significant intraoperative factors were injury to the pelvicalyceal system (P = 0.0005) and multiple access tracts (P = 0.022). Angiography revealed arteriovenous fistula in two patients and a pseudoaneurysm in seven patients. All patients underwent successful superselective angioembolization with preserved renal perfusion in six patients on control angiography postembolization. CONCLUSIONS: History of ipsilateral renal surgery, increased stone complexity, multiple access tracts, and injury to the pelvicalyceal system are risk factors predicting severe renal hemorrhage post-PCNL. Early angiography followed by angioembolization should be performed in patients with severe post-PCNL bleeding who fail to respond to conservative measures.

Transperitoneal laparoscopic repair of retrocaval ureter: Our experience and review of literature.

CONTEXT AND AIM: Retrocaval ureter (RCU), also known as circumcaval ureter, occurs due to anomalous development of inferior vena cava (IVC) and not ureter. The surgical approach for this entity has shifted from open to laparoscopic and robotic surgery. This is a relatively new line of management with very few case reports. Herein, we describe the etiopathology, our experience with six cases of transperitoneal laparoscopic repair of RCU operated at tertiary care center in India and have reviewed different management options. METHODS: From 2013 to 2016, we operated total six cases of transperitoneal laparoscopic repair of RCU. All were male patients with average age of 29.6 years (14-50). Pain was their only complaint with normal renal function and no complications. After diagnosis with CT Urography, they underwent radionuclide scan and were operated on. Postoperative follow-up was done with ultrasonography every 3 months and repeat radionuclide scan at 6 months. The maximum follow-up was for 2.5 years. RESULTS: All cases were completed laparoscopically. Average operating time was 163.2 min. Blood loss varied from 50 to 100 cc. Ureteroureterostomy was done in all patients. None developed urinary leak or recurrent obstruction postoperatively. Maximum time for the requirement of external drainage was for 4 days (2-4 days). Average postoperative time for hospitalization was 3.8 days. Follow-up ultrasound and renal scan showed unobstructed drainage. CONCLUSIONS: Transperitoneal or retroperitoneal approach can be considered equivalent as parameters like operative time, results are comparable for these two modalities. We preferred transperitoneal approach as it provides good working space for intracorporeal suturing.

Fractured Penis: Not So Rare!

INTRODUCTION: Penile fracture is a relatively common phenomenon. The main problem associated with this condition is the lack of patients' awareness on the urgency of the situation. This study reports the different modes of presentations and treatment results. MATERIALS AND METHODS: We reviewed 21 cases of penile fracture over 5 years. Parameters were mode of injury, age group, time interval before presentation, management, site of injury, urethral involvement, results, complications and erectile function at follow-up. RESULTS: The mean age of patients was 34 years, the mean time interval until presentation was 26 h. Cases involving the right corpus cavernosum comprised 57.14% and 42.85% were cases involving the left corpus cavernosum. Two patients had full circumferential urethral tear. Two patients developed wound infections and 2 patients developed mild penile curvature (<30°). These 4 patients had all presented late for treatment (>40 h). CONCLUSION: Urologists need to consider penile fracture a urological emergency and atypical presentations need to be considered when deciding on management.

Paediatric Post-Traumatic Bladder Neck Distraction Injury: Case Series.

The bladder neck distraction is a rare posterior urethral injury in paediatric age group. It mostly occurs secondary to road traffic accidents. We report three cases of paediatric bladder neck distraction injury. Three paediatric patients aged between 4 to 7 years (mean 5 year), who presented with post traumatic bladder neck distraction injury but no other major injury, they were treated with early urethro-vesical anastomosis. Postoperatively all patients were continent and with good urine flow rates. In paediatric bladder neck distraction injury, immediate urethro-vesical anastomosis gives good results.

Vesicovaginal fistula presenting as a large abdominal pseudocyst: A rare case.

We present a rare case of indirect vesicovaginal fistula (VVF) in a patient with small capacity bladder. The fistula was between abdominal pseudocyst (APC) arising from bladder and vagina - and hence, an indirect VVF. A 35-year-old female had a history of emergency obstetric hysterectomy with iatrogenic bladder injury. Postoperatively, the patient developed VVF and large APC. Patient's micturating cystourethrogram was suggestive of small capacity bladder with bilateral Grade IV vesicoureteral reflux with a well-defined APC arising from superior surface of bladder to L4-L5 lumbar vertebrae. Large APC arising from bladder and associated with an indirect VVF is very rare, and to the best of our knowledge, this is the first case reported in literature. The patient was successfully managed with exploratory laparotomy and excision of fistula tract and pseudocyst, adhesiolysis, and ileal augmentation cystoplasty. Multiple intraoperative adhesions should be suspected in APC. We would like to conclude that ileal augmentation cystoplasty is a safe procedure in a case of VVF with APC and small capacity bladder.