Role of gemcitabine and cisplatin as neoadjuvant chemotherapy in muscle invasive bladder cancer: Experience over the last decade.

OBJECTIVE: Neoadjuvant chemotherapy followed by radical cystectomy is considered the standard of care for patients with muscle invasive bladder cancer. In the last decade, interest in neoadjuvant chemotherapy has slowly shifted from methotrexate, vinblastine, doxorubicin and cisplatin regime to gemcitabine and cisplatin regime. There are many publications on gemcitabine and cisplatin regime in literature which cover different aspects of treatment. This review aims to summarise the findings published so far on gemcitabine and cisplatin regime and present it in a concise manner. METHODS: A systematic literature review was conducted searching the PubMed® database in December 2016 using the medical subject heading (MeSH) with the terms gemcitabine, cisplatin, chemotherapy, muscle invasive bladder cancer, and neoadjuvant. All relevant studies were included and results were analysed. RESULTS: A total of 13 studies were included which published between 2007 and 2015. These 13 studies comprised of 754 subjects suffering from muscle invasive bladder cancer. The proportion of male patients ranged from 60% to 86.4% and the median age ranged from 54.2 to 77.3 years in various studies. Complete pathological response (pT0) was seen in 30.0% of patients and pathological downstaging (

A prospective study evaluating impact on renal function following percutaneous nephrolithotomy using Tc99m ethylenedicysteine renal scan: Does multiplicity of access tracts play a role?

PURPOSE: A prospective study evaluating impact of percutaneous nephrolithotomy (PCNL) on renal function following PCNL using ethylenedicysteine (EC) renal scan. Does multiplicity of access tracts play a role? MATERIALS AND METHODS: A prospective observational study was done and patients undergoing PCNL for renal calculi at our urology department were selected. Renal Tc99m EC scan was done pre-surgery and at 3 months follow-up. An assessment was done on decline in glomerular filtration rate (GFR) in postoperative period based on number of access tracts required. RESULTS: A total of 110 patients were enrolled in the study. The total number of punctures was 170 with 141 being supra-costal puncture and 29 infra-costal. The total number of single punctures were 60 and classified as Group I whereas patients with double puncture and triple puncture (40 and 10 patients, respectively) were classified as Group II. Mean postoperative split renal function (in Tc99m EC scans) of patients of Group I (40.93±19.62%) was found to be higher than that of Group II (32.82±16.98%). Mean change (decline) in GFR for single, double and triple tracts were 2.68 mL/min, 3.80 mL/min, and 4.2 mL/min, respectively. CONCLUSIONS: PCNL used for stone removal can improve renal function by eradicating obstruction; however, this procedure may itself negatively impact the functions of the targeted kidney. Our study showed post PCNL decrease in GFR which worsens with an increasing number of accesses.

Cerebellar infarct following orchidopexy under spinal anesthesia / Infarto cerebelar após orquidopexia sob raquianestesia

Abstract The report describes a case of peri-operative stroke that presented as diplopia and gait difficulty on 2nd post-operative day after routine orchidopexy under spinal anesthesia in an otherwise healthy young boy. Magnetic resonance imaging of the brain revealed acute infarct in bilateral cerebellar hemispheres, left half of medulla and left thalamus. A diagnosis of acute stroke (infarct) was made and patient was started on oral aspirin 75 mg.day-1, following which his vision started improving after 2 weeks. Possible mechanisms of development of stroke in the peri-operative period are discussed, but, even after extensive investigations, the etiology of infarct may be difficult to determine. Acute infarct after elective non-cardiac, non-neurological surgery is rare; it may not be possible to identify the etiology in all cases. Clinicians must have a high index of suspicion to diagnose such unexpected complications even after routine surgical procedures in order to decrease the morbidity and long term sequelae.

Resumo O presente relato descreve um caso de acidente vascular cerebral perioperatório que resultou em diplopia e dificuldade de marcha no segundo dia após orquidopexia de rotina sob raquianestesia em um jovem, em outros aspectos, saudável. Ressonância magnética cerebral revelou infarto agudo em hemisférios cerebelares bilaterais, metade esquerda do bulbo e tálamo esquerdo. Um diagnóstico de acidente vascular cerebral agudo (infarto) foi feito e o paciente começou a receber tratamento com aspirina oral (75 mg.dia-1), após o qual sua visão começou a melhorar após duas semanas. Possíveis mecanismos de desenvolvimento de acidente vascular cerebral no período perioperatório são discutidos, mas, mesmo após extensas investigações, a etiologia do infarto pode ser difícil de determinar. O infarto agudo após cirurgia eletiva não cardíaca e não neurológica é raro; talvez não seja possível identificar a etiologia em todos os casos. Os médicos devem ter um elevado grau de suspeita para diagnosticar essas complicações inesperadas, mesmo após procedimentos cirúrgicos de rotina, para diminuir a morbidade e as sequelas em longo prazo.

[Cerebellar infarct following orchidopexy under spinal anesthesia]. / Infarto cerebelar após orquidopexia sob raquianestesia.

The report describes a case of peri-operative stroke that presented as diplopia and gait difficulty on 2nd post-operative day after routine orchidopexy under spinal anesthesia in an otherwise healthy young boy. Magnetic resonance imaging of the brain revealed acute infarct in bilateral cerebellar hemispheres, left half of medulla and left thalamus. A diagnosis of acute stroke (infarct) was made and patient was started on oral aspirin 75mg.day-1, following which his vision started improving after 2 weeks. Possible mechanisms of development of stroke in the peri-operative period are discussed, but, even after extensive investigations, the etiology of infarct may be difficult to determine. Acute infarct after elective non-cardiac, non-neurological surgery is rare; it may not be possible to identify the etiology in all cases. Clinicians must have a high index of suspicion to diagnose such unexpected complications even after routine surgical procedures in order to decrease the morbidity and long term sequelae.

Misplaced Foley catheter in ureter in a female with neurogenic bladder: a rare complication report.

Accidental placement of Foley catheter in ureter is a rare phenomenon. It is more common in females with neurogenic bladder who have hypocontractile bladder or there can be iatrogenic placement during surgical procedures. We describe a case of a female suffering from upper motor neuronal lesion due to trauma at T8 level (American Spinal Injury grade A) following which she developed neurogenic bladder. A Foley catheter was unintentionally placed in the ureter and subsequently removed through a novel technique of percutaneous ultrasound-guided balloon puncture. It is not only imperative to diagnose and manage such an aberrant Foley catheter placement but also more importantly proper steps must be taken to prevent such a complication from occurring in these patients.

Retroperitoneal teratoma simulating giant adrenal myelolipoma: a diagnostic puzzle.

Teratoma is a germ-cell tumour that is common in para-axial regions. Retroperitoneal teratoma is rare and comprise only about 1% of all teratomas. We present a 21-year-old female who presented with a lump in the abdomen. After radiological investigations, she was diagnosed as case of adrenal myelolipoma which on excision turned out histologically to be retroperitoneal teratoma. Our case highlights the limitation of radiological investigations in preoperative diagnosis of teratoma.

Spontaneous non-obstructive nephropleural fistula with an autoimmune disorder causing massive urinothorax: a rare association.

Urinothorax, an unusual and rare cause of pleural effusion, is usually secondary to urinary obstruction and abdominal trauma. We describe an uncommon case of left-sided urinothorax in a 35-year-old man with diabetes and hypothyroidism associated with an autoimmune disorder without obvious obstructive uropathy. Workup revealed pancytopenia, mild proteinuria, positive anti-nuclear and anti-dsDNA antibodies suggestive of probable systemic lupus erythematosus. Contrast-enhanced CT-chest and abdomen showed hepatosplenomegaly with bilateral renal abscesses and a fistulous connection between left superior calyx and left the pleural cavity. Patient was initially managed by intravenous antibiotics, intercostal tube drainage and ipsilateral double-J stent placement. The definitive management in the form of closure of nephropleural fistula was achieved with sclerotherapy using 0.1% povidone-iodine instillation, while oral steroids were started for the probable autoimmune disorder. To the best of our knowledge, this is the first case of spontaneous non-obstructive nephropleural fistula associated with an autoimmune disorder, managed by minimally invasive methods.

Giant hydronephrosis in a case of ureterocele with duplex system: an entity yet not reported.

Ureterocele, which is a cystic dilatation of the terminal ureter, is usually associated with the upper moiety in a case of the duplex system. Giant hydronephrosis, a rare entity, is usually due to pelviureteric junction obstruction and is usually diagnosed in infants and children. We report a unique case of a unilateral complete duplex system with ureterocele with giant hydronephrosis of the upper moiety in an adult woman presenting as an abdominal lump. To the best of our knowledge, this is the first case of giant hydronephrosis associated with ureterocele in an adult patient.

Congenital prepubic sinus (an epispadiac variant of dorsal urethral duplication) with dorsal penile curvature in an adult man: a rare association.

Urethral duplication is among a very rare congenital disorder with multiple anatomical variants reported. Urethral duplication of complete type is usually diagnosed during childhood with urinary incontinence or double urinary stream as common presentation. However, patients with incomplete urethral duplication usually present with intermittent mucous discharge from the accessory urethral opening. A 20-year-old man presented to us with intermittent mucous discharge from the accessory opening along with dorsal penile curvature making sexual intercourse very difficult. The epispadiac urethral tract with proximal fibrous tract was excised, and the dorsal penile curvature was corrected by ventral plication, implicating that the fibrous cord may be the causative factor for the development of dorsal curvature.

Rare Occurrence of Giant Metastatic Inguinal Lymph Nodes in Carcinoma Bladder.

Inguinal lymph node metastasis of a bladder cancer is a rare scenario. As of today, only 4 cases of inguinal lymph node metastasis from bladder cancer have been reported in the literature. We report a rare giant inguinal lymph node metastasis of transitional cell carcinoma of the bladder in a patient after radical cystoprostatectomy. Chemotherapy and radiotherapy were given, but the metastatic tumor remain unchanged.

Urethrocutaneous fistula mimicking vesicocutaneous fistula: a rare entity.

Urethral fistulas arising from the anterior urethra usually open on the ventral aspect and are located in the penile, scrotal or perineal region. A diabetic 65-year-old man presented with suprapubic urinary fistula that was communicating with a dorsally located internal urethral opening located in the bulbar region. Such unusual fistula has not been described before.

Grading of complications of transurethral resection of bladder tumor using Clavien-Dindo classification system.

INTRODUCTION: Clavien-Dindo classification system is used for grading complications of various oncological, renal, and endourological procedures. We applied this system for grading the severity of perioperative complications in patients undergoing transurethral resection of bladder tumor (TURBT) and identify parameters predicting these complications. MATERIALS AND METHODS: Data of 984 patients who underwent TURBT from 2006 to 2014 were included in this study. All data was retrospectively collected and analyzed for complications occurring within the first postoperative month. All complications were classified according to the five grades of modified CCS (.Clavien classification system). RESULTS: A total of 172 complications were observed in 138 patients. Majority were low grade complications (Grade 1 [77.3%] and Grade 2 [12.7%]). Higher grade complications were rare (Grade 3 [6.4%] and Grade 4 [3.0%]). There was one death (Grade 5 0.6%), with an overall mortality rate of 0.1%. The incidence of complications was significantly greater for age >60 years, baseline serum creatinine >1.4 mg/dl, size of tumor >4 cm, tumor located at dome, resection time >60 min, incomplete resection and if surgery performed by a resident urologist. CONCLUSIONS: Clavien-Dindo classification system can be easily applied to grade the complications of TURBT, and it is easily reproducible. We observed that TURBT was a safe procedure. Majority of complications were Grade 1-2 (90%) and Grade 3-5 were rare (10%). Postoperative bleeding is the most common complication. A greater rate of complications of TURBT was associated with patient age, size of tumor, location of tumor, surgeon experience, resection time, and completion of tumor resection.

Early removal of urinary catheter after excision and primary anastomosis in anterior urethral stricture.

OBJECTIVE: To investigate the feasibility of removing the urinary catheter 7 days after excision and primary anastomosis (EPA) performed with the indication of anterior urethral stricture disease. MATERIAL AND METHODS: Retrospective review of medical records of the patients who had undergone EPA between January 2005 and December 2010 was performed. These patients were divided into 2 groups: Group 1 (urethral catheter removed on or before 7. postoperative day) and Group 2 (urethral catheter removed on 8. postoperative day or later). We compared 2 groups as for the frequency of extravasation as detected on retrograde pericatheter urethrogram (PUG) and recurrence rate till the last follow-up. RESULTS: PUG was performed on an average day 7 and 14 in Groups 1 (n=102) and 2 (n=134), respectively followed by removal of the catheter. Extravasation on the first PUG was detected in 6.8% of the patients in Group 1, and in 4.5% of the cases in Group 2 had extravasation on the first PUG. Urethral catheter was left in situ in these patients and a repeat PUG after one week was performed which was normal in all cases. The incidence of extravasation and recurrence rate did not differ significantly whether catheter was removed on day 7 or 14 (6.8% vs. 4.5% and 4.9% vs. 5.2% respectively) (p>0.5). CONCLUSION: We conclude that removal of the catheter on postoperative day 7 after EPA does not increase the rate of extravasation and recurrence during long-term follow-up. Urethral catheter restricts physical activity in the postoperative period which is bothersome to the patient. Hence early removal of a catheter should be offered to men after EPA.

Holmium Laser vs Monopolar Electrocautery Bladder Neck Incision for Prostates Less Than 30 Grams: A Prospective Randomized Trial.

OBJECTIVE: To compare the efficacy and results of bladder neck incision (BNI) in bladder outlet obstruction (BOO) in men with a small prostate using holmium laser vs conventional monopolar electrocautery technique. MATERIALS AND METHODS: This study included 140 patients of BOO (prostate size ≤ 30 cc, American Urological Association (AUA) score ≥ 8, Qmax ≤ 15 mL/sec, and Schäfer grade ≥ 2) who were randomly assigned to holmium laser BNI (HoBNI) or conventional BNI (C-BNI). AUA score and Qmax were assessed preoperatively and postoperatively at 3, 6, and 12 months. At 6 months, detrusor pressure at Qmax, Schäfer grade, and postvoid residual were assessed. RESULTS: The incidence of postoperative hematuria and blood transfusion in the C-BNI group were 4.2% and 2.8%, respectively. No patient in the HoBNI group developed hematuria or required blood transfusion. Qmax and AUA score at each follow-up, and Pdet Qmax, Schäfer grade, and postvoid residual at 6 months were comparable between two groups but showed significant improvement when compared to baseline in both the groups. At 6 months, 2.9% patients in the HoBNI group and 4.3% in the C-BNI group remained obstructed urodynamically and underwent reoperation (P > .05). The incidence of retrograde ejaculation was significantly higher in HoBNI (22.9% vs 6.1%, P -.02) CONCLUSION: Both procedures are equally efficient in relieving BOO in patients with prostate size < 30 cc and have similar success rates. The risk of postoperative hematuria is less with HoBNI because of its better hemostatic properties, but its use must be counterbalanced with significant increase in incidence of retrograde ejaculation.

Vesicovaginal fistula following insertion of a foreign body in the vagina for sexual gratification: could it be catastrophic?

In developing countries such as India, the vesicovaginal fistula (VVF) is a commonly found entity in urogynaecology. VVFs secondary to obstructive labour still remain the most common cause in these countries. We report a very unusual case of a VVF in a young woman that developed due to self-insertion of a plastic box for sexual gratification.