Modified Technique of Doubly Folded Peritoneal Flap Interposition in Transabdominal Vesicovaginal Fistula Repair: Our Experience of 36 Cases.

PURPOSE: Correction of vesicovaginal fistula (VVF) using interpositional flaps is an established procedure. In open repair, omental flap gives good results. However, its availability in all the cases is questionable. We utilized our technique of doubly folded peritoneal flap and assessed the outcome of the repair. METHODS: Retrospective observational study included 36 cases of open VVF repair, performed during 2010-2019. Preoperative clinical examination, cystoscopy, and imaging were performed routinely. Open transvesical repair as described by O'Conor was performed and doubly folded peritoneal flap was utilized. Intra- and postoperative parameters were recorded. The outcome was assessed after 21 days of catheter removal. A minimum of 6 months of follow-up was done. RESULTS: Mean age was 44 ± 18 years, and 97.2% of VVF were iatrogenic, mainly after hysterectomy (75.0%) and caesarean section (22.2%). Fistula size ranged from 0.6 to 5.5 cm. Five cases had multiple fistulas and 3 cases were recurrent. Mean flap length and width were 8.0 ± 2.4 and 5.1 ± 1.1 cm, respectively. Mean operative time and estimated blood loss were 94 ± 15 min and 155 ± 45 mL, respectively. Fourteen of 36 patients developed complications of Clavien-Dindo grade I/II. Thirty-five out of 36 cases (97.2%) were cured and remained dry for 6 months after surgery. Three cases reported de-novo urgency and were treated medically. Satisfaction level was good in 91.2% of cases. CONCLUSION: Transvesical repair using doubly folded peritoneal flap provides an excellent and durable outcome. It is a suitable alternative to the omental interpositional flap.

A novel triple oral regime provides effective analgesia during extracorporeal shockwave lithotripsy for renal stones.

CONTEXT: Analgesia during extracorporeal shockwave lithotripsy for renal stone is an essential component. It not only makes the procedure comfortable but also increases the stone-free rate. AIMS: The aim of this study was to evaluate the efficacy of triple oral analgesic agents on stone fragmentation and pain relief in comparison to injectable analgesic agents. SETTINGS AND DESIGN: This prospective randomized study included 68 patients of renal calculi of size 5-15 mm. SUBJECTS AND METHODS: Group A had 32 patients, who received injection pentazocine and injection diclofenac, 45 min before the procedure. Group B consisted of 28 patients, who received a combination of oral acetaminophen, 325 mg, oral diclofenac 50 mg, and oral tramadol 37.5 mg, 45 min prior. Procedural findings, pain score visual analog scale (VAS), fragmentation rate, and outcome were recorded. STATISTICAL ANALYSIS USED: Independent t-test and Pearson's correlation test. RESULTS: A total of 60 patients were analyzed. The mean age was 40.2 ± 11.8 years. Both groups were comparable in body mass index, stone size, number, and density. Group A required more shocks than Group B (4274 vs. 3693, P = 0.043). A lower energy level of shocks (kV) was tolerated in Group A (2.5 vs. 3.2, P = 0.002). Group A required more sittings than Group B (2.3 vs. 1.9, P = 0.037). VAS score was significantly less in Group B (2.9 vs. 4.9, P = 0.0001). The overall fragmentation rate was similar among groups (81.2% vs. 89.3%); hence, the successful outcome was (59.4% vs. 75.0%, P = 0.274). The occurrence of adverse events was also equivalent in both groups (P = 0.199). CONCLUSIONS: Triple oral regime provides better analgesic effect and quicker stone-free rate than injectable agents but with similar final outcome.

Association and prognostic value of serum Cystatin C, IL-18 and Uric acid in urological patients with acute kidney injury.

PURPOSE: To assess the role of serum Cystatin C, IL-18 and Uric acid in acute kidney injury (AKI) in urological patients, along with their prognostic significance. MATERIALS AND METHODS: Prospective observational study included 61 cases, admitted in urology ward with baseline serum creatinine ≤1.5 mg/dL. All patients had at least one or more predisposing factors for AKI. Daily urine output and creatinine level were checked. Serum levels of biomarkers were measured at baseline and postoperatively after 24 h. Development of AKI and its outcome were analysed. RESULTS: Thirty nine patients (63.9%) developed AKI in the study. Patients with AKI were found to have a greater percentage rise of Cystatin C (118.7% v/s 81.8%, p = 0.005), IL-18 (59.0% v/s 25.5%, p = 0.004) and Uric acid (34.3% v/s 19.2%, p = 0.008) after 24 h. Absolute Uric acid level at day 1 was also significantly associated with AKI (5.18 ±â€¯0.91 v/s 4.45 ±â€¯0.86, p = 0.003). Risk stratification of AKI was poor for all biomarkers. Area under curve for Cystatin C, IL-18 and Uric acid was 0.715, 0.696 and 0.734 respectively. Renal function after 3 months, had a positive correlation with baseline creatinine and baseline Cystatin C levels (r = 0.56 & 0.39). CONCLUSIONS: Postoperative serum Cystatin C, IL-18 and Uric acid after 24 h were significantly associated with AKI. Baseline Cystatin C had moderate capability to predict short term renal function.

Isolated Involvement of Penis in Fournier's Gangrene: A Rare Possibility.

skin and subcutaneous tissue. Penis may be secondarily affected in some cases; however, primary isolated involvement of penis is rare. A 48-year male smoker presented with pain and blackish discoloration of the distal part of penis for the last 4 days which developed following rupture of a papulo-vesicular lesion over the prepuce of penis. It rapidly progressed to involve half of the skin of the penis. The patient was hospitalized and broad spectrum antibiotics were administered parenterally. Emergency wound debridement and urinary diversion by suprapubic cystostomy was done. After repeated wound debridement and dressings, the wound healed. Our case was unusual as the penis was the sole site of affection, which is very unusual and only few such cases are reported in the literature.

Giant Pyonephrosis Due to Ureteropelvic Junction Obstruction: A Case Report.

Pyonephrosis is a suppurative infection of upper urinary tract due to obstruction of the ureter. It is usually associated with suppurative damage of renal parenchyma and renal function loss. Patients are mostly symptomatic but may remain asymptomatic in 15% of cases. Severe infection in pyonephrosis may lead to urosepsis and may endangered life, if timely not treated with surgical intervention. We hereby report a rare case of Giant Pyonephrosis (GP), contained 11 liters of pus, due to Ureteropelvic Junction (UPJ) obstruction presented with haematuria. The patient was treated with open nephrectomy. The aetiology, clinical features, diagnosis and management of pyonephrosis with the review of literature of GP in the background of a rare case report have been discussed here.

Can a brief period of double J stenting improve the outcome of extracorporeal shock wave lithotripsy for renal calculi sized 1 to 2 cm?

PURPOSE: Extracorporeal shock wave lithotripsy (ESWL) is an established modality for renal calculi. Its role for large stones is being questioned. A novel model of temporary double J (DJ) stenting followed by ESWL was devised and outcomes were assessed. MATERIALS AND METHODS: The study included 95 patients with renal calculi sized 1 to 2 cm. Patients were randomized into 3 groups. Group 1 received ESWL only, whereas group 2 underwent stenting followed by ESWL. In group 3, a distinct model was applied in which the stent was kept for 1 week and then removed, followed by ESWL. Procedural details, analgesic requirements, and outcome were analyzed. RESULTS: Eighty-eight patients (male, 47; female, 41) were available for analysis. The patients' mean age was 37.9±10.9 years. Stone profile was similar among groups. Group 3 received fewer shocks (mean, 3,155) than did group 1 (mean, 3,859; p=0.05) or group 2 (mean, 3,872; p=0.04). The fragmentation rate was similar in group 3 (96.7%) and groups 1 (81.5%, p=0.12) and 2 (87.1%, p=0.16). Overall clearance in group 3 was significantly improved (83.3%) compared with that in groups 1 (63.0%, p=0.02) and 2 (64.5%, p=0.02) and was maintained even in lower pole stones. The percentage successful outcome in groups 1, 2, and 3 was 66.7%, 64.5%, and 83.3%, respectively (p=0.21). The analgesic requirement in group 2 was higher than in the other groups (p=0.00). Group 2 patients also had more grade IIIa (2/3) and IIIB (1/2) complications. CONCLUSIONS: Stenting adversely affects stone clearance and also makes the later course uncomfortable. Our model of brief stenting followed by ESWL provided better clearance, comfort, and a modest improvement in outcome with fewer sittings and steinstrasse in selected patients with large renal calculi.

Tuberculosis of the glans penis mimicking as carcinoma.

Penile tuberculosis (TB) is an uncommon variety of genitourinary TB. It is either primary (via local spread) or secondary (spread of infection from other organs). We encountered a case of rapidly growing penile ulceration, resembling carcinoma. Biopsy revealed the classic picture of TB, which responded well to antitubercular treatment.

Adult Idiopathic Renal Vein Thrombosis Mimicking Acute Pyelonephritis.

Renal Vein Thrombosis (RVT) is a rarely encountered condition. It occurs due to a hypercoagulable state in the body, caused by nephrotic syndrome and membranous nephropathy in the adults. Mode of presentation is variable. In chronic form, it may remain silent for a long time and presenting later with symptoms of pedal oedema, varicocele, proteinuria. In acute state, it manifests as flank pain, nausea or haematuria. We present a case of 25-year-old male, with left sided flank pain, haematuria and nausea for 4 days. Ultrasound showed enlarged kidney with altered echogenecity. No calculus was found on x-ray. Empirical antibiotics were started considering possibility of Acute Pyelonephritis (APN). With no improvement seen after 3 days along with no growth on urine culture, CT-urography was done. It revealed enlarged non-excreting left kidney with thrombus seen over left renal vein extending into Inferior Vena Cava (IVC). Immediate anticoagulant therapy was started. Patients recovered gradually and after 6 months, follow-up CT showed disappearance of thrombosis. Anticoagulants were withdrawn gradually. So we highlight the possibility of RVT as a differential diagnosis to APN or renal colic and its evaluation and management.

Emphysematous cystitis-gas in bladder: a rare urological emergency.

Emphysematous cystitis is an unusual inflammatory condition characterised by the presence of air within the bladder wall and lumen. It is usually seen in patients with diabetes, and in those with long-term catheterisation or of immunocompromised status. Its presentation varies from asymptomatic to frank urosepsis. It is diagnosed after radiological studies. Treatment requires establishment of prompt urinary drainage, antibiotic coverage and correction of offending factors, if any. We report a case of 41-year-old, non-diabetic, otherwise healthy woman presenting with lower urinary tract symptoms with pneumaturia, which was managed conservatively. A review of the recent literature is also presented.

Spontaneous discharging umbilical sinus secondary to infected cystic teratoma ovary: an atypical presentation.

Mature cystic teratomas are the most common ovarian neoplasm in patients younger than 20 years. Its complications include torsion, rupture, infection and malignant degeneration. Infection of teratoma is an uncommon event. We are reporting the first ever case of infected mature cystic teratoma presented as a chronic discharging sinus via umbilicus. 30 years old young primipara presented with complaint of seropurulent discharge from umbilicus for 6 months. Ultrasonography showed right sided complex adnexal mass. Umbilical exploration revealed sinus tract travelling deep into the pelvis attached to right ovarian mass. Salpingo- oopherectomy was done on right side and sinus tract excised. Cut-section of specimen showed heterogeneous mass of soft tissue with intact capsule containing hairs, cheesy white purulent material, fat and cartilage. Biopsy was suggestive of mature ovarian cystic teratoma.