Unilateral Versus Bilateral Vasoepididymal Anastomosis for Idiopathic Obstructive Azoospermia: A Randomised Controlled Trial.

Background: Men with idiopathic obstructive azoospermia (OA) are candidates for surgical reconstruction with a vasoepididymal anastomosis (VEA) performed on one or both testis. There are no randomised trials comparing the success of unilateral versus bilateral VEA. Objective: We conducted a randomised trial to compare the two surgical options. Design setting and participants: Between April 2017 and March 2022, men with infertility due to idiopathic OA were randomised to a unilateral (group 1) or bilateral (group 2) VEA in an ethics committee-approved clinical trial, registered with the Clinical Trials Registry. Outcome measurements and statistical analysis: The primary outcome was successful surgery, defined as appearance of sperm in the ejaculate, evaluated at 3 mo intervals after surgery. Additional outcomes were pregnancy rates and complications between the two groups. Men with successful surgery were compared with those without patency to identify the predictors of success. Results and limitations: Fifty-four men fulfilled the criteria and 52 who completed follow-up were included in the analysis. The overall patency rate was 36.5% (19/52 individuals). This was higher in men with bilateral surgery (12/26 patients, 46%) than in those with unilateral surgery (7/26 patients, 27%) but was not statistically significant (p = 0.1). The overall pregnancy rate with ejaculated sperm was significantly higher in the bilateral surgery group (4 vs 0, p = 0.037), while the spontaneous conception rate was higher but not statistically significant (3 vs 0, p = 0.074). The complication rates in the two groups were similar (p = 0.7), and all complications were Clavien-Dindo grade 1. Although bilateral surgery and presence of sperm in epididymal fluid were higher in men with patency, these were not statistically significant. Conclusions: A bilateral VEA was associated with higher patency and spontaneous pregnancy rates than unilateral surgery, but the results were not statistically significant. However, the overall pregnancy rate with ejaculated sperm, spontaneous and assisted, was significantly higher in the bilateral surgery group. Patient summary: In this study, we compared between unilateral and bilateral reconstructive surgery in azoospermic men and found better overall success with bilateral surgery. However, these results were not statistically significant.

Evaluation of cell-free seminal mRNA for the diagnosis of obstruction as the cause of azoospermia in infertile men: A prospective cohort study.

Differentiating obstructive (OA) from non-obstructive (NOA) azoospermia is clinically important in managing infertile men. Classically, the differentiation has been based on clinical, hormonal and histological analysis. Histological tests are invasive and may miss spermatogenic areas. Seminal fluid can serve as a medium to assess the status of spermatogenesis and presence or absence of certain markers can help diagnosing and differentiating azoospermia. We evaluated the role of cell-free seminal markers: DDX4, PRM1 and PRM2 in diagnosing and differentiating between OA and NOA and classifying their subtypes. We observed DDX4 was more sensitive for NOA compared with OA. Among various subtypes of NOA, DDX4 positivity was higher in patients with maturation arrest and hypospermatogenesis compared with Sertoli cell only syndrome. PRM1 and PRM2 had very low positivity rate for any meaningful comparison. Seminal cell-free markers can serve as non-invasive tests in diagnosing and differentiating etiologies of azoospermia but their validity needs to be proved in long-term trials with more refined molecular techniques.

Contemporary Outcomes of Open Radical Cystectomy: a 5-Year Experience from a Tertiary Care Center.

To evaluate the perioperative outcomes of patients undergoing open radical cystectomy for carcinoma bladder in a tertiary care center. A retrospective analysis of a prospectively maintained database of all patients undergoing open radical cystectomy with a urinary diversion from July 2014 to August 2019 was done. A total of 195 patients were included. A total of 172 patients (88.2%) underwent radical cystectomy with ileal or sigmoid conduit, 6 patients underwent orthotopic neobladder, and 17 patients underwent cutaneous ureterostomy. The mean American Society of Anaesthesiology (ASA) score was 1.4. On preoperative histopathology, 125 patients had the muscle-invasive disease. The mean operative time (± SD) was 303.6 ± 53.4 min and the operative time was significantly longer for neobladder (p = 0.033). The mean blood loss (± SD) was 977.5 ± 346.5 ml. Among the complications, a total of 350 events occurred in 96 patients (49.3%). Thirty-nine patients (20%) suffered grade I complications, 12 patients (6.2%) suffered grade II complications, 26 patients (13.3%) suffered grade III complications, and 9 patients (4.6%) suffered grade IV complications. Grade III, IV, and V complications were considered major complications and 46 patients (23.5%) had major complications. Among the grade III complications, the majority included fascial dehiscence (burst abdomen), i.e., 13.3%, and uretero-ileal leak, i.e., 2.6%. The overall 30-day mortality rate was 5.2% (10/195). On multivariate analysis, the presence of diabetes mellitus (p = 0.047), operative time (p = 0.003), and low preoperative albumin (p = 0.009) were significant predictors for major preoperative complications. Diabetes mellitus, serum albumin, and operative time are significant predictors of postoperative complications. The ASA score, low preoperative hemoglobin, and blood loss are significant predictors of perioperative mortality. Though radical cystectomy has been associated with significant perioperative morbidity and mortality, the advancements in surgical techniques and intensive care tools have led to a significant decrease in morbidity and mortality in the contemporary era.

Multimodal management of locally advanced rhabdoid tumour of the kidney in an adult.

Malignant rhabdoid tumours of the kidney (MRTK) are rare paediatric tumours known for their aggressive nature and early metastasis. However, MRTK in adults are even more rare with only a few cases reported in the literature. Herein, we report a case of 65-year-old woman with rapidly progressive left renal mass requiring en-bloc radical nephrectomy, splenectomy and distal pancreatectomy. Histopathology revealed a malignant rhabdoid tumour with characteristic histological and immunohistochemical findings with negative margins. To the best of our knowledge, this is the first reported case of aggressive surgical management of locally advanced MRTK. Despite surgery with curative intent, the patient developed early recurrence and started on tyrosine kinase inhibitor. Unfortunately, the patient expired after 8 months of surgery due to disease progression.

Percutaneous Management of Persistent Urine Leak After Partial Nephrectomy: Sealing the Leak Site with Glue.

Background: Localized urinary extravasation is a known complication after partial nephrectomy; however, rarely it forms a nephrocutaneous fistula. Nephrocutaneous fistula after partial nephrectomy is a management challenge for the treating surgeon. It is typically managed with indwelling ureteral stent placement. Persistent fistula after indwelling ureteral stent can be managed with percutaneous nephrostomy drainage. However, persistence after all these measures is a real therapeutic dilemma. Few reports are available on effective management of persistent urine leak by percutaneous obliteration of leak site using glue. Case Presentation: We report one such rare case of persistent nephrocutaneous fistula in a 41-year-old man of Indo-Aryan ethnicity. He was managed effectively with percutaneous cyanoacrylate glue application, when all the conservative methods failed. At 6 months follow-up he is doing well clinically and radiologically. Conclusion: Persistent nephrocutaneous fistula after partial nephrectomy is a rare and highly morbid condition, which leads to multiple intervention and prolonged hospital stay. Percutaneous glue application is a potential therapeutic approach to tackle such cases with good results.

Outcomes in morbidly obese adolescent patients undergoing laparoscopic sleeve gastrectomy in the Indian subcontinent: A retrospective review.

INTRODUCTION: There is a worldwide increase in the prevalence of obesity among the adolescent population in India from 16.3% in 2001 to 19.3% in 2010. Recent evidence suggests that bariatric surgery leads to resolution of comorbidities and associated long-term complications in adolescent patients with morbid obesity. AIM: The aim of this study is to determine the impact of bariatric surgery on the weight loss and comorbidities of morbidly obese adolescents. MATERIALS AND METHODS: A retrospective review of the data of 10 adolescent patients, who underwent Laparoscopic Sleeve Gastrectomy at our institute (tertiary care hospital), from July 2009 to July 2016 was carried out. RESULTS: Of the 10 patients, 4 patients had syndromic forms of obesity. The median age was 16.54 years. The median pre-operative weight and height were 112 kg and 154 cm, respectively, with a body mass index of 47.2 kg/m2. There was no intra-operative or post-operative complication except for suspected methylene blue toxicity in one patient which was treated conservatively. Median follow-up period was 1 year (0-5 years). The patients had an increase in excess weight loss (EWL) of 54.5% until the end of 1 year. There was a regain of weight between the 1st and 2nd year, followed by a sustained weight loss achieving 44.8% EWL at 3 years and 60% at the end of 5 years (only two patients followed up at 5 years). Similar results were found in syndromic patients. Among the four diabetic patients, three had complete resolution and one had improvement in diabetes status. Among the three patients with obstructive sleep apnoea, two patients had complete resolution, while one patient had improvement in symptoms. One patient with hypocortisolism improved after surgery with a decrease in the steroid requirement. Among the hypothyroid patients, one patient had a complete resolution, one patient had improvement in hypothyroid status while two patients had no change. CONCLUSION: Bariatric surgery is effective for morbidly obese adolescents, leading to significant resolutions of comorbid illness.

A Case of Type 1 Papillary Renal Cell Cancer with Pelvic Tumor Thrombus Masquerading as Urothelial Cancer with Review of Literature.

Background: Adult renal tumors vary from renal cell carcinoma (RCC) to upper tract urothelial cancer (UTUC). Tumor characteristics such as renal vein and inferior vena cava tumor thrombus are usually seen with RCC, but tumor thrombus into pelvicaliceal system (PCS) is a rare entity in RCC. At present only 11 cases have been reported in the literature. Case Presentation: We report an unusual case of papillary type 1 RCC in a young Muslim man mimicking as UTUC radiologically and found to have free tumor thrombus in PCS. At follow-up of 6 months after right nephroureterectomy with bladder cuff excision, he is doing well clinically and radiologically without any recurrence. Conclusion: RCC with tumor thrombus into PCS is an uncommon entity. It can give similar appearance as an urothelial cancer of the pelvis on radiologic imaging. Pelvic tumor thrombus is now considered as a factor of poor prognostic importance and rarely encountered with pure papillary type of RCC.

Combined caesarean with splenectomy in pregnancy with portal hypertension: defining plausibility.

24-year-old woman at 28 weeks gestation was referred from peripheral hospital with diagnosis of pregnancy with portal hypertension. She had received multiple transfusion for pancytopaenia in the past and had undergone endoscopic sclerotherapy for oesophageal varices. Initially, she was admitted in our hospital at 28 weeks gestation for blood transfusion and was evaluated by multispecialty team of doctors. She was advised splenectomy for transfusion-dependent pancytopaenia secondary to hypersplenism in non-cirrhotic portal hypertension. She was readmitted at 36 weeks gestation. A decision for caesarean was taken owing to failed induction of labour at 38 weeks gestation. She underwent combined caesarean with splenectomy. Mother and child had an uneventful postoperative recovery and were discharged on ninth postoperative day. Preconceptional counselling, treatment of oesophageal varices and multispecialty approach was paramount in the management. Combined caesarean with splenectomy is feasible and cost-effective treatment associated with improved quality of life. Prospective clinical trials are essential to prove safety and efficacy of treatment.