Intraoperative floppy iris syndrome in Indian population: a prospective study on incidence, risk factors, and impact on operative performance.

PURPOSE: The purpose of this study was to evaluate the incidence, risk factors, and impact of intraoperative floppy iris syndrome (IFIS) on surgical performance. MATERIALS AND METHODS: Consecutive cataract surgeries from October 2010 to Feb 2011 (1003 eyes, 980 patients; 568 males, 412 females) were analyzed prospectively. Operating surgeon, masked about medication history, noted the intraoperative details. Cases were identified as IFIS or non-IFIS. Multivariate analysis was performed to find risk factors for IFIS. RESULTS: Prevalence of tamsulosin use among men undergoing cataract surgery was 7.0% (41) with incidence of IFIS 4.78% (48). On multivariate analysis, hypertension (OR: 3.2, 95% confidence interval, 95% CI: 1.39-6.57; P = 0.005), use of tamsulosin (OR: 133.32, 95% CI: 50.43-352.48; P < 0.0001), or alfuzosin (OR: 9.36, 95% CI: 2.34-37.50; P = 0.002) were the factors associated with IFIS. Among men taking tamsulosin (n = 41) and alfuzosin (n = 28), 68.3% and 16.6% developed IFIS, respectively. In subgroup analysis of men on tamsulosin, no factor added to the risk posed by tamsulosin. Seventeen of 944 eyes not exposed to any drug had IFIS (0.018%). On subgroup analysis, only risk factor for IFIS was hypertension (OR: 4.67, 95% CI: 1.63-13.35; P = 0.002). Of 48 IFIS eyes, the surgeon observed increased difficulty in 57.1% (21) and additional measures were required in 9 eyes. Mean operative time was increased in IFIS eyes (11.68 ± 3.46 vs. 10.01 ± 0.22 min; P = 0.001). Surgical outcome was good in all cases. CONCLUSION: The prevalence of tamsulosin intake and IFIS incidence is higher in India. Current tamsulosin/alfuzosin use and hypertension are important risk factors. IFIS makes the surgery more difficult, significantly prolongs the operative time, and predisposes for other intraoperative complications. However, with appropriate management, final operative outcome is not affected.

Factors affecting response to medical management in patients of filarial chyluria: A prospective study.

INTRODUCTION: Filarial chyluria is a common problem in filarial endemic countries. Its management begins with medical therapy but some patients progress to require surgery. The present study aimed to determine factors affecting response to medical management in patients of filarial chyluria. MATERIALS AND METHODS: This prospective study conducted between August 2008 and November 2012, included conservatively managed patients of chyluria. Demographic profile, clinical presentation, treatment history and urinary triglycerides (TGs) and cholesterol levels at baseline were compared between the responders and non-responders. Apart from the clinical grade of chyluria, hematuria was evaluated as an independent risk factor. RESULTS: Out of the 222 patients (mean age, 37.99 ± 13.29 years, 129 males), 31 patients failed to respond while 35 had a recurrence after initial response; the overall success rate being 70.3% at a mean follow-up of 25 months. No difference was observed in demographics, clinical presentation, presence of hematuria, disease duration and mean urinary TGs loss between responders and non-responders. On multivariate analysis, patients with treatment failure were found to have a higher-grade disease (14.3% Grade-I, 36.6% Grades-II and 60% Grade-III), higher number of pretreatment courses (1.59 ± 1.08 vs. 1.02 ± 0.79) and heavier cholesterol (26.54 ± 23.46 vs. 8.81 ± 8.55 mg/dl) loss at baseline compared with responders (P < 0.05). CONCLUSION: Conservative management has a success rate in excess of 70%, not affected by the disease chronicity, previous episodes and recurrent nature. However, higher-grade disease, extensive pre-treatment with drugs and higher urinary cholesterol loss at baseline are the predictors of poor response. Hematuria is not an independent poor risk factor for conservative management.

Magnetic resonance-retrograde pyelography: A novel technique for evaluation of chyluria.

There are no standardized radiological investigations in a patient with chyluria. Retrograde pyelography (RGP) is usually done to demonstrate pyelo-lymphatic reflux before invasive therapy in the form of sclerotherapy and surgery. We describe magnetic resonance-RGP using gadolinium to demonstrate pyelo-lymphatic reflux in addition to the other intra-abdominal details provided by MRI. The advantages of this technique include avoidance of ionic contrast media and radiation exposure and possibility of better understanding of the disease pathophysiology.

A critical appraisal of complications of percutaneous nephrolithotomy in paediatric patients using adult instruments.

OBJECTIVE: To evaluate the complications (using the CROES Clavien scoring system) and various factors affecting them in children undergoing percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: We analysed prospectively maintained data of paediatric PCNL (patients ≤17 years) from January 2008 to December 2012. Stone complexity was defined according to validated Guy's stone score (GSS). Procedures were performed in the prone position by experienced urologists. The tract was dilated (24-30F) under fluoroscopic guidance, and an adult rigid nephroscope complemented with a cystoscope/ureteroscope were used. Complications were recorded according to the CROES-Clavien score, recently defined by the Clinical Research Office of the Endourological Society (CROES) Study Group. RESULTS: The study group comprised 158 procedures performed in 153 children (98 boys and 55 girls), with a mean (range) age 10.03 ± 4.51 (2-17) years. The mean (range) stone burden was 376.68 ± 265.23 (150-2400) mm(2) . The distribution of cases according to the GSS was 31% grade I, 35.4% grade II, 19% grade III, and 14.6% grade IV. The stone-free rate of PCNL monotherapy was 85.4%, which increased to 93.7% after relook PCNL/extracorporeal shock wave lithotripsy. In all, 62 children (39.2%) had operative complications; 84% were minor, i.e. Clavien grade 1/2, and managed conservatively. Stone size, GSS, tract size, number of punctures and operation duration were significantly associated with complications on univariate analysis (P < 0.05). However, on multivariate logistic regression analysis, operation duration was the only independent risk factor associated with complications (95% confidence interval: 1.013-1.065, odds ratio = 1.04; P = 0.038). CONCLUSIONS: Percutaneous nephrolithotomy in children using adult instruments is an effective and safe procedure for managing simple as well as complex renal calculi. Assignment of specific Clavien scores to all possible PCNL complications by the CROES PCNL Study Group have improved precision in reporting complications in a standard objective format, including the minor ones. Such models are very useful for making inter-observer comparisons to obtain clinically relevant inferences. Mean operation duration is the only independent factor affecting complications of the procedure.

Transurethral resection of prostate abscess: is it different from conventional transurethral resection for benign prostatic hyperplasia?

Purpose. To present our experience of prostate abscess management by modified transurethral resection (TUR) technique. Methods. Seventeen men with prostate abscess undergoing TUR between 2003 and 2011 were retrospectively analyzed. Details of demography, surgical procedures, complications, and followup were noted. Results. With a mean age of 61.53 ± 8.58 years, all patients had multifocal abscess cavities. Initially, 6 men underwent classical TUR similar to the technique used for benign prostatic enlargement (group 1). Next, 11 men underwent modified TUR (group 2) in which bladder neck and anterior zone were not resected. The abscess cavities resolved completely, and no patient required a second intervention. One patient in group 1 and three in group 2 had postoperative fever requiring parenteral antibiotics (P = 0.916). Three patients in group 1 had transient urinary incontinence, whereas none of the patients in group 2 had this complication (P = 0.055). Four and five men in group 1 and 2 reported retrograde ejaculation, respectively (P = 0.740). Conclusion. The modified technique of prostate resection edges over conventional TURP in the form of reduced morbidity but maintains its high success rate for complete abscess drainage. It alleviates the need for secondary procedures, having an apparent advantage over limited drainage techniques. Use of this technique is emphasized in cases associated with BPH and lack of proper preoperative imaging.

Stress urinary incontinence as a rare presentation of large prostatic stones in neurogenic bladder: implications and management.

We report a case of a 38-year-old man with a background of a neglected neurogenic bladder, who presented with a recent onset history of stress urinary incontinence. He was diagnosed as having large prostatic stones along with a low-compliance, small capacity bladder and bilateral hydronephrosis with deranged renal functions. As self-catheterisation was not possible due to obstructing prostatic stones, holmium-YAG laser lithotripsy of prostatic stones was performed as initial procedure that resulted in complete resolution of stress incontinence as well. Successful gastrocystoplasty was performed as a second step to deal with the underlying condition of neurogenic poorly compliant bladder. The present case describes the successful endoscopic management of prostatic calculi using holmium-laser lithotripsy and draws attention to other important issues that need to be addressed in certain special situations like neurogenic bladder.

Transurethral holmium-YAG laser lithotripsy for large symptomatic prostatic calculi: initial experience.

Symptomatic prostatic calculi are a rare clinical entity with wide range of management options, however, there is no agreement about the preferred method for treating these symptomatic calculi. In this study we describe our experience of transurethral management of symptomatic prostatic calculi using holmium-YAG laser lithotripsy. Patients with large, symptomatic prostatic stones managed by transurethral lithotripsy using holmium-YAG laser over 3-year duration were included in this retrospective study. Patients were evaluated for any underlying pathological condition and calculus load was determined by preoperative X-ray KUB film/CT scan. Urethrocystoscopy was performed using 30° cystoscope in lithotomy position under spinal anesthesia, followed by transurethral lithotripsy of prostatic calculi using a 550 µm laser fiber. Stone fragments were disintegrated using 100 W laser generators (VersaPulse PowerSuite 100 W, LUMENIS Surgical, CA). Larger stone fragments were retreived using Ellik's evacuator while smaller fragments got flushed under continuous irrigation. Five patients (median age 42 years) with large symptomatic prostatic calculi were operated using the described technique. Three patients had idiopathic stones while rest two had bulbar urethral stricture and neurogenic bladder, respectively. Median operative time was 62 min. All the patients were stone free at the end of procedure. Median duration of catheterization was 2 days. Significant improvement was observed in symptoms score and peak urinary flow and none of the patient had any complication. Transurethral management using holmium-YAG laser lithotripsy is a safe and highly effective, minimally invasive technique for managing symptomatic prostatic calculi of all sizes with no associated morbidity.

Incidentally detected bilaterally symmetrical seminal and vas calcification in young infertile male: a case report, literature review and algorithm for diagnosis.

Bilateral seminal and vas calcification is not common, especially in young age. Association with many disease conditions has been described, with diabetes mellitus being the most common association. A 34-year-old man presented with primary infertility and right upper ureteric calculus. His evaluation revealed extensive, bilateral seminal and vas calcification with normal semen analysis and first-time detected diabetes mellitus. His female partner was evaluated and found to have bilateral fallopian tubes blockage. We reviewed the literature and present here the algorithm for diagnosis of such patients, along with details of this particular patient.

Spontaneous erosion of ureterocele wall by stone: rare images.

The incidence of ureterocele at autopsy is estimated to be in 1/500 to 1/4000. A solitary stone in a single ureterocele is common, with a prevalence of 4%-39%. However, spontaneous rupture of the ureterocele wall by a stone has not been reported, to the best of our knowledge. We report the case of a 35-year-old man with right-side ureterocele, complicated by a stone that spontaneously eroded the ureterocele wall.

Pelvi-ureteric junction obstruction in autosomal-dominant polycystic kidney disease: an association yet to be reported.

Autosomal-dominant polycystic kidney disease (ADPKD) is the most common inherited renal cystic disease. It is characterised by the development of renal parenchymal cysts and a variety of other extrarenal manifestations. Pelvi-ureteric junction (PUJ) obstruction has not been described in association with ADPKD in the literature. We present a case of a 23-year-old man presenting with bilateral flank pain. On evaluation he was diagnosed to have ADPKD with bilateral renal calculi and left-sided PUJ obstruction. He underwent successful right percutaneous nephrolithotomy and left laparoscopic dismembered pyeloplasty with simultaneous stone removal.