Does Preoperative Function Affect the Outcome Following Pyeloplasty in Poorly Functioning Kidneys among Pediatric Population?

AIM: To determine the efficacy and outcome of pyeloplasty in poorly functioning kidneys in the pediatric population and whether pyeloplasty could be offered as an upfront procedure in such patient population, instead of nephrectomy. MATERIALS AND METHODS: A retrospective data analysis of 83 patients who underwent pyeloplasty in poorly functioning kidneys from 2010 to 2015 was performed. Success was defined based on improvement in symptoms, stable or improved function, and better drainage on post-operative Tc-99m Diethylene Triamine Pentaacetic acid scan instead of DTPA scan renography done after 3 months and yearly thereafter. RESULTS: Eighty-three patients with a mean age of 6.8 ± 2.88 years with poor function on isotope renogram (<30%) were included in the study. Three patients were excluded in view of postoperative outflow obstruction. Out of the remaining 80 patients, 56 were male and 24 were female. They were divided into two groups based on preoperative differential renal function (DRF), Group I (n = 26) having preoperative DRF of <10% and Group II (n = 54) having preoperative DRF of 10%-30%. All patients underwent laparoscopic dismembered pyeloplasty with ureteral stenting. The mean DRF improved from 7.58 ± 2.39 to 29.71 ± 5.16 postoperatively in Group I. However, in Group II, DRF improved from 20.81 ± 5.68 to 37.25 ± 7.11 postoperatively. At a follow-up of 24 months, the overall success rate was 98%. CONCLUSION: Pyeloplasty gives good intermediate-term results even in extremely poorly functioning kidneys and an upfront pyeloplasty instead of nephrectomy should be offered to all pediatric patients irrespective of preoperative function.

Herniation of the Right Renal Pelvis through a Posterolateral Diaphragmatic Defect (Bochdalek Hernia).

Diaphragmatic herniations are the rarest form of ureteral herniations with only around 9 cases reported since 1958.1-10 Though uncommon, it should be considered in the differential diagnosis of a posterior diaphragmatic or paraspinal opacity with associated hydronephrosis. Correct diagnosis is of paramount importance and can be easily established by noninvasive imaging technique. In symptomatic individuals, laparoscopic intervention can be offered with good results in fit patients with ureteral stenting reserved for poor surgical candidates. Here we present a successful laparoscopic management of an elderly female who presented with right flank pain and was diagnosed with a right sided diaphragmatic ureteral herniation.

Persistent Incontinence Following Surgery for Ureteric Triplication With Contralateral Duplication-A Management Dilemma.

Ureteral triplication is a rare congenital anomaly of urinary tract with wide spectrum of presentation. The presentation with incontinence has usually been taken as a sign of ureteral ectopia in these cases. However, ectopia cannot explain all cases with incontinence. We report a case of a 14-year-old girl with ureteral triplication with contralateral duplication and vesicoureteral reflux of the upper moiety on the triplicate side and dysplastic upper moiety on duplicated side, who had persistent incontinence following a left ureteroureterostomy and right heminephrectomy. The clinical features of this rare case and the management of this peculiar postoperative situation is discussed herewith.

Black pearl in urology: Inadvertent anastomosis of gonadal vein to ureter leading to malpostioning of stent into the inferior vena cava.

Double- J (JJ) stents are commonly used in urological procedures. Minor and self limiting complications are common following JJ stenting. Malpositioning of JJ stent into the vascular system is a rare and a possibly fatal complication. We are reporting a case of a malpositioned JJ stent in the inferior vena cava (IVC), during Boari flap procedure for post-hysterectomy uretereovaginal fistula. Patient had undergone hysterectomy three months previously, and had ureterovaginal fistula possibly due to iatrogenic intraoperative injury. Patient underwent right-sided ureteroneocystostomy with Boari flap one week previously at other institute. Patient was admitted in our institution with complaints of fever, pain in abdomen and vomiting. In view of the symptoms of the patient, cross-sectional imaging with computed tomography scan was done which revealed an intraoperatively malpositioned JJ stent in the IVC, and well healed Boari flap was seen.

Self-inflicted foreign bodies in lower genitourinary tract in males: Our experience and review of literature.

OBJECTIVES: To study retrospectively the frequency, demographic, phenomenological, and psychiatric profile in patients presented with self-insertion of foreign bodies in the lower genitourinary tract in our institute. MATERIALS AND METHODS: From January 2009 to 2015, the records of patients admitted with self-insertion of foreign bodies into the lower urinary tract were analyzed retrospectively regarding demographic and phenomenological profile, the mode of presentation, diagnosis, management, complications, and possible contributing factors leading to the event. RESULTS: Out of 17,978 inpatients, ten patients (0.055%) presented with foreign body insertion in the lower genitourinary tract in last 6 years. Mean age was 28.1 ± 13.9 (7-50) years. Objects used for insertion were varied from seeds, twigs to the electric wire. The contributing factors were lack of partner, misconception about masturbation, and underlying psychiatric illness. The presenting symptoms were pain and swelling of the penis, difficulty in voiding, and skin ulceration. The diagnosis was possible by simple observation in four patients, X-ray kidney, ureter, and bladder, and sonography of the pelvis in six patients. Five patients had endoscopic retrieval of foreign body, 2 had an open, suprapubic cystotomy, urethrotomy was needed in one patient, and forceps removal in two patients. There were no postoperative complications. Psychiatric profile was evaluated in nine patients. CONCLUSIONS: Foreign body insertion to lower urinary tract was rare. A main cause for insertion of foreign bodies was autoerotism, misconceptions regarding masturbation, and underlying psychiatric illness. In addition to suitable method of surgical removal, counseling and psychiatric evaluation are necessary to prevent recurrences or for early detection of psychiatric problems.

Video-assisted anal fistula treatment.

BACKGROUND AND OBJECTIVES: Fistula in ano is a common disease seen in the surgical outpatient department. Many procedures are advocated for the treatment of fistula in ano. However, none of the procedures is considered the gold standard. The latest addition to the list of treatment options is video-assisted anal fistula treatment (VAAFT). It is a minimally invasive, sphincter-saving procedure with low morbidity. The aim of our study was to compare the results with a premier study done previously. METHODS: The procedure involves diagnostic fistuloscopy and visualization of the internal opening, followed by fulguration of the fistulous tract and closure of the internal opening with a stapling device or suture ligation. The video equipment (Karl Storz, Tuttlingen, Germany) was connected to an illuminating source. RESULTS: The study was conducted from July 2010 to March 2014. Eighty-two patients with fistula in ano were operated on with VAAFT and were followed up according to the study protocol. The recurrence rate was 15.85%, with recurrences developing in 13 cases. Postoperative pain and discomfort were minimal. CONCLUSION: VAAFT is a minimally invasive procedure performed under direct visualization. It enables visualization of the internal opening and secondary branches or abscess cavities. It is a sphincter-saving procedure and offers many advantages to patients. Our initial results with the procedure are quite encouraging.

Evaluation of gastroesophageal reflux after laparoscopic cholecystectomy using combined impedance-pH monitoring.

BACKGROUND AND AIM: Postoperative gastroesophageal reflux (GER) is one of the causes of post-cholecystectomy syndrome (PCS). Reports studying the effect of cholecystectomy on GER show conflicting results and only a few studies have used the more sensitive technique of combined impedance-pH monitoring. This study aimed to study the effect of laparoscopic cholestectomy on GER (acid/non-acid reflux) using impedance-pH monitoring. METHODS: Sixty three consecutive patients of symptomatic cholelithiasis were evaluated. All patients underwent esophageal mannometry and 24-hour impedance-pH monitoring pre- and postoperatively. Frequency scale for the symptoms of GERD (FSSG) scoring was also done in each patient pre- and postoperatively. RESULTS: Out of sixty three patients, four developed symptoms of reflux postoperatively as detected by FSSG scoring. However, no significant changes were observed in lower esophageal sphincter (LES) characteristics, acid and non-acid reflux characteristics, total number of reflux episodes, or in the physical character of the refluxate following laparoscopic cholecystectomy. Significant decrease in the proximal acid reflux episodes was observed. CONCLUSION: The chemical characteristics (acid or non-acid reflux) as well as physical properties (liquid, gas or mixed) of reflux episodes remain unaffected following laparoscopic cholecystectomy. Cholecystectomy itself doesn't increases GER.

Xanthogranulomatous appendicitis with a fulminant course: report of a case.

Xanthogranulomatous inflammation is a well-described entity with involvement of various body organs. But the involvement of vermiform appendix in the disease process is quite rare with only few cases are reported in literature. This case report describes a 50-year-old man, who was diagnosed as a case of acute appendicitis with appendicular lump on the basis of clinical history, physical examination, and hematological and radiological investigations. Patient underwent surgical interventions twice. But, he succumbed to the disease. We are reporting this case in view of rarity of the disease and the fulminant course, which has not been described in any other reports.