Laparoscopic management of a hydatid cyst of the adrenal gland.

Hydatid disease is endemic in parts of India, yet genitourinary involvement is rare. Laparoscopic management of such cases is uncommonly reported. We present a case of an adrenal hydatid and its management by laparoscopic aspiration, instillation of scolicidal solution, and partial excision of the cyst.

Large bilateral adrenal leiomyomas presenting as calcified adrenal masses: a rare case report.

We report the case of a 55-year-old woman with bilateral, large, calcified adrenal tumors who was treated by laparoscopic adrenalectomy. The patient presented with upper abdominal discomfort for the past 5 years. Her imaging showed bilateral enlarged adrenal glands up to 10-cm size with punctate calcifications. Positron emission tomography scan demonstrated moderate fluorodeoxyglucose avidity in the left adrenal mass. Bilateral laparoscopic adrenalectomy was performed through a transperitoneal approach. The postoperative period was uneventful, and the patient was discharged on the third postoperative day. Histology findings were consistent with adrenal leiomyomatosis.

Randomized Controlled Trial to Assess the Efficacy of the Combination Therapy of Alfuzosin and Tadalafil in Patients with Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia.

OBJECTIVE: The purpose of our study was to evaluate the effect of alfuzosin and tadalafil as combination therapy compared with each monotherapy, in patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). METHODS: Men over the age of 50 years with LUTS secondary to BPH and an International Prostate Symptom Score (IPSS) 8 or higher, were randomized to receive 10 mg alfuzosin (n = 25), 10 mg tadalafil (n = 25) or the combination of both the drugs (n = 25) once daily for 3 months. Symptoms were assessed at baseline, 6 weeks and 3 months. The primary endpoint was the change in IPSS from the baseline. Secondary endpoints were changes in IPSS storage and voiding subscores, peak urinary flow rate, residual urine volume, IPSS quality of life score and erectile domain score. RESULTS: There were significant improvements in all IPSS scores, peak urinary flow rate and IPSS quality of life score from baseline at both 6 weeks and 3 months in all the three groups (P < 0.003). Combination therapy was better than monotherapy in improving IPSS scores and reducing post-void residual urine volume (P < 0.005). Combination therapy was similar to alfuzosin regarding improvement in maximum urine flow rate (P = 0.22), similar to tadalafil in improvement on erectile function (P = 0.22) and better than each monotherapy in improving the IPSS quality of life (P ≤ 0.015). CONCLUSION: Alfuzosin and tadalafil combination therapy provides greater symptomatic improvement as compared to either monotherapy in men with LUTS due to BPH.

Unusual causes of Hematuria in dialysis patients: Diagnostic dilemma, risks and management.

Two male patients with end-stage renal disease (ESRD) developed a spontaneous hemorrhage of one of their native kidneys and were referred to our institution. Symptoms included sudden onset abdominal pain, hematuria and shock. Symptoms were associated with a hemoglobin decrease. Computerized tomography (CT) was done and nephrectomy undertaken in both the cases. Histologic findings confirmed bleeding and there was no abnormality other than those related to renal insufficiency (cysts and atrophy). In chronic hemodialysis (HD) patients with hematuria, if other common causes are not identified spontaneous subcapsular or renal cyst rupture should be kept in mind. Surgery is our preferred treatment because of the diagnostic dilemma of tumors and the potential mortality of massive hematomas in morbid patients.

Benign medullary fibroma of the kidney: a rare diagnostic dilemma.

Renomedullary interstitial cell tumor or medullary fibroma, is a small tumor that commonly presents as an incidental finding, but in rare cases maybe large and symptomatic. Although it is a benign tumor, it is difficult to differentiate this lesion from other malignancies of the kidney on radiological basis and hence many patients undergo radical nephrectomy. We present a case of renal medullary fibroma and various nuances associated with radiological identification of this lesion and its management related dilemmas.

Adrenal artery pseudoaneurysm in pheochromocytoma presenting with catastrophic retroperitoneal haemorrhage.

Spontaneous rupture of adrenal pheochromocytoma is an extremely rare condition which presents as an abdominal catastrophe. Unrecognized, this transformation can rapidly lead to death. We report a case of a 63-year-old male who presented with hemorrhagic shock secondary to ruptured adrenal pheochromocytoma. The clinical course is notable for immediate transarterial catheter embolization for control of bleeding, followed by optimization and elective adrenalectomy. High mortality is associated with an operative intervention in the face of an unrecognized pheochromocytoma. This reinforces the need for maintaining a high index of suspicion in the setting of a suprarenal mass despite hypotension.

Randomized controlled trial to compare the safety and efficacy of naftopidil and tamsulosin as medical expulsive therapy in combination with prednisolone for distal ureteral stones.

PURPOSE: To compare the safety and efficacy of naftopidil and tamsulosin with prednisolone as medical expulsive therapy for distal ureteric stones. MATERIALS AND METHODS: Between July 2010 and March 2012, 120 adult patients presenting with distal ureteric stones of size 5 to 10 mm were randomized equally to tamsulosin (group A), naftopidil (group B) or watchful waiting (group C). Tamsulosin or naftopidil was given for a maximum of four weeks. In addition patients in group A and B were given 5 mg prednisolone once daily (maximum one week). Stone expulsion rate, time to stone expulsion, analgesic use, number of hospital visits for pain, follow-up and endoscopic treatment and adverse effects of drugs were noted. Statistical analyses were done using chi-square test, Mann-Whitney test and analysis of variance. RESULTS: There was a statistically higher expulsion rate in groups A (70%) and B (87.5%) as compared to group C (32.5%) (p<0.001). The expulsion rates were not statistically different between groups A and B (p=0.056). The mean time to expulsion was comparable between groups A and B but longer in group C. Analgesic use was significantly lower in groups A and B. Average number of hospital visits for pain, follow-up and endoscopic treatment was similar in all groups. There was no serious adverse event. CONCLUSIONS: Medical expulsive therapy for the distal ureteric stones using either naftopidil or tamsulosin in combination with prednisolone is safe and efficacious.

Efficacy of holmium laser urethrotomy in combination with intralesional triamcinolone in the treatment of anterior urethral stricture.

PURPOSE: To evaluate the outcome of visual internal urethrotomy with a holmium:yttrium-aluminum-garnet laser along with intralesional triamcinolone injection. MATERIALS AND METHODS: Patients with an anterior urethral stricture less than 3 cm in length were evaluated by clinical history, physical examination, uroflowmetry, and retrograde urethrogram preoperatively. All patients were treated with holmium laser urethrotomy and intralesional triamcinolone (80 mg) injection under general or regional anesthesia. An 18 F urethral catheter was placed for 5 days. All patients were followed up for 12 months postoperatively by history, uroflowmetry, and if required, retrograde urethrogram or urethroscopy every 3 months. RESULTS: The mean age of the patients was 42.9 years (range, 14 to 70 years). The overall recurrence rate was 24%. The success rate in patients with strictures less than 1 cm in length was 95.8%, whereas that in patients with strictures of 1 to 3 cm in length was 57.7% (p=0.002). The outcome did not depend on age, duration of symptoms, etiology, or location of stricture. CONCLUSIONS: Holmium laser urethrotomy with intralesional triamcinolone is a safe and effective minimally invasive therapeutic modality for urethral strictures. This procedure has an encouraging success rate, especially in those with stricture segments of less than 1 cm in length.

Fragmented pigtail percutaneous nephrostomy tubes: etiology and management.

PURPOSE: To review our experience with the management of fragmented and retained pigtail percutaneous nephrostomy (PCN) tubes and to explore the reasons for the fragmentation. MATERIALS AND METHODS: We retrospectively reviewed our institute database from January 2006 to December 2011 for patients who had undergone retrieval of fragmented PCN tubes. We assessed the preoperative factors, operative technique, and post-operative outcomes. RESULTS: A total of seven patients (4 males and 3 females) had been diagnosed with fragmented PCN tubes. The mean age of the patients was 41.5 years. Of the seven patients, five required antegrade instrumentation by way of a percutaneous tract to remove the foreign body, mostly along with stone retrieval. One patient underwent ureterorenoscopy and pneumolithotripsy for a ureteric stone along with ureteroscopic removal of the PCN fragment. Another patient underwent nephrectomy of the kidney containing the PCN fragment because it had become nonfunctioning. All patients were free of stones and symptoms on follow-up. CONCLUSIONS: A prolonged waiting period for definitive surgery, urinary infection, and associated stone disease are significant factors causing fragmentation of PCN tubes. Proper insertion techniques, regular timed changes of the PCN tube, appropriate care of the PCN tube, and early surgery for underlying stone disease are required to avoid this complication. Patients with retained PCN tubes can be managed effectively with antegrade or retrograde endoscopic techniques while definitive management of the primary pathology is carried out, without any additional morbidity.

Autosomal dominant polycystic kidney disease with situs inversus.

Situs inversus totalis and autosomal dominant polycystic kidney disease (ADPKD) occur with an incidence of 1/10,000 in the general population and 1 in 1000 live births, respectively. Association of the two conditions is rare and there are few pediatric case reports. Association of situs inversus totalis and autosomal recessive polycystic kidney disease has also been reported. Recent studies have revealed ciliary dysfunction as a cause of both conditions.

Dengue hemorrhagic fever as a rare cause of bleeding following percutaneous nephrolithotomy.

Post percutaneous nephrolithotomy (PNL) bleeding is an uncommon yet serious complication and is almost always related to a surgical cause. Nevertheless, medical cause of bleeding is rarely encountered as a cause of this dangerous complication. Dengue has been rarely reported as a cause of post operative bleeding. Bleeding diathesis in dengue occurs not only due to thrombocytopenia but also due to dysfunctional surviving platelets and increased fibrinolysis. We report a patient who developed bleeding after an uneventful PNL due to dengue hemorrhagic fever. Medical causes of bleeding such as locally endemic viral hemorrhagic fevers should also be kept in mind and evaluated especially when a surgical cause of the bleed is not found or suspected in bleeding after any surgery.

Laparoscopic management of a rare urogenital fistula.

Ureteral injury is usually iatrogenic after gynecologic or obstetric surgeries. Ureterouterine fistula is a rare complication. It most commonly occurs after a caesarean section. A 24-year-old woman presented with paradoxic incontinence 1 week after caesarean section. Intravenous urography revealed a left ureterouterine fistula. She was treated successfully by laparoscopic ureteroneocystostomy.