Management Outcomes of Large Renal Angiomyolipoma Presenting with Wunderlich Syndrome-Experience from a Tertiary Center.

Renal angiomyolipoma is an uncommon, benign-mixed mesenchymal tumor consisting of thick-walled blood vessels, smooth muscles, and mature adipose tissues. Twenty percent of these tumors are associated with tuberous sclerosis. Wunderlich syndrome (WS), an acute nontraumatic spontaneous perirenal hemorrhage, can be a presentation of large angiomyolipoma. This study evaluated the presentation, management, and complications of renal angiomyolipoma with WS in eight patients who presented to the emergency department between January 2019 and December 2021. The presenting symptoms included flank pain, palpable mass, hematuria, and bleeding in the perinephric space on computerized tomography. Demographic data, symptoms at presentation, comorbidities, hemodynamic parameters, the association with tuberous sclerosis, transfusion requirements, need for angioembolization, surgical management, Clavien-Dindo complication, duration of hospital stay, and 30-day readmission rates were evaluated. The mean age of presentation was 38 years. Of the eight patients, five (62.5%) were females and 3(37.5%) were males. Two (25%) patients had tuberous sclerosis with angiomyolipoma, and three (37.5%) patients presented with hypotension. The mean packed cell transfusion was three units, and the mean tumor size was 7.85 cm (3.5-25 cm). Three of them (37.5%) required emergency angioembolization to prevent exsanguination. Embolization was unsuccessful in one patient (33%) who underwent emergency open partial nephrectomy, and one (33%) patient developed post-embolization syndrome. A total of six patients underwent elective surgery-four underwent partial nephrectomy (laparoscopic - 1, robotic - 1, open - 2) and two underwent open nephrectomy. Three patients encountered Clavien-Dindo complications (Grade 1, n = 2 and IIIA, n = 2). WS is a rare, life-threatening complication in patients with large angiomyolipoma. Judicious optimization, angioembolization, and prompt surgical intervention will help deliver better outcomes.

Recurrent Hemangioma of the Penile Urethra - An Unusual Etiology of Gross Hematuria Managed Successfully with Holmium Laser Coagulation.

Urethral hemangioma is a benign uncommon vascular tumor. It presents with hematuria and macroscopic urethrorrhagia. Urethrocystoscopy is the main diagnostic modality. We share the case of a 14-year-old male child who presented with recurrent massive hematuria and was treated with urethra-cystoscopic holmium laser coagulation.

Outcomes of bladder neck botulinum toxin injection for female primary bladder neck obstruction-does subjective improvement correlate with an objective assessment?

INTRODUCTION AND HYPOTHESIS: Common options for management of primary bladder neck obstruction (PBNO) in women include medications and surgical treatment. Less invasive treatment such as bladder neck botulinum toxin injection can be an alternate therapy in patients with failed conservative management. In this study, we describe the subjective and objective outcomes, patient satisfaction, and willingness for repeat treatment with bladder neck botulinum toxin injection in females with PBNO. METHODS: A retrospective analysis of ten female PBNO patients managed with bladder neck botulinum toxin injection was performed. Subjective parameters were quantified with symptom assessment, International Prostate Symptom Score (IPSS), and Quality of life (QoL) score. Objective parameters were assessed with maximum flow rate (Qmax) in uroflowmetry and postvoid residual (PVR). RESULTS: The mean pre-treatment IPSS, QoL score, Qmax, PVR was 24.2 ± 5.0, 4.8 ± 0.63, 5.73 ± 3.18 ml/s, and 210 ± 66 ml, respectively. Seven of the ten patients subjectively improved (IPSS 12.9 ± 9.6, QoL2.9 ± 1.6, p < 0.05). Three patients improved objectively (mean Qmax 17.3 ± 2.7 ml/s, PVR 42.7 ± 7.5 ml, p < 0.05). Three patients accepted repeat botulinum toxin injection. Three patients who showed no improvement underwent bladder neck incision with resolution of symptoms. CONCLUSION: Botulinum toxin can be an intermediary therapy in female patients with PBNO who want a minimally invasive procedure.

"Labia Majora Fasciocutaneous Flap Reconstruction in Complex Urogynecological Fistulas With Vaginal Deficit - A Versatile Approach".

OBJECTIVE: To appraise the pivotal points of different modifications of labia majora fasciocutaneous flap in combating the challenges of complex urogynecological fistula repair in the form of 7 cases. METHODS: Seven patients with complex urogynecological fistulas with vaginal deficit were treated over last 3 years. The challenges associated with them were non-capacious rigid vagina, irradiated and inflamed surrounding tissues, inelasticity, long-standing fistula with radiation-induced vesicovaginal fistula(VVF), an iatrogenic urethrovaginal fistula with anterior vaginal wall loss with vaginal stenosis, and a case of vesicolabial fistula with a history of forceps delivery and transvaginal VVF repair. Transvaginal repair with labia majora fasciocutaneous flap along with fat pad with relevant technical modifications was contemplated in all. RESULTS: All radiation-induced VVF patients demonstrated no leak in the postoperative period barring one who became dry after transvaginal colpocleisis later. The patient with urethrovaginal fistula and vaginal stenosis was continent, had capacious vagina, and without any leak with regular menstrual periods. The female with vesicolabial fistula remained dry at the end of 6-month follow-up. CONCLUSION: Transvaginal repair using the labia majora fasciocutaneous flap and the demonstrated technical modifications can be a feasible option in repairing complex urogynaecological fistulas associated with vaginal wall deficit.