Current insights on haemorrhagic complications in percutaneous nephrolithotomy.

OBJECTIVE: Percutaneous nephrolithotomy (PCNL) is the standard procedure for the management of large and complex renal stones. Blood loss during PCNL may occur during puncture, tract dilatation, and stone fragmentation. Therefore, despite recent advances in PCNL, haemorrhagic complication still occurs. This study aims to enlighten on various aspects of haemorrhagic complication in PCNL, mainly focusing on risk factors and management of this dreadful complication. METHODS: Literature search for the study was carried out using advanced search engines like PubMed, Cochrane, and Google Scholar, combining keyword "percutaneous lithotomy" with other keywords like "bleeding", "haemorrhage", "complications", "stone scoring systems", "mini-PCNL vs. standard", "dilatation techniques", "supine vs. prone", "USG-guided", "endoscopic combined intra-renal surgery", "papillary vs. non-papillary puncture", "bilateral", and "angioembolization". The articles published between January 1995 and September 2020 were included for the review. RESULTS: A total of 3670 articles published from January 1995 to September 2020 were screened for the review. Although not consistent, multiple studies have described various preoperative and intraoperative risk factors related to significant bleeding in PCNL. Identification of these risk factors help urologists to anticipate and promptly manage haemorrhagic complications associated with the procedure. A conservative approach suffices to control bleeding in most cases; nevertheless, bleeding can be life-threatening and few still need surgical intervention in the form of angiographic embolisation or open surgical exploration. CONCLUSION: As hemorrhagic complication in PCNL is associated with considerable morbidity and mortality, prudent intraoperative decision and postoperative care are necessary for its timely prevention, detection, and management.

Bipolar vessel sealing system versus silk ligation of lymphatic vessels in renal transplant recipient lymphatic complications: a randomized controlled trial.

PURPOSE: This study was aimed to compare lymphatic complications of bipolar vessel sealing system with silk ligation of lymphatic vessels among renal transplant recipients. METHODS: This was a prospective randomized controlled trial done among 68 patients undergoing renal transplantation in Tribhuvan University Teaching Hospital. They were randomly assigned to either silk ligation or Enseal bipolar vessel sealing lymphatic dissection. Postoperative drain volume and duration of drain placement were measured in all patients. Ultrasound was used to find lymphocele formation in six and 12 weeks. RESULTS: Total of 30 patients in silk ligation group and 28 patients in bipolar vessel sealing group were analyzed. The baseline characteristics of the patients in each group were similar. Overall, lymphatic complications (either lymphorrhea or lymphocele formation) were in 16 cases (27.58%), 7 (25%) in the bipolar group, and 9 (30%) in the silk ligation group (p = 0.67). A total of 13 patients (22.41%) had lymphorrhea, 6 (21.4%) patients in the bipolar group, and 7 (23.3%) patients in the silk ligation group. Median drain volume was 415 ml (Q1 275 ml, Q3 675 ml) in the bipolar group and 542 ml (Q1 290, Q3 775) in silk group (p = 0.72). Median drain removal day was 5 in each bipolar and silk group with Q1 and Q3 being 5 days in each arm (p = 0.95). A total of five patients (8.62%) developed symptomatic lymphocele, two (7.1%) in the bipolar group, and three (10%) in the silk ligation group, but the difference was not statistically significant. In univariate analysis, double renal arteries in the donor's kidney (p = 0.03) and graft rejection (p = 0.04) were risk factors for the development of lymphatic complications. However, in multivariable analysis, these factors were not statistically significant. CONCLUSIONS: This study did not find any significant differences in lymphatic complications between bipolar vessel sealing system and silk ligation. However, large sample multi-centric studies should be done to add evidences on lymphatic complications differences between these two techniques. TRIAL REGISTRATION NUMBER: UMIN000039354, Date of registration-2020, Feb 01.

Clinicopathological patterns of bladder carcinoma over 1 year: experience from University Hospital of Nepal.

PURPOSE: To define the clinical and pathological patterns of urinary bladder carcinoma from the University Hospital of Nepal. METHODS: This is a retrospective analytical study. Patients with bladder mass who underwent surgery over 1 year and who had data record were included in the study. Demographic profile, type of surgery, findings on clinical examination, cystoscopy findings, histopathological report, tumor stage, and post-surgery adjuvant therapy were analyzed. RESULTS: Out of 86 patients who underwent transurethral resection of bladder tumor, 77 patients had biopsy-proven malignant bladder tumor. Urothelial cancer was present in 96.1%. Male were 78.6%. The mean age of diagnosis was 65.5 ± 11.8 years. Non-muscle-invasive bladder cancer (NMIBC) was 3.7 times more common than muscle-invasive bladder cancer (MIBC). High-grade tumors (58.6%) were more common than low grade (41.4%). The detrusor muscle was present inthe biopsy specimen of 48 patients (64%). Re-TURBT within 2-6 weeks was considered based on histopathology reports for about half of the patients (45.3%). Upstaging and upgrading of the tumor was present in 5.8 and 5.8% of the patients, respectively. Residual tumor without upstaging and upgrading was present in 23.5%. One patient (1.3%) had Clavien-Dindo grade 1, three (4%) patients had grade 2 and two patients (2.7%) had grade 3b. CONCLUSION: In the present study, patients with bladder cancer are younger than reported in other studies. Smokers are strongly predisposed. The histological pattern is similar to the Western and Asian populations. NMIBC and MIBC occur in proportion to that described as in other studies. We had a lower rate of recurrence, upstaging and upgrading. We had a lesser rate of acceptance for radical cystectomy in our patients.

Renal Metastasis of Osteosarcoma with IVC Thrombus.

Renal metastasis from osteosarcoma is a rare entity, and tumour thrombus is even rarer. To date, only 15 cases of osteosarcoma with tumour thrombus have been reported in the literature. We present a case of an 18-year-old female diagnosed as having right distal femur osteosarcoma, later presenting with renal osteosarcoma with IVC thrombus.

Myxoid liposarcoma of bladder: a rare case.

INTRODUCTION: Myxoid liposarcoma of the bladder is a rare mesenchymal tumor which is difficult to diagnose and carries a poor prognosis. The primary treatment is complete surgical resection which is usually followed by adjuvant chemotherapy. PRESENTATION OF CASE: We report a case of 26 years female who presented with a large abdominal mass and was initially misdiagnosed to be arising from ovaries and subsequently discovered to be a mesenchymal tumor arising from the bladder. DISCUSSION: Myxoid liposarcoma is an exceedingly rare but aggressive mesenchymal tumor of the bladder often with misleading imaging appearances. CONCLUSION: Surgical resection, when feasible, plays the leading role in its management, and should be attempted in all potential patients.

Gestational choriocarcinoma presenting with bilateral kidney and lung metastases with unknown primary: An uncommon clinical scenario.

Gestational choriocarcinoma with kidney and lung metastases with delayed presentation after term pregnancy is rare event and not described frequently in literature. We describe a rare case of 24-year-old female with hematuria after 3 years of term delivery. Management includes chemotherapy and even renal embolization in case of life threatening hematuria.

Efficacy of Tamsulosin plus Tadalafil versus Tamsulosin as Medical Expulsive Therapy for Lower Ureteric Stones: A Randomized Controlled Trial.

INTRODUCTION: Urolithiasis is one of the common disorder with which about 1/5th is found in the ureter, of which 2/3rd is seen in the lower ureter. Medical expulsive therapy is one of the routine modalities of treatment which uses various drugs acting on the ureter smooth muscle by different mechanism. We aim to compare the efficacy of combination vs. single drug. METHODS: This randomized controlled trial was done in 176 consecutive patients over a period of six months (March 2019 to August 2019) in Department of Urology and Kidney Transplant Surgery, Tribhuvan University Teaching. Participants were divided into two groups (Group A, tamsulosin plus tadalafil, and Group B, tamsulosin) from computer-generated random numbers. Therapy was continued for a maximum of 3 weeks. Stone expulsion rate, time to stone expulsion, analgesic use, number of colic and emergency room visits for pain, early intervention, and adverse effects of drugs were recorded. RESULTS: Among 176 patients who were enrolled in study, 7 were lost to follow-up, and 5 people required immediate intervention. There was a significant higher stone passage rate in group A than group B (64 vs. 50; P=0.025) and shorter expulsion time (1.66 vs. 2.32 weeks P=0.001) and less number of emergency room visits and colic episodes. No significant side effects were noted during study. CONCLUSION: Tamsulosin plus Tadalafil is more effective than tamsulosin with early passage of stone and decreased number of colic episodes and emergency visits without significant side effects for lower ureteric calculi of 5 mm to 10 mm.

Segmental renal artery and popliteal artery embolism in an adult patient with rheumatic heart disease and atrial fibrillation: A case report.

INTRODUCTION: Renal artery embolism is uncommon cause of flank or back pain. Of all embolic episodes in patients with atrial fibrillation, 2-4% are renal artery embolism. Early thrombolysis within 90 min has favorable renal outcome. Long term anticoagulation can prevent recurrent embolic episodes. Two different embolic phenomenon within short span in same patient is not described in literature. PRESENTATION OF CASE: We describe fifty-year-old female with rheumatic heart disease with atrial fibrillation presented as renal segmental artery emboli with popliteal artery emboli within seven-day interval. DISCUSSION: Embolic phenomenon is well known in atrial fibrillation. High index of suspicion in patient with risk factors of thromboembolism with appropriate use of contrast enhanced computed tomography can help early diagnosis. Renal artery embolism is managed with anticoagulation or thrombolysis based on duration of presentation. Peripheral artery embolism can be diagnosed with Doppler ultrasonography. Thrombus can be removed with endovascular procedure or open surgical technique. Holistic patient management includes cardiac workup and treatment of factors predisposing to embolization. CONCLUSION: Early identification and urgent treatment is key to the management of embolic episode in patient with atrial fibrillation. Long term prophylaxis can prevent further episodes.

Persistent Mullerian duct syndrome with transverse testicular ectopia: A case report.

Persistent Mullerian duct syndrome (PMDS) is a rare entity of internal male pseudohermaphroditism. Transverse testicular ectopia (TTE) is the condition in which one testis moves to the other side and both testes pass the same inguinal canal. The combination of PMDS with TTE is rarer. Here, we present a case a phenotype male with left inguinal hernia and right undescended testis. On exploration of left inguinal region, uterus like tissue with its tubal structures were found. Both testes were in same side, one in left inguinal region and the other in the left scrotum.