Male Urethral Diverticulum with Stones Presenting as Acute Urinary Retention.

The urethral diverticulum is an outpouching of the urethral wall communicating with its lumen. Acquired male urethral diverticulum is a rare entity and arises secondary to intervention or distal urethral obstruction. Most patients present with lower urinary tract symptoms (LUTS). Development of calculi is seen in 4-10% of cases. We describe a case of a 63-year gentleman who presented with urinary tract infection (UTI) and acute urinary retention (AUR). He denied history of urolithiasis. Per-urethral catheterization failed, so a supra-pubic catheter was placed and UTI was managed with broad-spectrum parenteral antibiotics. On workup, he was found to have a large tubular urethral diverticulum in the anterior urethra with multiple stones and urethral strictures. The case was managed endoscopically with optical urethrotomy and fragmentation and retrieval of stones using a semi-rigid ureteroscope and pneumatic lithoclast. Key Words: Urethra, Diverticulum, Male, urethral calculus, Lithoclast.

Validation of a Bench-Top Training Model for Retrograde Intrarenal Surgery.

OBJECTIVE: To validate the in-house built Styrofoam box bench-top training model for retrograde intrarenal surgery (RIRS). MATERIALS AND METHODS: This study was performed in the setting of a half-day RIRS course. During the course, participants performed RIRS on a locally built bench-top model. We recruited 26 participants, comprising 20 trainees and 6 experts. Trainees and experts were asked to fill a self-administered questionnaire assessing various components of RIRS to assess the face and content validity. For construct validity, experts using Objective Structured Assessment of Technical Skills (OSATS) rated trainees and the mean OSATS score of junior versus senior residents was compared. RESULTS: As per trainees, the model was 86% (4.3/5) realistic, which was backed by experts who found this model to be 87.6% (4.38/5) realistic. The overall face validity of the model was 86.4% (4.32/5). The overall content validity of this model was 83.4% (4.17/5). Majority of the participants thought that this tool is useful for learning technique (4.38 ± 0.49) and safe-conduct (4.31 ± 0.73) of the procedure. The trainees concurred that the skills acquired are transferable to the operating room (4.23 ± 0.76). However, the construct validity by comparing mean OSATS score of junior versus senior residents was 19.5 ± 3.5 and 23 ± 4.5. A p value of 0.11 could not be established. CONCLUSION: This study has demonstrated the face, content, and construct validity of the bench-top training model for RIRS. Further evaluation is necessary to compare its effectiveness against other available models to demonstrate concurrent validity.

Predicting emergency interventions in patients with acute ureteral colic using acute renal colic scoring system in a Pakistani cohort.

OBJECTIVE: To evaluate the acute renal colic score (ARC) in predicting the need of emergency intervention (EI) in patients with ureteric colic secondary to a ureteral stone. PATIENT AND METHODS: In an emergency room (ER) of a university hospital, we conducted a prospective cohort study over a period of 6 months. ARC score was calculated using four parameters, i.e., serum creatinine, total white cell count (TLC), stone length and level. Primary outcome measure was EI, which was defined as the need of endourological intervention within 48 h of presentation. ARC was calculated for each patient against the two possible outcomes, i.e., EI vs. no EI. The need of intervention was based on patient-related clinical factors and the decision of the attending urologist. RESULTS: The study included 132 patients. EI was performed in 85 patients (64.4%). URS was the most common intervention performed in 81 (95.3%) patients, followed by the a insertion of a double J stent in two (2.4%) patients for forniceal rupture and high TLC count and percutaneous nephrostomy in two (2.4%) patients for raised creatinine and TLC. All four variables in ARC score including serum creatinine (p < 0.001), TLC (p < 0.001), stone size (p < 0.001) and stone level (p < 0.001) were found to be significantly associated with need for EI. Using ROC the sensitivity and specificity of the score was 92.9% and 87.5%, respectively, with AUC of 0.93. CONCLUSIONS: ARC score is highly sensitive and specific in determining the need of EI in patients with uncomplicated ureteric colic within 48 h of initial presentation.

Hounsfield units-a significant predictor of lasering time and energy in the management of upper urinary tract stones using Holmium: Yttrium-Aluminum Garnet lasers.

PURPOSE: To study the impact of stone density as assessed by Hounsfield units (HU) on total laser energy (TLE) used and total laser time (TLT) spent in complete fragmentation of upper urinary tract stones. In addition, we also studied the impact of stone composition on the laser energy and time required for fragmentation. METHODS: Thirty consecutive patients fulfilling inclusion and exclusion criteria were included in the study. Patients with renal or proximal ureteral stones with a size of 5-20 mm were included. Stone fragmentation was performed using Ho:YAG 100 W laser and TLT and TLE were correlated with the HU and stone composition. RESULTS: The mean stone diameter was 10.83 ± 3.5 mm and the mean HU was 893 ± 315. The mean TLE and TLT were 8.86 ± 3.12 kJ and 18.46 ± 6.9 min, respectively. We observed a strong positive correlation between HU and TLE (r = 0.84, p value < 0.001) and between HU and TLT (r = 0.58, p value = 0.001). However, the stone composition did not influence the lasering energy (p value = 0.36) and lasering time (p value = 0.30). Stone diameter also had significant positive correlation with TLE (r = 0.41; p = 0.02) and TLT (r = 0.54; p- 0.002). When controlling for stone size the correlation of HU with TLE (r = 0.83; p < 0.001) and TLT (r = 0.52; p = 0.004) remained significant. CONCLUSIONS: HU and stone diameter are significant predictors of TLE and TLT when using Ho:YAG laser for stone fragmentation. However, stone composition and stone location failed to show any significant effect on either of these parameters.

Stented Pancreatico-duodenectomy: Does it lead to decreased pancreatic fistula rates? A prospective randomized study.

OBJECTIVE: To compare clinically relevant pancreatic fistula rates in patients with stented versus non-stented pancreatico-jejunostomies. METHODS: The randomised comparative clinical trial was conducted at Civil Hospital, Karachi, from September 2009 to August 2015, and comprised patients presenting to the Surgical Unit 4 with a diagnosis of resectable periampullary carcinoma, carcinoma of head of pancreas, duodenal carcinoma involving the second part, and distal cholangiocarcinomas. Pancreatic fistula or leakage was defined as amylase-rich fluid lasting over 5 days, collected from the peripancreatic drains on day 1, 3 and 7 postoperatively, and the rate of clinically relevant fistulas was taken as primary study endpoint. RESULTS: There were 102 patients with a male to female ratio of 2.4:1. The overall mean age was 53.16±12.11 years (range: 30-80 years). Of the total, 53(51.9%) patients had pancreatic duct stent and 49(48%) did not. Clinically relevant pancreatic leak was seen in 13(12.7%) patients of whom 8(61.5%) were stented (p=0.46), 9(69.2%) patients had soft pancreatic texture (p=0.54) and 7(53.8%) had pancreatic duct <3mm (p=0.11). CONCLUSIONS: Pancreatic fistula rates between stented and non-stented anastomosis did not show any significant difference.

Metabolic Syndrome: An Indicator of Complicated Gall Stone Disease?

Background Gallstone disease is a common surgical entity worldwide and accounts for a major portion of hospital admissions and surgeries. Metabolic syndrome is diagnosed when three of the following medical conditions are positive: central obesity, high blood pressure, increased fasting glucose levels, low high-density lipoprotein (HDL) levels and high serum triglycerides. Objective To compare the frequency of metabolic syndrome in patients with uncomplicated gallstone disease and complicated gallstone disease. Study design Observational, cross-sectional study. Methodology A total of 104 patients, above age 18 years, visiting the outpatient department (OPD) or the emergency department, diagnosed as having gallstone disease. The study was conducted in surgical unit VI, civil hospital Karachi from June 2014 to June 2015. Patients' demographics, abdominal waist circumference, blood pressure, serum fasting blood sugar, triglyceride level and HDL levels were recorded. Final outcome was labeled as presence or absence of metabolic syndrome. Presence of metabolic syndrome was compared in patients with complicated gallstone disease as well as in patients with uncomplicated gallstone disease. Chi square test was used to detect statistical significance and a p-value of <0.05 was taken as significant. Results The ages were comparable between the two groups, that is, the complicated and uncomplicated gallstone disease at 42.42 +/- 12.15 years in the former and 39.24 +/- 10.41 years in the latter group. Metabolic syndrome was more predominant in the complicated arm 40.38% when compared to uncomplicated arm 25% but it was not significant statistically with a p-value of 0.2. Conclusion Metabolic syndrome is associated with complicated gallstone disease though this study failed to reach statistical significance due to small sample size, it re-enforces the findings of previous studies. It is an easily assessable and useful measure to predict complications associated with gall stone disease.