Importance of time in management of fracture penis: A prospective study.

BACKGROUND: The presentation of penile fracture may vary depending on the delay to seek medical attention and on the presence of associated injuries. Delay in presentation has been linked previously to embarrassment associated with this condition. AIMS AND OBJECTIVES: The study aims to share our clinical experience in management of penile fracture and its complications and specifically highlights the impact of time delay on post-operative outcome in patients presenting with penile fracture. MATERIAL AND METHODS: The study is a prospective observational study conducted from July 2014 till January 2017. All the patients presenting to the emergency with a clinical presentation of penile fracture and a tear in the tunica albuginea of the penile cavernosal tissue, confirmed on ultrasound were included in this study and intraoperative and postoperative data was analysed. RESULTS: The most common cause for fracture noted was coitus. The average time delay from the time of insult to presentation to the emergency department was 25.11 ± 12.48 hours. The parameters that have significantly been altered by a time delay of more than 24 hours include post-operative wound infection, erectile dysfunction at 1-year, post-operative hospital stay. Two patients develop chordee at 6 and 9 months respectively and both patients presented beyond 24 hours. All patients with hematoma size on color Doppler of more 10cc and intraoperative tear >10mm had developed post-operative wound infection. Patients with urethral injury or post-operative cavernositis or wound infection had significant association with erectile dysfunction. CONCLUSION: Penile fracture although a rare urologic emergency, it has a significant impact on sexual health of a young man. An early intervention along with identifying and managing early complications factors would help patients of fracture penis lead an almost normal sexual life.

Placenta percreta with bladder invasion: The armamentarium available in its management.

Placenta percreta is a rare life-threatening condition associated with high morbidity and mortality due to severe obstetric hemorrhage. It can be associated with bladder invasion which leads to hematuria. Treatment is decided on a case-to-case basis, and there have been no guidelines proposed so far. Strategies include obstetric hysterectomy, leaving the placenta in situ with postoperative methotrexate therapy and removal of the placenta with bladder reconstruction in a single stage. An unusual case of a patient with placenta percreta and bladder invasion who presented with delayed hematuria after the placenta was left in situ has been reported. The patient was managed conservatively for 10 days postdelivery after which a decision to do an obstetric hysterectomy with focal cystectomy was taken in view of persistent hematuria. An algorithm for managing cases of placenta percreta with bladder invasion has been proposed to manage these difficult situations.

Transperitoneal laparoscopic repair of retrocaval ureter: Our experience and review of literature.

CONTEXT AND AIM: Retrocaval ureter (RCU), also known as circumcaval ureter, occurs due to anomalous development of inferior vena cava (IVC) and not ureter. The surgical approach for this entity has shifted from open to laparoscopic and robotic surgery. This is a relatively new line of management with very few case reports. Herein, we describe the etiopathology, our experience with six cases of transperitoneal laparoscopic repair of RCU operated at tertiary care center in India and have reviewed different management options. METHODS: From 2013 to 2016, we operated total six cases of transperitoneal laparoscopic repair of RCU. All were male patients with average age of 29.6 years (14-50). Pain was their only complaint with normal renal function and no complications. After diagnosis with CT Urography, they underwent radionuclide scan and were operated on. Postoperative follow-up was done with ultrasonography every 3 months and repeat radionuclide scan at 6 months. The maximum follow-up was for 2.5 years. RESULTS: All cases were completed laparoscopically. Average operating time was 163.2 min. Blood loss varied from 50 to 100 cc. Ureteroureterostomy was done in all patients. None developed urinary leak or recurrent obstruction postoperatively. Maximum time for the requirement of external drainage was for 4 days (2-4 days). Average postoperative time for hospitalization was 3.8 days. Follow-up ultrasound and renal scan showed unobstructed drainage. CONCLUSIONS: Transperitoneal or retroperitoneal approach can be considered equivalent as parameters like operative time, results are comparable for these two modalities. We preferred transperitoneal approach as it provides good working space for intracorporeal suturing.

A Case Report of Largest Documented Multilocular Cystic Nephroma Removed by Thoracoabdominal Approach.

Large renal tumours are not uncommon in developing countries. Enhancing renal tumours are considered to be malignant unless proved otherwise and radical surgical resection remains the mainstay of treatment of such tumours. A giant renal tumour, especially on right side, poses a big challenge for the operating team and requires a thoracoabdominal approach for successful excision. We report successful removal of the largest documented Multilocular Cystic Nephroma (MLCN, 5.5 kg) from a 28-year-old female who presented with right abdomen lump since two years. The surgery was done through a 9th intercostal thoracoabdominal incision as the mass (31 x 19 x 19.6 cm) extended from right sub-diaphragmatic space up to the dome of the bladder. We discuss here the technique of removing such a huge renal mass and the challenges an operating surgeon may encounter.

Wunderlich Syndrome due to Ruptured Pseudoaneurysm of Angiomyolipoma in First Trimester: A Rare Case Report.

Angiomyolipoma (AML) is a rare benign tumour of kidney which demonstrates rapid growth during pregnancy due to hormonal stimulation, leading to rupture. Majority of reported ruptured AMLs are in third trimester. We report a case of ruptured angiomyolipoma at 10th week of gestation, the earliest rupture known in singleton pregnancy. The AML had pseudo-aneurysm formation with extra-tumoural rupture during pregnancy, a finding never reported in literature yet. The patient had active bleeding with expanding peri-nephric haematoma during initial two days of conservative management. Hence, after counselling and taking prior informed written consent for Medical Termination of Pregnancy (MTP), computed tomography scan of abdomen with angiography followed by emergency coil embolization of the bleeding right upper polar segmental artery was done. After stabilization, MTP was done at 12th week of gestation. Counselling and consent for continuing or aborting the pregnancy is of utmost importance for best possible outcome for patient and foetus.

TRUS Biopsy Yield in Indian Population: A Retrospective Analysis.

INTRODUCTION: The reported cancer detection rate of Trans-Rectal Ultrasonography (TRUS) biopsies (TRUS biopsy yield) has been around 30 percent in western countries. However it is much lower in Asian countries, including India. Hence a larger proportion of patients in India undergo unnecessary biopsies. AIMS: To find out the cancer detection rate of TRUS biopsy (TRUS biopsy yield) in contemporary Indian population. Also, to study the positive predictive values at different serum Prostate-Specific Antigen (PSA)/PSA Density (PSAD) cut off levels and suspicious Digital Rectal Examination (DRE) findings. MATERIALS AND METHODS: This retrospective study was carried out in a tertiary care institute. All symptomatic patients who underwent TRUS guided biopsy for indication of raised serum PSA level (>4 ng/ml) or suspicious DRE findings (nodule, irregularity, hard consistency, immobile rectal mucosa) from January 2012 to December 2014 were included. For serum PSA range (4-10) ng/ml, TRUS guided biopsy was done in patients with percent free/total PSA < 25. Statistical analysis used were Chi-square test, Mann-Whitney U-test, Spearman's rank correlation analysis and Receiver-Operating Characteristic (ROC) curve. RESULTS: Out of the 235 patients included, 60 patients had malignancy (overall cancer detection rate= 25.53%). The cancer detection rate for PSA ranges of (4-10) and (10-20) ng/ml was as low as 5.95% and 13.16% respectively. Patients with malignant disease had significantly smaller prostate gland size than patients with benign disease (53.89 vs 63.06; p-value <0.05). On the other hand, cancer detection rate was 100% for PSA greater than 50ng/ml. The cancer detection rates were only upto 10% for PSA density ranges upto 0.25 ng/ml/cm3. The Area Under the Curve (AUC) for PSA and PSAD was 0.876 and 0.884 respectively. Only one patient (0.43%) had post-biopsy complication (acute bacterial prostatitis) requiring hospital admission. CONCLUSION: The current serum PSA and PSAD cut offs of 4 ng/ml and 0.15 ng/ml/cm3 need to be raised for Indian population to increase its positive predictive value. Prospective study validation of this finding is lacking.

Role of calculated glomerular filtration rate using percutaneous nephrostomy creatinine clearance in the era of radionuclide scintigraphy.

CONTEXT: Gates method tends to over-estimate glomerular filtration rate (GFR) in borderline functioning kidneys. We study the role of calculated GFR in these cases in decision-making regarding performing kidney-sparing surgery or nephrectomy. AIMS: The aim of this study is to find the correlation between GFR calculated by percutaneous nephrostomy (PCN) urine creatinine clearance in obstructed kidneys and GFR by radionuclide scintigraphy. It also studies the role of this calculated GFR in borderline functioning kidneys. SETTINGS AND DESIGN: Single tertiary care center; retrospective. MATERIALS AND METHODS: A total of 46 patients in whom PCN was inserted as an emergency measure in an obstructed kidney and for whom diethylene-triamine-penta-acetic acid/ethylene-di-cysteine (DTPA/EC) scan was also done (Gates method) were analyzed retrospectively. PCN creatinine clearance was calculated for 3 consecutive days, and the mean value was used. STATISTICAL ANALYSIS USED: Pearson's correlational analysis; Chi-square test. RESULTS: Overall strong correlation was found between the two GFR values (Pearson's r = 0.540692, P < 0.001). Totally 26 patients (56.52%) had comparable GFR values (P > 0.05). Among the 36 patients with borderline functioning kidneys, DTPA/EC scan significantly over-estimated GFR in one-third of the patients. The management plan was changed in 7 out of those patients (46.67%), with nephrectomy performed in all instead of kidney-sparing procedure. When the highest value of calculated GFR was compared, 28 patients had comparable GFRs (60.87%). CONCLUSIONS: GFR based on radionuclide scintigraphy may be insufficient for evaluation of residual renal function to determine the management of obstructed kidney with borderline function. For adequate decision-making, other factors including creatinine clearance via PCN should also be considered. Gates method tends to overestimate GFR as compared to calculated creatinine clearance at low GFR levels.

Reconstruction of Female Urethra with Tubularized Anterior Vaginal Flap.

INTRODUCTION: Female urethral injury is a rare disease. Causes of urethral injuries are prolonged obstructed labour, gynaecological surgeries like vaginoplasty and post traumatic urethral injuries. The present study was conducted to evaluate outcome of female urethral reconstruction using tubularized anterior vaginal wall flap covered with fibroadipose martius flap and autologous fascia sling in patients with urethral loss. AIM: Aim of study was to evaluate outcome of reconstruction of female urethra with tubularized anterior vaginal flap. MATERIALS AND METHODS: Retrospective analysis of all the patients with complete urethral loss was done from August 2008 to July 2015. Total seven patients were included in study. All patients presenting with total urethral loss were included. These patients were treated with tubularized anterior vaginal flap. Neourethra was covered with Martius labial flap and autologous fascia lata or rectus abdominis fascia sling. Most common cause of urethral loss was obstructed labour (57.1%). Postoperatively patients were assessed for continence, urine flow rate, ultrasound for upper urinary tract and post void residue. RESULTS: Mean operative time was 180 minutes (160-200 minutes) and Intraoperative blood loss was 220ml (170-260 ml). Mean postoperative hospital stay was eight days (seven to nine days) Mean post surgery maximum urine flow rate was more than 15ml/sec (6.7-18.2ml/sec) and mean post void residual urine was 22.5ml (10-50ml). Median follow-up time was 35 months. All patients were catheter free and continent post three weeks of surgery except one patient who developed mild stress urinary incontinence. One patient developed urethral stenosis which was managed by intermittent serial urethral dilatation. CONCLUSION: Female neourethral reconstruction with tabularized anterior vaginal flap and autologous pubovaginal sling is feasible in patients of total urethral loss with success rate of approximately 86%. It should be considered in patients of complete urethral loss with adequate healthy vaginal tissue.

A Rare Case of an Adult with Untreated Bladder Exstrophy Presenting with Signet-Ring Cell Adenocarcinoma of Urinary Bladder.

Untreated bladder exstrophy in an adult is rare, as the defect is obvious and primary reconstruction is usually done in infancy. There are less than 90 reported cases of primary adenocarcinoma in an untreated bladder exstrophy in literature and only two such case reports from India. Of these, only one case was of signet-ring cell type of mucinous adenocarcinoma. Here we report the second case of signet-ring cell adenocarcinoma in a 63 year old male with untreated bladder exstrophy (oldest patient in literature), to highlight the extreme rarity, yet distinct possibility and challenges faced in surgical management of such cases.