A randomised controlled trial comparing two protocols of preoperative antibiotics in patients with positive urine culture undergoing percutaneous nephrolithotomy.

AIM: To compare the outcomes of two different protocols of antibiotic prophylaxis in patients with positive urine culture undergoing percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: Patients were prospectively enrolled for the randomised study to either group A which included patients where an attempt to sterilise the urine was made with a 1 week course of sensitive antibiotics or group B that included patients who received a shorter duration of prophylaxis using sensitive antibiotics for 48 h prior to procedure which was continued for 48 h postoperatively. Enrolled patients had stones requiring percutaneous nephrolithotomy and had a positive preoperative urine culture. Primary outcome was difference in sepsis rates between the groups. RESULTS: A total of 80 patients randomised into two groups of 40 each based on the antibiotic protocol used were analysed in the study. There was no difference in infectious complication rates between groups on univariate analysis. The rate of SIRS in Group A and Group B was found to be 20% (N = 8) and 22.5% (N = 9) respectively. The rate of septic shock in Group A and Group B was 7.5% and 5% respectively. On multivariate analysis, longer duration of antibiotics did not decrease the risk of sepsis compared to shorter antibiotic course (p = 0.79). CONCLUSION: Attempts to sterilise urine before PCNL may not decrease the risk of sepsis in patients with positive urine culture undergoing PCNL and may only result in unnecessary prolonging of antibiotic usage thereby increasing the chances of antibiotic resistance.

Presentation, management and outcomes of pediatric urogenital tuberculosis: 20 years' experience from a tertiary center.

BACKGROUND: Urogenital tuberculosis (UGTB) has traditionally being a diagnosis of adulthood and is supposed to be rare in children, as it is believed that the symptoms of renal tuberculosis do not appear for 10 or more years after the primary infection. While this may be true in developed countries, where childhood pulmonary tuberculosis is a rarity nowadays. In developing countries, childhood pulmonary tuberculosis is still a major issue and hence, UGTB is not an uncommon diagnosis in younger children and adolescents in these countries. Considering this dearth of data on childhood UGTB, we retrospectively evaluated our series of children with this disease, with special emphasis on the role of surgery. OBJECTIVE: To analyze the clinical presentation, management strategies and outcomes of pediatric UGTB managed in a tertiary care center. MATERIALS AND METHODS: Case records of children and adolescents ≤18 years diagnosed with UGTB during the period July 1998 to June 2018 at our center were reviewed. Clinical features, organ involvement, investigations, treatment and outcome of therapy were studied. RESULTS: There were 41 children and adolescents (M: F = 22:19) identified, with a mean age of 14.8 ± 3.9 years who fulfilled the inclusion criteria. The most common presentation was flank pain and irritative storage symptoms. Mycobacterium tuberculosis was identified on urinary examination in only 17 (41.5%) cases. Six patients were lost to follow up after initial diagnosis. A total of 45 procedures (35 primary and 10 secondary) were performed in 35 children. Initial diversion in the form of PCN and DJS were done in 11 and 12 patients respectively, of which 8 were managed with stenting alone. Surgical management was done mostly in the form of nephrectomy (15), nephrectomy along with reconstruction (5) and reconstruction only (6). On univariate analysis, factors associated with nephrectomy were poor initial function and nephrostomy as initial diversion. Overall median follow-up was 25 (IQR 15.5-74.25) months. During follow up, chronic renal failure developed in nearly 53.8% of patients who underwent major reconstruction. CONCLUSIONS: Urogenital tuberculosis presents with a wide spectrum of clinical features and pathological lesions. Diagnosis is often delayed because of late presentation and many children present with cicatrization sequelae. Antitubercular drug therapy and judicious application of minimally invasive diversions and surgery (both ablative and reconstructive) achieve satisfactory results in the majority of cases. Children undergoing major surgical reconstruction in particular need to be followed up rigorously and counselled about possibility of development of renal failure.

Ehlers-Danlos syndrome with huge bladder diverticulum in pregnancy - A rare and interesting case report.

Ehlers-Danlos syndrome (EDS) is one of the commonest inheritable connective tissue disorders (CTD) affecting one in 5000 people globally. The incidence of bladder diverticula (BD) is reported to be 1.7% seen more commonly in children without any bladder outlet obstruction. BD are associated with congenital syndromes, namely, EDS. We report a case of huge BD in pregnancy that became symptomatic as the pregnancy progressed to term with urinary retention, recurrent urinary infections and fetal malpresentation. The patient was taken for elective Lower segment cesarean section (LSCS) wherein intra-operative findings of soft abdominal wall, velvety and jelly-like rectus muscle made us suspect connective tissue disorder. A thorough retrospective evaluation of medical history, physical examination along with orthopedic evaluation led to the diagnosis of EDS. To the best of our knowledge, this is the first case report of EDS with huge BD in pregnancy.

Renal Replacement Lipomatosis-A Rare but Often Underdiagnosed Cause of Progressive Renal Damage in Calculus Disease.

Renal replacement lipomatosis is a rare condition characterized by extensive fat deposition in hilum with parenchymal thinning and progressive detoriation of function.1-4 Though uncommon, it should be considered as a possibility in patients with history of intervention for stone disease.5,6 Correct diagnosis can be easily established by cross sectional imaging and is helpful to counsel patients about the possibility of progressive functional detoriation and poor salvageability of the affected kidneys.7-10 Here, we present 2 patients with previous history of intervention for calculus disease who had developed progressive renal damage due to RRL with one patient ultimately needing nephrectomy.

Mortality from hepatocellular and biliary cancers: changing epidemiological trends.

OBJECTIVES: The incidence of hepatocellular carcinoma may be rising in the United States. The aim of this study was to determine the epidemiological trends in mortality from hepatocellular carcinoma (HCC) and biliary cancers (BCs) in Maryland during the last 3 decades. METHODS: The number of deaths due to HCC and BCs from 1970 to 1997 were obtained from the Maryland State Department of Health & Hygiene vital statistics database. Malignant neoplasms of the gallbladder and intrahepatic and extrahepatic bile ducts were grouped together as biliary cancers. To determine the trend in mortality, the total time period was divided into seven 4-yr periods. RESULTS: Mortality from HCC increased from 0.94 to 1.84 per 100,000 population (rate ratio = 1.94, CI = 1.87-2.03) and that from BCs increased from 1.28 to 1.7 per 100,000 population (rate ratio = 1.31, CI = 1.26-1.36) over the study period. Although mortality due to HCC doubled in men (1.34 to 2.7 per 100,000) during this period, only a modest increase was observed among women (0.59 to 1.06 per 100,000). Because of a marked increase in the number of deaths among white Americans, the difference in HCC-related mortality between white Americans and African Americans decreased considerably during this period. Mean age at death increased steadily for BCs from 67 to 73 yr, whereas there was no real trend for HCC. Among African Americans, the death from HCC remained stable, but there was a 2-fold increase in BC-related death. CONCLUSIONS: There was a marked increase in deaths from HCC over the past 3 decades in Maryland. This increase was more evident among men and white Americans. Deaths due to BCs increased modestly during the same period of observation. The marked rise in BC-related deaths among African Americans remains unexplained.