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   Table of Contents - Current issue
Coverpage
October-December 2019
Volume 11 | Issue 4
Page Nos. 339-456

Online since Wednesday, October 9, 2019

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REVIEW ARTICLE  

Management of urinary tract infection in women: A practical approach for everyday practice Highly accessed article p. 339
Nassib F Abou Heidar, Jad A Degheili, Aline A Yacoubian, Raja B Khauli
DOI:10.4103/UA.UA_104_19  
A common health-care problem worldwide, urinary tract infection (UTI), represents a disease of significant impact on every country's economy, being the most common cause of hospitalization among elderly people and the most common cause of antibiotic prescription in primary care. Diagnosing and managing upper and lower UTI have always been a challenge to physicians, given its high prevalence, risk of recurrence and improper treatment, and the fact of worldwide increase in antibiotic resistance, necessitating implementation of a proper antibiotic stewardship. Urinary infections are twice more likely to occur in females compared to males and its prevalence increases with increasing age. The following is a comprehensive review paper about UTI in females, discussing the various factors leading to a complicated infection. The various etiologies and microbiologies of UTI are also highlighted. In addition to various usual antibiotic regimens for treating UTI, a significant number of nonantimicrobial treatment modalities are highlighted and described in this manuscript, including the novel use of intravesical antibiotics and vaccines for suppression treatment. Finally, a pathway is suggested for the proper diagnosis and treatment that ensures antibiotic stewardship in order to decrease long-term complications.
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ORIGINAL ARTICLES Top

Prevalence and characterization of urolithiasis in the Western region of Saudi Arabia p. 347
Anmar M Nassir
DOI:10.4103/UA.UA_56_19  
Objectives: The main objective of this study is to determine the prevalence and risk factors of urolithiasis among the Saudi population in Makkah region. Methods: A cross-sectional survey was conducted on February 2017 in Makkah region (Makkah, Jeddah, and Taif). Data were obtained through direct interviews with participants, using an 18-questions-self-questionnaire, inquiring about demographic data (age, gender, weight, height, location, and occupation), educational level, history of renal stone disease (symptoms, modality of diagnosis, hospital admission, and previous treatment), and risk factors of stone formation such as family history and daily fluid intake. Results: A total of 1506 individuals were interviewed, including 82% from Makkah, 15.7% from Jeddah, and only 2.3% from Taif. The overall percentage of those diagnosed urolithiasis was 6.2%; including 6.6% males and 5.8% females (P = 0.06). Of those with stones, 5% were medically treated, 1.7% were hospitalized, and 1.2% were surgically managed for stones. There was a positive linear correlation between the prevalence of stones and participants' age group (r = 0.87, P = 0.01). More than 80% of participants were highly educated, which did not impact the prevalence of stones formation (P = 0.14). Urolithiasis was reported by 8.9% obese participants, 5.9% overweight, and 5.4% with normal body mass index (r = 0.68, P = 0.03). When stratified by jobs, stone prevalence significantly increased in retired participants (17.2%) than in workers (8.8%), followed by those without work (7.7%) and finally by students (3.3%) (P < 0.001). There was no significant difference between urolithiasis and type of drinking water (P = 0.62). Conclusion: The prevalence of urolithiasis in the Western region of Saudi Arabia has not changed much since the previous report, which was 30 years ago. It seems that the middle-aged population in their third decade of life, those who are overweight and obese people are at a high risk of developing urolithiasis.
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The incidence and pattern of renal cell carcinoma recurrence after robotic partial nephrectomy p. 353
Mohamad W Salkini, Nabhan Idris, Abdul Raof Lamoshi
DOI:10.4103/UA.UA_134_18  
Background: Robotic partial nephrectomy (RPN) is a rapidly growing treatment for small renal mass (SRM). In fact, RPN has shown good functional and oncologic outcome. In this manuscript, we are reporting on the incidence and pattern of recurrence of renal cell carcinoma (RCC) treated with RPN. Patients and Methods: We reviewed prospectively collected data of patients who underwent RPN between September 2009 and March 2018. We selected patients with final pathologic diagnosis of RCC after the resection of their SRM. We described the incidence and pattern of recurrence in the patients who had it. Results: A total of 335 patients with SRM underwent RPN. We found 269 patients to have RCC on the final pathologic evaluation of the SRM. Eight cases of recurrence were found with a recurrence rate of 2.9% after the mean follow-up period of 31 months (range 18–72). The pattern of recurrence presented as follows: two patients (0.7%) had trocar site recurrence (TSR), one patient (0.37%) had locoregional recurrence, and three patients (1.1%) had recurrence of the disease at the resection bed. Two patients (0.7%) developed second primary tumor in the other kidney. No cancer-related mortality occurred during the follow-up period. Conclusion: TSR, locoregional recurrence, tumor bed recurrence, and contralateral tumor development are observed patterns of RCC recurrence after RPN. Recurrence was seen in up to 72 months. RPN provides great cancer control and high cure rate when utilized to treat RCC presenting as SRM.
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Outcome of thulium laser enucleation of prostate surgery in high-risk patients with benign prostatic hyperplasia p. 358
Ketan P Vartak, Kshitij Raghuvanshi
DOI:10.4103/UA.UA_175_18  
Background: Benign prostatic hyperplasia (BPH) is one of the most common diseases in aging men and a significant cause of burden worldwide. Here, we report our experience of Thulium LASER enucleation of the prostate (ThuLEP) in high-risk patients with BPH. Methods: This was a prospective study conducted between July 2011 and June 2016. The study participants were patients with a confirmed diagnosis of BPH, who required surgery, and were clinically eligible for ThuLEP. Results: A total of 109 patients were included in the study. Of the total 109 patients, 82 patients had American Society of Anesthesiologists (ASA) Grade 3 and 27 had ASA Grade 4. The most common comorbidity was ischemic heart diseases (72.5%), followed by hypertension (57.8%) and diabetes mellitus (48.6%). During the procedure, a total of 11 (10.1%) patients had a fall in blood pressure requiring noradrenaline or mephentine and seven (6.4%) patients had early left ventricular failure. Sixteen (14.8%) patients had arrhythmias (benign) and seven (6.4%) patients with arrhythmias required antiarrhythmic drugs. The overall duration of surgery ranged from 55 to 70 min, laser time ranged from 25 to 35 min, hospital stay ranged from 30 to 36 h, and the mean catheter time was around 24 h. Overall, the change in hemoglobin ranged from 0.5 to 0.8 g/dL. Conclusion: Results show that ThuLEP could be a better option in high-risk patients with BPH.
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Efficacy of intercostal nerve block with 0.25% bupivacaine in percutaneous nephrolithotomy: A prospective randomized clinical trial p. 363
Iqbal Singh, Om Kumar Yadav, Sanjay Gupta
DOI:10.4103/UA.UA_141_18  
Introduction and Aim: Several techniques have been used to lower the morbidity of percutaneous nephrostomy (PCN) tube after percutaneous nephrolithotomy (PCNL). The outcomes of intercostal nerve block (ICB) versus peritubal block (PTB) with 0.25% bupivacaine to alleviate post-PCNL pain were compared. Materials and Methods: After obtaining an informed written consent and local institutional ethics clearance, 64 patients undergoing PCNL were computer randomized to receive either an intercostal block/ICB (Group I) or a peritubal block/PTB (Group II) using 0.25% bupivacaine infiltration, after termination of the procedure. They were evaluated for visual analog scale (VAS) score, first analgesic requirement, and the total analgesic demand along with fall in hematocrit, PCN indwelling time, blood transfusion rate, complications, and mean hospital stay in the postoperative period. The protocol was registered with CTRI/2018/03/012717. Results: Patients in both the groups were comparable on the basis of demographic data, preoperative renal function, stone burden, and hematocrit value. The mean VAS score at 6, 12, 24, and 48 h was significantly lower in the Group II versus Group I (P < 0.001). The total mean analgesic requirement was 160.16 and 103.13 mg of diclofenac sodium in Group I and Group II, respectively, which was significantly higher in Group I versus Group II (P < 0.001). The time to first analgesic demand was significantly higher in PT group (8.06 ± 1.99 h vs. 12.97 ± 1.96 h) in Group I/ICNB and Group II/PT, respectively (P < 0.001). Both the groups were comparable in terms of postoperative hematuria, hematocrit fall, nephrostomy site leak, hospital stay, need of blood transfusions, stone-free rate/retreatment rate, postoperative urinary tract infections, and overall complication rate (Modified Clavien–Dindo classification) which were not statistically significant. Conclusion: Post PCNL, PTB was associated with significantly lower post operative pain and discomfort versus ICB as demonstrated by the significantly lower DVAS pain scores, higher mean time to first analgesic demand and lower mean total analgesic demandt with ICB. Bupivacaine was a safe and effective local anesthetic agent for PTB in select patients for facilitating quick relief from the morbid postoperative pain and discomfort following PCNL.
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Oral dissolution therapy for renal radiolucent stones, outcome, and factors affecting response: A prospective study p. 369
Shady Mohammed Salem, Mohammed Farag Sultan, Atef Badawy
DOI:10.4103/UA.UA_20_19  
Background: Urolithiasis is a widespread problem, that affects up to 10% of population. Uric acid stones come second to calcium stones in prevalence (around 10% of urolithiasis). Potassium citrate is currently the treatment of choice for urine alkalization with minimal side effects and high tolerability. Aims and Objectives: This study is trying to present the outcome of oral dissolution therapy (ODT) for treating radiolucent renal stones and evaluating factors affecting its success in a prospective manner. Materials and Methods: Between 2015 and 2018, 147 patients with solitary radiolucent renal stones were offered ODT using potassium sodium hydrogen citrate (K citrate). The study included patients diagnosed by noncontrast computed tomography (NCCT) with stone size of 5–30 mm in the longest dimension and attenuation less than 600 Hounsfield units (HU) . Patient compliance, blood pressure, creatinine level, K level, and tolerance to side effects were followed up at days 3, 7, and 15 and then monthly for 3 months. Follow-up renal ultrasound at 6-week intervals and a final NCCT at the end of treatment. Successful dissolution was defined as complete stone dissolution or residual that measures up to 2 mm in maximum length. Data were collected, tabulated, and analyzed using Stata 12.0 software (Stata Corporation, College Station, TX, USA). Results: One hundred and thirty-nine patients were included in the analyses. The age was 45.1 ± 10.5 years. DJ stent was used in 47 (33.8%) patients. Overall response rate was 64.8%. The stone location within the kidney (pelvic or calyceal) showed no difference between responders and non-responders. Stone longest diameter was smaller in responders ( 17 ± 5.7 mm) versus 19.2 ± 6.1 mm in nonresponders (P value = 0.039). The mean stone attenuation value (HU) was also lower in responders( 347.4 ± 68.5 HU) versus (428.9 ± 84.0 HU) in nonresponders with P < 0.001. DJ insertions seemed to have marginal effect on stone dissolution on univariate analysis but found insignificant in multivariate analysis. Conclusion: ODT is safe and effective in the treatment of radiolucent renal stones. The efficacy was affected by stone density and stone size with more tendencies to failure with bigger stones and denser stones. Double J stent insertion may facilitate dissolution rate. There was no effect of the baseline urinarypH, hyperuricemia, or stone location on the dissolution rate of the stones.
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Modification of microsurgical longitudinal intussusception technique of vaso-epididymal anastomosis: A single-center experience p. 374
Rajendra K Shimpi, Krutik V Raval, Darshan N Patel
DOI:10.4103/UA.UA_90_18  
Purpose: Microsurgical intussusception vasoepididymostomy (VE) is well-established treatment option for obstructive azoospermia due to epididymal obstruction. In this study, we evaluated patency rates and complications of our modified longitudinal intussusception technique of microsurgical VE. We have modified the intussusception technique by taking only adventitia of epididymal tubule. Methods: This was a prospective, single-center (tertiary care center) study conducted from February 2008 to January 2016. Study patients were men aged more than 18 years with infertility due to azoospermia. All participants underwent microscopic VE with our modified intussusception technique. Patency rates, complications, and improvement in semen quality were assessed. Results: A total of 42 patients were included in the study and underwent unilateral VE using longitudinal intussusceptions technique. The mean age of the patients was 30.21 years. Of these 42 patients, 40 patients had congenital obstruction. Average operative time was 130.42 min. A total of 36 (85.7%) patients had motile sperms in the epididymal fluid. Patency at 3 months was observed in 25 (62.5%) patients with an average sperm count of 17.1 million/mL. Only two patients (5%) had hemotoma at the site of surgery. Conclusion: Our modified technique of microsurgical longitudinal intussusception VE using epididymal adventitial stitch showed a reasonable patency rate after surgery.
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To study the incidence and preintervention factors associated with acute kidney injury in patients diagnosed with ureteric calculi p. 380
Sheshang Uday Kamath, Bhushan Patil, Sujata Kiran Patwardhan
DOI:10.4103/UA.UA_96_18  
Aims and Objectives: The study aims to evaluate the incidence and factors associated with acute kidney injury (AKI) among patients presenting with ureteric calculi. We also intend to study the impact of time delay since first symptom to presentation to our hospital among patients with ureteric calculi and its influence on AKI. Material and Method: The study is a prospective observational study and included all symptomatic ureteric calculi patients. AKI was defined as per the KDIGO guidelines. All the patients diagnosed with ureteric calculi were grouped into those having an episode of AKI and those without an episode on AKI. Results: The incidence of AKI in our study was 14.63% (18 patients) among 123 patients of ureteric calculi. Average time delay from time of diagnosis to presentation among patients with AKI was 31.7±6.2 days (mean ± S.D) as compared to 19.5±5.7 (mean ± S.D) days among all cases. Factors which were significantly associated with AKI in patients with ureteric calculi include time delay, diabetes mellitus, bilateral ureteric calculi, stone size greater than 10 mm, solitary functioning kidney and urine culture showing gram negative growth. Fifty percent of the AKI group eventual required nephrectomy of one renal unit. Conclusion: This study will help us streamline our resources predominantly towards those patients who present with factors associated with increased risk of AKI. As the time delay to presentation in patients with AKI with ureteric calculi is significantly higher, it is imperative to counsel patients with stone disease.
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Retrospective review of experience with sarcomatoid renal cell carcinoma: Multimodality treatment remains an unmet goal p. 385
Gowrinath Kondisetty, Pallavi Vijay Borkar, Sandeep Kondisetty, Appu Thomas
DOI:10.4103/UA.UA_106_18  
Background: Sarcomatoid change in Renal cell carcinoma(RCC) is associated with adverse outcomes with median survival of 6 months. Settings and Design: This is a retrospective study of patients diagnosed of sarcomatoid RCC(sRCC) between 2007 and 2013 which were followed up till 2017. Methods and Material: Patients (n=22) were grouped based on whether they received additional chemotherapy following nephrectomy. Two groups were followed up until 2017 and overall survival was record. Overall survival curves were estimated by Kaplan-Meier method and compared using Log Rank (Mantel-Cox) test between two groups. Statistical analysis used: Kaplan-Meier method and Log Rank (Mantel-Cox) test. Results: The patients who had chemotherapy had 13.4 cm of mean tumour size with a mean survival of 20.4 ± 8.3 months. The patients who did not undergo chemotherapy had mean tumour size of 11.7 cm with a mean survival of 21 ± 5.9 months. There was no much statistical difference between the two groups in OS with P value = 0.99. Conclusion: The current adjuvant chemotherapy used in sRCC patients who develop metastasis gives no survival advantage.
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Tuberculosis of the prostate gland masquerading prostate cancer; five cases experience at IGIMS Highly accessed article p. 389
Kumar Gaurav Mishra, Ahsan Ahmad, Gaurav Singh, Rajesh Tiwari
DOI:10.4103/UA.UA_119_18  
Objectives: Tuberculosis (TB) of the prostate is a very rare disease. Most urologists are not familiar with it. Here, we present our experience with five cases of this disease and a review of literature. Materials and Methods: This is a retrospective study in a tertiary care center (IGIMS, Patna, Bihar, India) from January 2013 to February 2018. Results: All the patients were in their fourth to sixth decades of life. Lower urinary tract symptom was the most common presentation, predominantly irritative symptoms. A history of pulmonary TB was present in one case. Four out of five cases (80%) had a suspicious prostate on the digital rectal examination (DRE) (hard in consistency). Serum prostate-specific antigen (PSA) level was slightly elevated with a mean of 13.24 ng/ml. Urine analysis revealed sterile pyuria in all patients, and the urine culture was negative. The urine for acid-fast bacilli was positive in one case (20%). Mycobacterium tuberculosis culture test was positive in two cases (40%). The transrectal ultrasonogram showed hypoechoic areas with irregular outlines in three cases (60%) and calcification in two cases (40%). Histopathological examination showed chronic granulomatous prostatitis with few Langhans-type giant cells in four cases (80%). All patients were scheduled to receive 6 months of chemotherapy with isoniazid, rifampicin, and ethambutol or pyrazinamide. Conclusion: TB of the prostate may present like cancer prostate with raised serum PSA and suspicious prostate on DRE; hence, a high index of suspicion with a wide range of investigations may be required to achieve a complete diagnosis of prostatic TB.
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Adult urethral stricture: Practice and expertise of urologists in Saudi Arabia p. 393
Abdullah M Al Khayal, Manerh A Bin Mosa, Khalid A Alrabeeah, Saad M Abumelha
DOI:10.4103/UA.UA_159_18  
Objective: The aim of this study is to determine the methods used to evaluate and manage urethral strictures by urologists practicing in Saudi Arabia. Materials and Methods: This is a cross-sectional study based on a validated questionnaire directed to all urologists and senior residents practicing in Saudi Arabia. Categorical data reported as frequencies and percentages. A Chi-square test was used for inferential analysis. P < 0.05 was considered statistically significant. Results: We received 112 responses, of which 78% were from board-certified urologists. The majority were working in government hospitals. The rate of endoscopic procedures performed exceeded open urethroplasty. Direct Vision Internal Urethrotomy was the most common procedure performed as stated by 85% of the responses. Uroflowmetry with postvoid residual was the most common investigation requested to assess strictures before and after the operation usually in adjunction with retrograde urethrogram and or cystoscopy. Most of the urologists believed in a step-wise approach in the management of strictures and that urethroplasty is indicated only after repeated trials of endoscopic management. Conclusion: Our results revealed a preference, and perhaps misuse, of endoscopy which might raise a concern regarding patients' prognosis with repeated endoscopic management. Most of the urologists seem to be reluctant to proceed to a definitive treatment on the time of diagnosis either due to a lack of experience or knowledge. The results showed no difference between practice in government and private hospitals.
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Laparoscopic appendicovesicostomy and ileovesicostomy: A step-by-step technique description in neurogenic patients p. 399
Pedro Costa, Carlos Ferreira, Damiano Bracchitta, Pierre-Émmanuel Bryckaert
DOI:10.4103/UA.UA_167_18  
Aims: This study aims to describe our surgical technique and report our preliminary experience with laparoscopic ileal or appendicovesicostomy in adult patients with neurogenic bladder caused by spinal cord injury. Subjects and Methods: From January 2014 to March 2017, seven patients were submitted to an appendicovesicostomy under Mitrofanoff procedure and two patients to an ileovesicostomy under Yang-Monti procedure by laparoscopy. Clinical indications were patients with a history of neurogenic bladder secondary to spinal cord pathology, with proper dexterity and willing to have a more accessible continent derivation. Surgical steps include: (1) identification and mobilization of appendix; (2) ligation of appendix' base; (3) endoloop reinforcement of proximal end; (4) silicon catheter insertion in appendix' lumen; (5) mesoappendix dissection; (6) Retzius space opening; (7) posterior bladder dissection; (8) anterior transcutaneous bladder dome fixation; (9) vertical midline detrusor incision; (10) opening of bladder mucosa; (11) excision and espatulation of appendix tip; (12) appendico vesical anastomosis; and (13) exteriorization of appendix through umbilicus and creation of catheterizable stoma. In the two patients submitted to a Yang-Monti diversion, the ileum reconfiguration and calibration was done extracorporeally. One patient had simultaneous bladder augmentation. Results: The mean follow-up was 21.5 ± 11.9 months. The mean operative time was 161 min (123–220). There was no conversion to laparotomy and no need of postoperative blood transfusion. The mean hospitalization length was 4 days. No early postoperative complication was registered. Late postoperative complications were: one surgical stoma revision, one false-passage (solved by transient catheterization), and one bladder stone (solved by endoscopic approach). All patients are continent. Conclusions: This series presents our laparoscopic technique for continent urinary diversions, showing that it is feasible and safe in adult patients with neurogenic bladder.
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Importance of time in management of fracture penis: A prospective study p. 405
Bhushan Patil, Sheshang Uday Kamath, Sujata Kiran Patwardhan, Abhishek Savalia
DOI:10.4103/UA.UA_80_18  
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.
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Retrospective comparison of outcomes of laparoscopic pyeloplasty using barbed suture versus nonbarbed suture: A single-center experience p. 410
Vikas Giri, Sher Singh Yadav, Vinay Tomar, Amit K Jha, Amit Garg
DOI:10.4103/UA.UA_123_15  
Introduction: laparoscopic pyeloplasty is an important tool in urology armamentarium. The most important & also the difficult part of this surgery is intracorporial suturing and knotting. There are only a few reports of knotless Barbed sutures for upper tract reconstruction. We report the comparative outcomes of Laparoscopic Pyeloplasty with barbed suture vs non barbed sutures used for uretero-pelvic anastomosis. Materials and Methods: We retrospectively reviewed patients' records that underwent Laparoscopic pyeloplasty at our Institution from January 2013 to May 2014. Total 37 patients were underwent LP in this period. Whole of the procedure was same as conventional LP except suture material. 3-0 barbed suture was used in 21 patients and 3-0 vicryl used in 16 patients for uretero-pelvic anastomosis and continuous suturing technique was employed. Patients' demographics, total operative time, intracorporial suturing time, post operative complications, symptoms & renal isotope scan were recorded. Results: Average total operative time was significantly less in barbed suture group vs vicryl group (162 vs 208 minutes) (p=0.0811). Average time taken for intracorporial suturing was 31.2 minutes vs 70 minutes (p=0.0576). 1 patient developed post operative urine leak which persisted for 5 days in barbed group (4.76 %) vs no leak in vicryl group. Most common complication was UTI presented in 2 patients (9.5 %) vs 2 in vicryl (12.5%). JJ stent was removed at 4 weeks. Median follow up was 3 months with 7 patients lost to follow up. None of the patients found to have obstructive drainage or deterioration of split function on follow up isotope renogram at 3 months. Conclusions: In this study, Laparoscopic pyeloplasty with barbed suture has acceptable outcome when compared to conventional non barbed suture on short term basis. Laparoscopic Pyeloplasty with barbed suture can potentially become the standard approach in near future.
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Emphysematous pyelonephritis: Does a standard management algorithm and a prognostic scoring model optimize patient outcomes? p. 414
Amit Jain, Ramanitharan Manikandan, Lalgudi Narayanan Dorairajan, Sreerag Kodakkattil Sreenivasan, Sriharsha Bokka
DOI:10.4103/UA.UA_17_19  
Objective: The objective of the study is to analyze the risk factors determining the outcomes of patients with emphysematous pyelonephritis (EPN) by the adoption of a standardized management algorithm as well as to develop a prognostic scoring model to risk stratify these patients. Materials and Methods: The hospital records of 72 consecutive patients with EPN from February 2012 to January 2018 were retrospectively reviewed. Demographic, clinicoradiographic, and laboratory characteristics were recorded. Patients were managed with a standard management protocol and based on outcomes divided into three groups. Group I survived with conservative management, Group II survived after emergency nephrectomy, and Group III expired. The risk factors for nephrectomy and mortality were analyzed. Results: The mean age was 53 years. Male to female ratio was 4:5. There were 61 (84.7%), 4 (5.6%), and 7 (10%) patients in Groups I, II, and III, respectively. Diabetes mellitus was the most common comorbidity detected in 62 (86%) of patients. Type II EPN was the most common radiological presentation observed in 32 (44%) patients. Overall survival rate was 90%, and kidney salvage rate was 80%. Escherichia coli was the most common organism isolated. Thirty-two (45%) patients exhibited resistance to third-generation cephalosporin antibiotics. Thrombocytopenia, low body mass index (BMI), presence of >2 comorbidities, high total leukocyte count (TLC), and hypoalbuminemia were significantly associated with mortality. On adoption of the prognostic scoring system, mortality rates according to the risk subgroups were as follows: favorable - 0%, intermediate - 19%, and poor - 100%. Conclusion: Conservative management adopting appropriate algorithm reduces mortality and avoids unnecessary emergency nephrectomies. Thrombocytopenia, low BMI, presence of >2 comorbidities, high TLC, and hypoalbuminemia were significantly associated with mortality.
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Antibiotic prophylaxis in children with ureteric stents: Bliss or misery? p. 421
Basim S Alsaywid, Abdullah A Mesawa, Abdullah Khalid Mohammedkhalil, Mohammed Almarghoub, Zhour Barnawi, Wesam T Abuznadah
DOI:10.4103/UA.UA_116_18  
Introduction: The risk of urinary tract infection (UTI) in patients with a ureteric stent is influenced by several factors such as duration of stenting. Antibiotic prophylaxis has been previously used for the prevention of UTI in patients with common urological pathologies. The aims of this study were to evaluate the incidence, to identify the risk factors of symptomatic UTI in pediatric patients with ureteric stents, and to review the effectiveness of antibiotic prophylaxis in reducing the rate of symptomatic UTI compared to a no intervention (control) group. Materials and Methods: This was a retrospective cohort study that was held at a tertiary hospital in Jeddah, Saudi Arabia. The study included 110 pediatric patients who were younger than 18 years and who required ureteric stent insertion. Disregarding gender difference, the patients were divided into two main groups: an antibiotic group and a control group. The patients in the antibiotic group (Group 1) received continuous antibiotic prophylaxis from the date of ureteral stent insertion until removal, while the patients in the control group (Group 2) received antibiotics during the perioperative period only. Results: A total of 110 patients were included in the final analysis. Group 1 patients who were given antibiotic prophylaxis during the presence of ureteric stent were 54 patients (49%). Group 2 patients who were only given antibiotic during the perioperative period were 56 (51%). Males compromised 73% (n = 80) of the sample population, while females were 27% (n = 30). The prevalence of symptomatic UTI was significantly reduced from 25% in the control group to 7% in the antibiotic group (P < 0.004). Conclusion: Antibiotic prophylaxis has significantly reduced the risk of symptomatic UTI by 68% in comparison to the control group.
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Percutaneous nephrolithotomy versus shock wave lithotripsy for high-density moderate-sized renal stones: A prospective randomized study p. 426
Mohamed Gadelmoula, Ahmad A Elderwy, Islam F Abdelkawi, Ahmed M Moeen, Ghaleb Althamthami, Ahmed M Abdel-Moneim
DOI:10.4103/UA.UA_63_19  
Context: The management of renal stones of high density (>1000 Hounsfield units) on non-contrast computed tomography (NCCT), and moderate sized (15-25 mm) is still debatable. Aims: The aim of this study was to compare the outcomes of percutaneous nephrolithotomy (PCNL) and shock wave lithotripsy (SWL) for the high-density and moderate-sized renal stones regarding the stone-free rate (SFR), morbidity, and patients' quality of life. Settings and Design: This is a prospective randomized study. Patients and Methods: Eighty consecutive patients with renal stones, excluding those with lower calyceal stones, were randomized to receive either PCNL or SWL (40 in each arm). Patients were followed up by abdominal ultrasound and plain X-ray (NCCT if indicated) till clearance of stone. Outcomes, complications, costs, and SF-8 Health Survey scoring were recorded for each group. Statistical Analysis: We used Stata software, version 9.2 (Intercooled STATA®; StataCorp LP College Station, Texas, USA). Comparison of the two groups was made with regard to patient and stone criteria and the procedure details. Continuous variables were compared using the Mann–Whitney U-test with values shown as the median and interquartile range. Categorical variables were compared using the Pearson's Chi-square/Fisher's exact test. Multivariate logistic regression analysis was used to identify variables independently associated with the stone clearance after two sessions of SWL. P < 0.05 was considered statistically significant. Results: The basic characteristics of both groups were comparable. After a single treatment session, the SFR was 80% and 27.5% for PCNL and SWL, respectively (P < 0.001). The overall 3-month SFR was 87.5% versus 90%, respectively (P = 0.723). The median number of the required maneuvers was 1 (range: 1–3) for PCNL versus 2 (range: 1–4) for SWL (P < 0.001). The complication rate was 10% and 7.5%, respectively (P = 0.692). The cost of SWL was significantly lower (P < 0.001). On multivariate analysis, a single stone was an independent predictor for stone clearance after two sessions of SWL (odds ratio: 7.26, 95% confidence interval: 1.13–46.62, P = 0.037). Conclusions: PCNL for the dense, and moderate-sized renal stone provides higher initial success and lower re-treatment rates compared with SWL with comparable outcome after 3 months of therapy. However, SWL is an alternative, especially for a single stone.
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CASE REPORTS Top

Bladder hernia complicated with cystolithiasis and bladder tumor: Two cases' analysis p. 432
Khaled Ben Ahmed, Khaireddine Bouassida, Kamel Ktari, Mehdi Jaidane
DOI:10.4103/UA.UA_135_18  
Inguinal hernia is frequent and reaches up to 8% of the population. It was reported that over 20 million inguinal hernia repairs are performed annually. The bladder may herniate in 1%–3% of the cases through the inguinal canal that can be responsible for various symptoms. The most specific is the classic “two-stage micturition.” However, the diagnosis usually remains unspecific, and a surgeon can fall in the trap of a “simple” inguinal hernia and cause accidental damages to an undiagnosed bladder hernia. Therefore, a clear diagnosis must be assessed based on clinical and radiological findings to avoid complications. In these two presented cases, the patients presented cystolithiasis complicating the bladder herniation. One of the patients also developed a bladder tumor which appeared to be urothelial carcinoma.
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Neuroendocrine tumor of the kidney: Diagnostic challenge and successful therapy p. 435
Jamal Zekri, Haleem Jawed Rasool, Abdelrazak Meliti, Jawairiya Rasool
DOI:10.4103/UA.UA_169_18  
The management of gastrointestinal and pancreatic (GEP) neuroendocrine tumors (NETs) has evolved over the recent decade. Primary renal NETs are extremely rare as neuroendocrine cells are not recognized in the normal renal parenchyma. We report a case of primary renal NET characterized by the initial diagnostic challenges. Recurrent and metastatic disease was managed along the lines of management of GEP-NETs, leading to prolonged progression-free survival.
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Intense fluoro-2-deoxyglucose uptake in high-grade prostatic adenocarcinoma with negligible prostate-specific membrane antigen expression p. 439
Tansel Cakir, Selcuk Guven, Bahar Muezzinoglu, Cengiz Erol, Mustafa Yucel Boz, Tamer Atasever
DOI:10.4103/UA.UA_11_19  
While 68Gallium prostate-specific membrane antigen positron emission tomography/computed tomography (68Ga-PSMA) has demonstrated increasing utility in the evaluation of prostatic carcinoma, it is essential to be aware of false-negative findings. Further subtype analyses of prostate cancer will be helpful in the understanding of the underlying reasons. We herein present a high-grade prostate adenocarcinoma, with metastatic lesions showing high 18F-labeled fluoro-2-deoxyglucose uptake instead of 68Ga-PSMA.
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Spontaneous knotting of urinary catheters placed with nonindwelling intent: Case series and literature review p. 443
Vijay Pal Singh, Sanjay Sinha
DOI:10.4103/UA.UA_15_19  
Urethral catheters are placed with nonindwelling intent chiefly for clean intermittent catheterization (CIC), imaging, or collection of a urine sample. Catheter knotting can be a troublesome complication, especially when it occurs in children often resulting in interventions under anesthesia in the operating room. Three children (4 years male, 4 years female, and 6 years male) presented with knotted feeding tubes placed for CIC. Details of these and an additional 31 patients are discussed in a short review. Knotting occurred almost exclusively in children (33/34, 97%), was more common in boys (22/34, 65%) and most often involved a feeding tube (27/34, 79%) with knotting in the bladder (28/34, 82%). Insertion length, caliber and stiffness of catheter, technique, and patient factors are important factors. Avoiding excessive insertion and use of an appropriate size of catheter (that is not too small) may reduce the risk. Manipulation alone (12/34, 35%), with guidewire (5/34, 15%), or with dilatation (3/34, 9%) is most often successful and is best accomplished under general anesthesia. Endourology (7/34, 21%), laparoscopy (1/34, 3%), or an incision (5/34, 15%) may be necessary in some patients. Safeguarding urethral integrity is the overarching concern.
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Tunica albuginea cyst presenting with milk of calcium p. 447
Erdal Karavas, Onur Taydas
DOI:10.4103/UA.UA_163_18  
Tunica albuginea cysts are rarely seen but are important and can be diagnosed easily with ultrasonography. Calcium milk is defined as the precipitation of calcium in a cyst or other fluid-containing structure and can be seen in many organs. In this case report, calcium milk seen in a tunica albuginea cyst is discussed.
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Zinner syndrome mimicking bladder outlet obstruction managed with aspiration p. 449
Ronal Kori, Lovenish Bains, Pawan Lal, Swati Gupta
DOI:10.4103/UA.UA_152_18  
Zinner syndrome is a rare cystic malformation of seminal vesicle which consists a triad of unilateral renal agenesis, ipsilateral seminal vesicle cyst, and ejaculatory duct obstruction. The usual presentation is between the third and fourth decades of life, with infertility being the most common complaint. Ultrasound, cystoscopy, and magnetic resonance tomography (MRI) can easily detect this condition. Treatment option varies according to the presenting symptoms of the patient. We present a case of a 19-year-old male with recurrent episodes of urinary tract infection (UTI) and poor urinary stream. On ultrasound examination, the patient was found to have absent right kidney with a cystic swelling noted to be arising from prostate or seminal vesicle region which was further confirmed on MRI examination. Cystoscopy reveals a bulge on the right side of the verumontanum abutting the neck of the bladder. An ultrasound-guided aspiration of the cyst was performed which relieved the symptoms of the patient. Cystic abnormalities of the seminal vesicle are very uncommon. Symptomatic cases may present as recurrent UTI, infertility, bladder outlet obstruction, and painful ejaculation. Surveillance may be the option in the absence of clinical manifestations. Interventions such as image-guided aspiration or surgical procedures are appropriate when conservative measures prove ineffective.
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LETTER TO EDITOR Top

Initial clinical presentation of prostate adenocarcinoma with hernial sac metastasis: A review of literature p. 453
Sudarshan Vishnu, Ashima Kapoor, Michael Maroules, Hamid Shaaban, Gunwant Guron
DOI:10.4103/UA.UA_71_19  
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