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   Table of Contents - Current issue
Coverpage
April-June 2020
Volume 12 | Issue 2
Page Nos. 107-203

Online since Tuesday, April 14, 2020

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REVIEW ARTICLE  

Spectrum of tuberculosis in urology: Case series and review of the literature Highly accessed article p. 107
Nirmal Kesavan Ponnayyan, Aravind Surendran Ganapath, Venugopal Ganapathy
DOI:10.4103/UA.UA_121_19  
Urologists are confronted with various forms of extrapulmonary tuberculosis (TB) having an atypical presentation. The disease presents late with complications and sequelae. Four cases of extrapulmonary TB who presented to the urology department are reported here. The cases reported are TB adrenalitis, tuberculous cystitis, renal TB, and TB prostatitis. The prsentation of these cases shows GUTB as being a great imitator of other diseases. So there is a need for a very high index of suspicion for early diagnosis and to avoid misdiagnosis to prevent the devastating sequelae like organ damage. Furthermore, there is a need to develop better diagnostic tools for TB. Multidrug chemotherapy and judicious use of surgery form the mainstay of management.
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ORIGINAL ARTICLES Top

Trocar site recurrence after robotic partial nephrectomy to treat of renal cell carcinoma Highly accessed article p. 112
Mohamad Waseem Salkini
DOI:10.4103/UA.UA_121_18  
Introduction: Wound seeding during surgical excision of malignant tumor is known problem in the oncologic surgery. Trocar site recurrence (TSR) is well described in laparoscopic oncologic surgery. Little has been reported about TSR after robotic partial nephrectomy (RPN) performed for renal cell carcinoma (RCC). Here, we report on the incidence of TSR and demonstrate the presentation of this type of RCC recurrence. Patients and Methods: We reviewed prospectively collected data about patient who underwent RPN at our institute from September 2009 to March 2018. We reviewed the medical record of the patients who had the diagnosis of RCC on the final pathology. We identified the patient with TSR and demonstrated their presentation and treatment along with the outcome. Results: A total of 335 patients underwent RPN during the study period for renal mass. Two hundred and sixty-nine (80.3%) patients were found to have RCC on the final pathologic evaluation of their mass. We identified two patients (0.7% of all the RCC in the study) who developed TSR during an average follow-up period of 31 months (ranging from 18 to 72 months). The first recurrence appeared 18 months after the surgery. The second recurrence presented 72 months after RPN. Both cases underwent open surgical excision of the trocar site, in which the recurrence appeared. Conclusion: TSR is potential type of RCC recurrence after RPN, though it is rare and underreported. Special attention should be given to examine the trocar site during the surveillance follow-up of RCC treated with RPN. It can develop up to 72 months after the surgery.
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Monthly maintenance protocol Bacillus Calmette–Guerin as a viable alternative to Southwest Oncology Group maintenance protocol in nonmuscle-invasive bladder cancer: A prospective randomized study p. 116
Naveen Kumar Gupta, Debansu Sarkar, Dilip Kumar Pal
DOI:10.4103/UA.UA_29_19  
Introduction: Bladder cancer is the most common malignancy of the urinary tract, and recurrence following transurethral resection poses the biggest challenge. Intravesical Bacillus Calmette–Guerin (BCG) maintenance with the Southwest Oncology Group (SWOG) protocol remains the gold standard but with poor patient compliance.Materials and Methods: The present study aims to compare the SWOG maintenance protocol with a monthly maintenance protocol comprising 12 monthly doses of intravesical BCG. Patients are included in the study only if induction BCG is completed and cystoscopy at 3 months is negative. All patients receive 80 mg BCG in each dose with strict cystoscopic surveillance every 3 months.Results: Patient demographics and tumor characteristics were similar in the two groups. There were no statistically significant differences in outcome in terms of recurrence, progression, and adverse reactions in both the groups. Although a larger number of patients in the SWOG maintenance group were lost to follow-up, the difference was not statistically significant proportions.Conclusion: From this study, we can conclude that monthly maintenance BCG for 1 year is comparable in terms of outcome with SWOG protocol maintenance BCG. A greater percentage of patients in the monthly maintenance protocol completed the treatment as planned.
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Is plasma sterilization the modality of choice of sterilization today for endourological procedures such as ureterorenoscopy and retrograde intrarenal surgery? A single-center retrospective evaluation of 198 patients p. 122
Kandarp Priyakant Parikh, Ravi Jineshkumar Jain, Aditya K Parikh
DOI:10.4103/UA.UA_61_19  
Introduction: The prevalence of infective complications among patients undergoing Retrograde Intrarenal Surgery (RIRS) for renal stone is 1.7%-18%, including fever, Systemic Inflammatory Response Syndrome (SIRS) and sepsis. The infectious complications of RIRS can be minimised by strict aseptic precautions and plasma sterilization. The Sterrad Next Generation (Sterrad NX) System, a low-temperature sterilizer represents the next generation of low-temperature hydrogen peroxide gas plasma sterilizers. This study was conducted to evaluate the efficacy of plasma sterilization among patients undergoing ureterorenoscopy (URS) and RIRS. The primary endpoint of this study was incidence of septicemia or related complications. Till date, there is no study on the incidence of infection rate in RIRS in relation to a specific mode of sterilization. Material and Methods: This is a retrospective study comprising of 198 patients undergoing URS and/or RIRS. The parameters studied were incidence of post-operative fever, Systemic Inflammatory Response Syndrome (SIRS), pyelonephritis or septicemic shock. Results: Out of 198 patients, incidence of post-operative fever was 3.5%, SIRS was 1.7%, pyelonephritis was 0.7% and septicemic shock was 0%. This is statistically significantly low septicemia rate among patients undergoing URS and /or RIRS as compared to the available literature. No health hazards of plasma sterilization were noted. No damage to the endoscopes or instruments was noted. Conclusion: Sterrad NX based on hydrogen peroxide gas plasma (HPGP) technology is highly efficacious, safe and the modality for sterilization of instruments, including heat labile instruments such as semi rigid, flexible and chip on the tip endoscopes and other EndoUrology armamentarium.
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Trends of upper urinary tract stone management in a high volume stone center in Saudi Arabia, 12 years analysis p. 128
Rakan Al Darrab, Abdulmalik M Addar, Ibrahim Al Shohaib, Yahay Ghazwani
DOI:10.4103/UA.UA_49_19  
Introduction: Urolithiasis is a common urological problem globally with tremendous health and economic burden. In Saudi Arabia, an estimation has shown that the risk of developing a stone episode is 50% higher than that in Western countries. About 20% of males would experience at least one episode by 70 years of age. The introduction of minimally invasive and noninvasive methods such as shockwave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotripsy (PCNL) has driven the urologists to more complex decision-making with a noted variance in management options. Objectives and Methods: The objective of the study was to observe the trend of upper urinary tract stone management in our institution in the past 12 years. Methods: Charts of patients who underwent upper urinary tract lithotripsy procedures of any kind were reviewed. The information obtained included, patient's age, surgeon, surgery type, stone size, stone location, and duration of surgery. Analysis: The data obtained were from 2006 to 2016. Excel sheets used for the collection of data and SPSS software was used for analysis. Results: The results showed that the majority of the patients were males accounting for 65%. ESWL was the predominant approach from 2006 to 2010. In 2006, ESWL accounted for 77.7% of the cases, 76% in 2007, 70% in 2008, 64% in 2009, and 62% in 2010. However, in 2011, the rates dropped to almost 18% and URS rates have increased from a few cases per year to 64%. The frequency of URS continued to rise through the years until 2015 where URS rates reached 75%. During the 12-year period, URS is the most common upper tract procedure conducted when compared to ESWL and PCNL, accounting for 63%, 16%, and 20%, respectively. Conclusion: In our institution, the frequency of URS rose over the years being the most abundant procedure done. ESWL rates have decreased over the years.
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Histopathology, pharmacotherapy, and predictors of prostatic malignancy in elderly male patients with raised prostate-specific antigen levels – A prospective study p. 132
Dhinesh Kumar Mathaiyan, Satya Prakash Tripathi, Jeffrey Pradeep Raj, Bodapati Sivaramakrishna
DOI:10.4103/UA.UA_68_19  
Background: Prostate cancer is the second most common cancer among adult men in the world, and the diagnosis requires biopsy. Prostate-specific antigen (PSA) test along with digital rectal examination (DRE) increases the detection rate of prostate cancer than DRE alone. The objective of this study was to correlate serum PSA level with histopathological diagnosis, identify the predictors of malignancy, and describe the pharmacotherapy of patients with serum PSA levels >4 ng/ml. Materials and Methods: This was a hospital-based observational study done among patients who presented with lower urinary tract symptoms and PSA levels >4 ng/ml who were planned to undergo prostatic biopsy. DRE followed by transrectal ultrasound (TRUS) assessment and guided sextant (6-core) prostatic biopsy was performed. Results: One hundred and four patients were screened and 87 were included. Nineteen patients were diagnosed with malignancy, and among them, eight had bone metastasis. Spearman's correlation coefficient between PSA and malignancy was 0.449 (P ≤ 0.001). Multivariate analysis suggested that the factors (adjusted odds ratio; 95% confidence interval; P value) such as increasing age (1.127; 1.013, 1.253; 0.027), nodular prostate (22.668; 4.655, 110.377; P < 0.001), and PSA (1.034; 1.004, 1.064; 0.024) were significant predictors of prostate cancer. All patients with benign prostatic hyperplasia were advised a combination therapy with 5-alpha reductase inhibitor and selective alpha-1 receptor antagonist while those with malignancy were prescribed androgen deprivation therapy with antiosteoporosis therapy. Conclusion: In elderly patients with raised PSA levels or suspicious DRE findings, TRUS-guided prostate is recommended to rule out malignancy and plan appropriate management.
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Forgotten double-J stent: Experience of a tertiary care center p. 138
Vinayak Vajpeyi, Saurabh Chipde, Faiz Ahmed Khan, Sanjay Parashar
DOI:10.4103/UA.UA_73_19  
Introduction: We share our experience of managing 15 cases of forgotten double-J (DJ) stent in our tertiary care center. Methods: This is a retrospective analysis of cases with forgotten DJ stent for a period of 2 years spanning from January 2017 to January 2019. The details included sex, age, literacy, socioeconomic status, stenting indication, duration of indwelling stent, presenting complaints, type of encrustations, various treatments given, intraoperative complications, and their management and eventual outcome. Results: The male-to-female ratio was 2:1, and the mean age was 39.5 years (17–65). The mean indwelling time was 31.7 months. The majority of patients had an education score of 1 out of 7 and belonged to lower socioeconomic class according to the modified Kuppuswamy scale. The most common presentation was irritative voiding symptom. The complicated and heavily encrusted stents were managed by combination of endourological procedures, and procedures were staged whenever deemed necessary. Majority of the stents were removed with simple retrograde cystoscopic removal. There was no mortality in our study. Conclusions: A forgotten DJ stent affects population having low education score and belonging to the lower end of the socioeconomic class. Endourological procedures are quite successful in managing a forgotten DJ stent, provided the treatment options are selected judiciously and meticulously. We also suggest some protocols to be followed in our study in order to prevent a forgotten DJ stent.
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Correlation of metabolic syndrome and urolithiasis: A prospective cross-sectional study p. 144
Keerthi Rams, S Joseph Philipraj, Rohit Purwar, Balabhaskar Reddy
DOI:10.4103/UA.UA_77_19  
Background: Correlation between urolithiasis and metabolic syndrome has been demonstrated in the literature. This study assessed the association of metabolic syndrome and its components with urolithiasis in Indian patients. Methods: A cross-sectional prospective observation study included patients aged >18 years with urolithiasis. Demographic details, body mass index (BMI), waist circumference, blood pressure, and laboratory parameters were examined. Results: Total 1200 patients with urolithiasis were divided into two groups (with [n = 208] and without metabolic syndrome [n = 992]). The mean age of total population was 47.26 (14.68) years with 721 males and 479 females. The mean height, weight, BMI were significantly different between both groups (P < 0.001). Proportion of obese (BMI >25) patients, proportion of patients with hyperuricemia, waist circumference, blood pressure, triglyceride, fasting blood sugar (FBS) levels were significantly higher in patients with metabolic syndrome; however, high density lipoprotein (HDL) levels were significantly reduced in metabolic syndrome group (P < 0.001). A significantly increasing trend in mean waist circumference, triglycerides, FBS, systolic blood pressure and diastolic blood pressure and a decreasing trend in mean HDL with increase in number of metabolic components were observed (P < 0.001). Female patients were 19.6 times more likely to develop metabolic syndrome than male patients (P < 0.001). Increasing waist circumference, triglycerides, FBS, blood pressure were associated with increased risk of metabolic syndrome (P < 0.05). Decreasing HDL was associated with reduced risk of metabolic syndrome. Patients with hyperuricemia were 5.68 times more likely to exhibit metabolic syndrome (P = 0.006). Conclusion: This study indicates the presence of a significant association of metabolic syndrome and its components with urolithiasis.
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Comparison of magnetic resonance defecography with pelvic floor ultrasound and vaginal inspection in the urogynecological diagnosis of pelvic floor dysfunction p. 150
Bara Barakat, Ali Afzal, Dorothee Schweda, Amin Laali
DOI:10.4103/UA.UA_78_19  
Introduction: The aim of the study is to evaluate the use of pelvic floor (PF) ultrasound and vaginal inspection in the quantification of prolapse and to compare findings with magnetic resonance (MR) defecography in a blind study. Materials and Methods: Data from the dynamic MR imaging (MRI) defecography were compared and evaluated with PF ultrasound and vaginal examinations (VEs) in 45 female patients aged from 52 to 94, between the years 2016 and 2018. With regard to the pelvic organ prolapse (POP), MRI defecography revealed changes in the mid-pubic line. According to Bump et al., the bladder neck descent, degree of the retrovesical angle, and urethral rotation were measured to identify anterior vaginal wall descent extent. POP quantification (POP-Q) was determined by VE. Results: With regard to the presence of a Grade II prolapse in the anterior and posterior vaginal walls, the intraclass correlation coefficient (ICC) showed a significant correspondence (ICC = 0.85, 95% confidence interval [CI] 0.67–0.92), (ICC = 0.77, 95% CI 0.63–0.88). With regard to the accordance in the ICC between the VE results (POP-Q) and the dynamic MRI defecography, there was an excellent match in high Grade III and IV in all compartments. In addition to bladder neck funneling, hypermobility of the urethra was identified by ultrasound in seven women (n 7/45, 15.5%). Conclusion: Despite different reference systems in the quantification of results, both the methods allow for a similarly successful separate assessment of all three compartments. The agreement between methods and interobserver agreement for the clinical diagnosis is good. Based on the results, we would recommend the supplemental dynamic PF ultrasound for part of the noninvasive examination for the diagnosis of POP.
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Renal salvage, an achievable goal in patients with emphysematous pyelonephritis: Outcomes of an algorithmic renal preserving strategy p. 156
Rajeshkumar Reddy Adapala, Ranjit Shetty, P Venugopal, G G. L. Prabhu, Durgarao Yalla, B Unnikrishnan
DOI:10.4103/UA.UA_67_19  
Introduction: Emergency nephrectomy has been the time-honored treatment of choice for emphysematous pyelonephritis (EPN), a fatal gas-forming necrotizing infection. Recent years have seen a shift toward nonextirpative approach aimed to achieve higher rates of renal salvage, limiting the indications for nephrectomy to severe grades of the disease. This study aimed at analyzing the role of initial renal preserving measures algorithmically applied across grades of EPN. Materials and Methods: We prospectively analyzed the clinical data and outcome of 36 consecutive patients of EPN in 5 years' study period, treated by renal preserving measures, which include aggressive resuscitation, parenteral antibiotics, effective drainage of infected fluid/gas, and relieving the urinary tract obstruction. Huang-Tseng computed tomography-based classification system was used to categorize the patients as well as to employ suitable treatment modality. Results: The mean age of the patients was 57.5 ± 12 years with female preponderance (2:1). Diabetes mellitus (97%) was the most common associated factor. Escherichia coli was (72%) the most frequent causative organism found. Urinary tract obstruction was seen in 27 patients (75%) attributable to ureteric calculi, renal papillary necrosis, ureteric stricture, and fungal bezoar in the descending order of frequency. Only 2 (6%) out of 36 patients managed according to our hospital renal salvage protocol required salvage nephrectomy. The overall survival rate was 94%. Conclusion: Our hospital-based algorithmic renal preserving strategy not only improved the survival but also decreased the need for nephrectomy.
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The outcomes of renal cell carcinoma in a single tertiary care facility in Saudi Arabia p. 163
Lujain Alqurashi, Marwan Al-Hajeili, Ehab Alsayyed, Budoor Salman, Hibatallah Mashat, Rana Bokhary
DOI:10.4103/UA.UA_142_18  
Background: Amidst an era of rising malignancies worldwide, renal cell carcinoma (RCC) is the 7th most commonly detected, owing to 144,000 cancer-related deaths annually. Demographic knowledge of such cases in Saudi Arabia is poorly portrayed. According to the 2014 Saudi Cancer Registry, RCC has rated the 10th most common malignancy among males, posing a significant disease burden. Global studies have depicted a great discrepancy of 15 folds in the incidence of RCC among different countries, which is commonly attributed to variations in each countries development. We aimed to assess the overall survival (OS) and disease-free survival (DFS) in patients who underwent nephrectomy in our health-care facility. Materials and Methods: This is a retrospective study done at a tertiary care facility of all cases of RCC as per the pathology department database for the period of 2007–2017. The OS and DFS were statistically determined using Stata/SE 15.0. Results: Overall, 109 RCC patients were included in the study. Mean age at diagnosis was 53.8 (range: 24–89) years. Demographic data revealed a total of 71 (65.14%) males included in the study and 38 (34.86%) females. The OS at 2 years and 5 years was noted to be 95.3% and 92.6%, respectively. The DFS was found to be 90.8% at 2 years and 85.4% at 5 years. On multivariate analysis of the results, step-wise model was utilized to eliminate irrelevant variables affecting the OS, with a probability to eliminate variables with P > 0.2. Metastasis (M) was found to be a relevant variable (hazards ratio [HR]: 52.25 [P = 0.003]; 95% confidence interval [CI]: 3.75–728.88). On multivariate analysis of the DFS, variables were found to be significant which include gender (HR: 0.15 [P = 0.063]; 95% CI: 0.02–1.105), nationality (HR: 16.1 [P = 0.034]; 95% CI: 1.24–209.13), age at diagnosis (HR: 0.93 [P = 0.031]; 95% CI: 0.87–0.99), and pathological stage (T) (HR: 7.89 [P = 0.003]; 95% CI: 1.98–31.36). Conclusions: Our results revealed a notable discrepancy in the 5-year OS and the 5-year DFS as compared to studies in the literature. However, our study was limited to a single center and the majority of our patients were diagnosed at a rather early stage. With the rising number of RCC cases worldwide and in Saudi, this further necessitates extensive disease surveillance for trends in all parameters.
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CASE REPORTS Top

Sporadic giant renal angiomyolipoma: A case report and literature review of clinical presentation, diagnosis, and treatment options p. 167
Mohammed Alshehri, Basel Hakami, Nasser Aljameel, Mohammad Alayyaf, Ali Abdel Raheem
DOI:10.4103/UA.UA_26_19  
Giant angiomyolipoma (AML) is uncommon benign renal neoplasm that occurs sporadic or in association with tuberous sclerosis syndrome. There is no specific cutoff tumor size and/or weight to define giant AMLs. Ovarian stimulation hormones might cause a marked increase in its size and subsequent bleeding risk. Incidental findings are not common in those patients as mass-associated symptoms always present. Computed tomography scan is the standard diagnostic imaging study except for tumors with poor fat content. According to the clinical presentation, site and side of renal involvement giant sporadic AMLs have different treatment options, for example, active surveillance, selective renal artery embolization, nephron-sparing surgery, and/or radical nephrectomy. In the present case report, we present a 22-year-old female with huge right renal mass (29 cm × 23 cm × 21 cm) and treated with right radical nephrectomy which proved to be renal AML on pathology examination.
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Metastatic prostate cancer to an ischiorectal fossa lymph node identified on multiparametric magnetic resonance imaging Highly accessed article p. 172
Andrew M Fang, Samuel J Galgano, Jennifer B Gordetsky, Sunil Sudarshan, Andrew M McDonald, Soroush Rais-Bahrami
DOI:10.4103/UA.UA_31_19  
Prostate cancer is the most common noncutaneous malignancy in American men. Its lymphatic drainage is very well established throughout literature. We report the case of a 72-year-old Caucasian male with elevated serum prostate-specific antigen and biopsy-confirmed high-risk prostate cancer who underwent multiparametric magnetic resonance imaging (MRI) for staging and treatment planning. The imaging revealed suspicious lymph nodes in the left ischiorectal and right obturator fossae that were biopsy confirmed as metastatic prostate adenocarcinoma. Herein, we present the divergence from the well-established lymphatic drainage of prostate cancer and the role of MRI in detecting this prostate cancer site of spread.
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The use of gracilis muscle flap as a cover of tabularized buccal mucosal graft in the posterior urethral injury p. 176
Sandesh Vithal Parab, Gaurav Goyal, Sudarshan Jadhav, Hemant Pathak, Mukund Andankar, Chetan Gadekar
DOI:10.4103/UA.UA_9_19  
This is a case report of 35-year-old male patient, who underwent abdominoperineal resection for rectal cancer. There was postoperative wound complication which resulted in the formation of sinus in the perineal wound. During excision of the sinus tract, there was injury to the posterior urethra which leads to the formation of urethrocutaneous fistula presenting as urinary incontinence. These findings were confirmed by ascending urethrogram and cystoscopy. We describe the use of gracilis muscle flap as support and cover for buccal mucosal graft which has been used for the repair of the posterior urethral injury. On removal of Foley's catheter after 3 weeks of the surgery, there was no leakage of urine from the perineal wound, and the patient was continent. The highly vascularized muscle flap is beneficial in patients with a poor graft bed secondary to prior radiotherapy, avoiding urinary diversion in most patients.
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A testosterone-producing Leydig cell tumor metastasis during hormonal treatment of prostate cancer p. 180
Laura Stokkel, Henk G van der Poel, Sigrun I Langbein, J Martijn Kerst, Jeroen de Jong, Bas W. G van Rhijn
DOI:10.4103/UA.UA_38_19  
We describe a patient with a testosterone-producing metastasis discovered during the follow-up of prostate cancer. The patient had a history of a Leydig cell tumor (LCT) in the right testicle for which he underwent radical orchiectomy at the age of 60 years. Within a year after orchiectomy, he was diagnosed with prostate cancer. He received a radical prostatectomy with pelvic lymph node dissection. Due to recurrent prostate cancer, he underwent salvage radiation to the prostatic fossa and pelvic lymph node stations with hormonal treatment for 3 years. After approximately 1.5 years of chemical castration, a significant increase in testosterone level occurred. Further, diagnostic evaluations and surgery revealed a testosterone-producing LCT metastasis in the retroperitoneum.
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Giant pancreatic mucinous cystadenoma masquerading as renal hydatid disease p. 184
Shanmugasundaram Rajaian, Ashwin Shekar Paulraj, Lakshman Murugesan, Premanand Sengottaiyan
DOI:10.4103/UA.UA_51_19  
Mucinous cystic neoplasms of the pancreas are the most common pancreatic cystic neoplasms. A 54-year-old female presented with an abdominal mass and was diagnosed to have a multilocular hydatid cyst from the left kidney by imaging. During surgery, a large thick-walled cyst with multiple loculi was seen arising from the upper pole of the left kidney and adherent to the distal pancreas and splenic vessels. The cyst was completely excised without hilar clamping. Histopathological examination confirmed mucinous cystadenoma arising from the pancreas. In conclusion, imaging can be unreliable in differentiating benign renal cysts from tumors of adjacent organs, raising a diagnostic dilemma. Surgical excision only would be able to differentiate the conditions as in our case.
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Multifocal nephrogenic adenoma treated by intravesical sodium hyaluronate p. 187
Nicola Santoni, Lorna Cottrell, Jennifer Elizabeth Talia Jones, Holly Jane Bekarma
DOI:10.4103/UA.UA_74_19  
Nephrogenic adenoma is a rare benign urinary tract lesion. There are pediatric cases that have been managed with intravesical sodium hyaluronate, but there are no published adult cases. We present the first case of an adult successfully treated with intravesical sodium hyaluronate without resection. A 77-year-old man was investigated with cystoscopy for lower urinary tract symptoms (LUTS) unresponsive to medical therapy. This revealed multifocal flat black bladder lesions. Biopsy showed the lesions to be nephrogenic adenoma. His LUTS were treated with 6 weeks of intravesical sodium hyaluronate. He returned 6 weeks later for resection of his bladder lesions. However, resection was abandoned as the bladder lesions had entirely resolved. The resolution of the bladder lesions following intravesical sodium hyaluronate was unexpected but does agree with existing literature. The two reported pediatric cases also suggest that intravesical sodium hyaluronate is therapeutic for nephrogenic adenoma.
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Case report of a rare urinary bladder tumor variant (carcinosarcoma) p. 190
Hatem Hamed Althubiany, Rami Mohammad Hasan, Saeed Abdullah Alzahrani, Salem Bahdilh
DOI:10.4103/UA.UA_76_19  
Carcinosarcoma of the bladder is a rare and aggressive variant of bladder tumor. The causes are not clear for this bladder tumor variant. Early diagnosis with immediate surgical resection is the most accepted management as reported so far in the literature, but the optimal management is unknown to date. Here, we report a case of a 62-year-old woman with bladder carcinosarcoma who presented with macroscopic hematuria.
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Renal sinus angiomyolipoma: A rare case p. 193
Abhimanyu Gupta, Shivam Priyadarshi, Nachiket Vyas
DOI:10.4103/UA.UA_134_19  
Angiomyolipoma (AML) consists of <10% of all renal tumors and is the most common benign mesenchymal neoplasm of the kidney. It arises from the renal cortex and extends toward perirenal fat. Fat-poor AML as well as those arising from rare locations may pose diagnostic difficulties. In our case, we report a rare presentation of this tumor arising from the renal sinus extending toward the pelvis thereby leading to an alternative diagnosis of transitional cell carcinoma of renal pelvis.
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Combination of urolithiasis and anomaly: Bifid ureter with fusion in the intramural part p. 196
Vladimir Vladimirovich Protoshchak, Nikolay Yurievich Iglovikov, Maksim Vladimirovich Shevnin
DOI:10.4103/UA.UA_142_19  
Kidney and upper urinary tract anomalies account for 23% of all birth defects. Partial duplication is slightly more prevalent than complete, 70% and 30%, respectively. A very low fusion of ureters, i.e., in the intramural part, is a rarer case. As a result, the joint section is very short (<1 cm) and may be invisible for radiological diagnosis. This case shows a rare variation of incomplete bifid ureter coupled with urolithiasis, which should be taken into account by the physician when determining urolithiasis treatment.
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Pure cutaneous paratesticular leiomyosarcoma of the scrotum: A rare case report p. 199
Vipul D Yagnik, Sushil Dawka, Bhargav Yagnik, Arun K Agnihotri, Smriti Agnihotri
DOI:10.4103/UA.UA_156_19  
Leiomyosarcoma (LMS) is a malignant mesenchymal neoplasm arising from the smooth muscle. Paratesticular LMSs are commonly located in the epididymis or spermatic cord. Pure scrotal cutaneous paratesticular LMS arising from the dartos muscle is very rare. Less than 40 cases have been reported in the literature to date. We report a case of pure scrotal cutaneous LMS in a 45-year-old patient.
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ERRATUM Top

Erratum: Prevalence and characterization of urolithiasis in the Western region of Saudi Arabia p. 203

DOI:10.4103/0974-7796.282513  
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