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   Table of Contents - Current issue
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January-March 2018
Volume 10 | Issue 1
Page Nos. 1-121

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REVIEW ARTICLES  

Penile-sparing modalities in the management of low-stage penile cancer Highly accessed article p. 1
Paurush Babbar, Nitin Yerram, Alice Crane, Daniel Sun, Kyle Ericson, Andrew Sun, Abhinav Khanna, Hadley Wood, Andrew Stephenson, Kenneth Angermeier
DOI:10.4103/UA.UA_93_17  PMID:29416267
Penile-sparing modalities are gaining widespread adoption for the management of low-stage penile cancer due to an increasing demonstration of sound oncologic, cosmetic, sexual, psychosocial, and quality of life outcomes. This review aims to provide a comprehensive overview of the respective treatment options in the armamentarium of the practicing urologist in dealing with this rare but problematic condition.
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Robot-assisted ureteral reconstruction – current status and future directions p. 7
Paurush Babbar, Nitin Yerram, Andrew Sun, Sij Hemal, Prithvi Murthy, Darren Bryk, Naveen Nandanan, Yaw Nyame, Maxx Caveney, Ryan Nelson, Ryan Berglund
DOI:10.4103/UA.UA_94_17  PMID:29416268
Robotic surgery in the treatment in certain urological diseases has become a mainstay. With the increasing use of the robotic platform, some surgeries which were historically performed open have transitioned to a minimally invasive technique. Recently, the robotic approach has become more utilized for ureteral reconstruction. In this article, the authors review the surgical techniques for a number of major ureteral reconstuctive surgeries and briefly discuss the outcomes reported in the literature.
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ORIGINAL ARTICLES Top

Transrectal ultrasound-guided prostate rebiopsy: How many core sampling should be applied to which patient? p. 15
Akın Soner Amasyali, Uğur Yücetaş, Erkan Erkan, Murat Demiray, Emre Karabay, Cemalettin Murat, Gökhan Toktaş, Erdinç Ünlüer
DOI:10.4103/UA.UA_110_17  PMID:29416269
Background: We investigated the correlation between the sampled number of cores in rebiopsy and the cancer detection rate (CDR). Materials and Methods: Two hundred and twelve patients with normal rectal examination who had undergone rebiopsy in the past 5 years were examined retrospectively. Moreover, 68% of them had undergone 12 cores (Group 1) while 32% had undergone 20 cores (Group 2). Both groups were compared with respect to the CDR. Results: There was no difference between groups in terms of age, total prostate-specific antigen, and prostate volume (P > 0.05). Forty-one (19%) of 212 patients were diagnosed with cancer, and the CDR was significantly higher in Group 2 (30.9% vs. 13.9%, P = 0.004). This rate increased from 6.5% to 20% (P = 0.025) and from 0% to 33.3% (P = 0.023), respectively, with 12-core and 20-core rebiopsies in patients whose initial pathology indicated benign and high-grade prostatic intraepithelial neoplasia (HGPIN). Furthermore, cancer was detected in 24 (40%) of 60 patients who were diagnosed with atypical small acinar proliferation (ASAP) in the initial biopsy. However, despite being higher in 20-core biopsy group (47.6% vs. 35.9%), this was not statistically significant (P = 0.377). Conclusions: At least 20 cores should be sampled in rebiopsy, especially in the patients diagnosed with benign and HGPIN. However, we believe that standard systematic sampling will be sufficient for the patients diagnosed with ASAP.
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Evaluation of testicular workup for ischemia and suspected torsion score in patients presenting with acute scrotum p. 20
CS Manohar, Avneet Gupta, R Keshavamurthy, M Shivalingaiah, BR Sharanbasappa, Vinish Kumar Singh
DOI:10.4103/UA.UA_35_17  PMID:29416270
Background: Testicular torsion is one of the causes of acute scrotum and it requires timely evaluation and surgical treatment. Color Doppler is considered investigation of choice, but it may delay treatment, as, many times, it may not be available for emergency situations. Barbosa et al. created Testicular Workup for Ischemia and Suspected Torsion (TWIST) score based on clinical parameters for clinical diagnosis of testicular torsion. We have evaluated this score in our population. Materials and Methods: We retrospectively calculated TWIST score in patients of acute scrotum admitted to tertiary teaching institute. Patients without complete TWIST score were excluded from the study. The scoring system consisted of testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1), and high-riding testis (1). Statistical analysis was done to evaluate the validity of scores. Results: A total of 118 patients were included in the study, out of which 45 (38%) patients had testicular torsion. The mean age of patients was 16.6 years in testicular torsion patients and 15.2 years in other patients. Cutoff for low-risk and high-risk patients was two and five, respectively. Fifty percent, 26.2%, and 23.8% of patients were present in low-, intermediate-, and high-risk groups. Negative predictive value of TWIST score for low-risk patients was 96.61% while positive predictive value for high-risk patients was 92.86%. Conclusions: TWIST score has high predictive value and can be used for clinical diagnosis of testicular torsion. It can decrease the need of color Doppler in about 50% of cases and can prevent delay in treatment.
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Safety and efficacy of ultrasound-guided percutaneous suprapubic cystostomy in resource-poor setting: A 7-year review p. 24
Abubakar Sadiq Muhammad, Ngwobia Peter Agwu, Abdullahi Abdulwahab-Ahmed, Khalid Abdullahi, Ismaila Arzika Mungadi
DOI:10.4103/UA.UA_104_17  PMID:29416271
Introduction: Percutaneous cystostomy techniques are usually done using disposable sets in developed countries which are not affordable in poor-resource settings. However, the percutaneous technique can be done using reusable trocar or selected big size surgical blades. This is simple, safe, and cost effective in poor-resource setting. The procedure is best done under ultrasound guidance but can also be done blindly in select cases. We present our 7-year experience in ultrasound-guided percutaneous suprapubic cystostomy. Materials and Methods: This is a 7-year retrospective review of patients, who had ultrasound-guided percutaneous suprapubic cystostomy at Urology Unit of our institution from January 2010 to December 2016. Disposable cystostomy sets were used for the initial experience, but this was replaced with more cost-effective reusable metallic trocar or selected big size surgical blade methods in the later experience. Data were extracted from procedure register and patients' case notes and entered into pro forma and analyzed using Statistical Package for Social Sciences 20.0 version (2011) for windows (IBM, SPSS Incorporation, Chicago, IL, USA) 20.0 version for Windows. Results: A total number of 135 patients had percutaneous cystostomy, which was ultrasound guided in 134 patients (99.3%). The mean age of the patients was 50.5 ± 23.3 years with a range of 2–90 years. The indications for the procedure include urine retention with failed urethral catheterization in 119 patients (88.1%), urethral injury in 14 patients (10.4%), and urethrocutaneous fistula in 2 patients (1.5%) with spinal cord injury. No major complication was recorded. Conclusion: Ultrasound-guided suprapubic cystostomy using reusable trocar or selected surgical blade is simple, safe, effective, and associated with minimal complications in poor-resource setting.
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Is retrograde intrarenal surgery the game changer in the management of upper tract calculi? A single-center single-surgeon experience of 131 cases p. 29
Kandarp Priyakant Parikh, Ravi Jineshkumar Jain, Aditya Parikh Kandarp
DOI:10.4103/UA.UA_118_17  PMID:29416272
Introduction: Success of any modality for stone disease needs to be evaluated in terms of Stone Free Rates (SFR), auxiliary procedures needed; complications and follow up. SFR in RIRS is subject to parameters like stone burden, location, number, hardness, composition; calyceal and ureter anatomy; use of ureteric access sheath (UAS); surgeon experience etc. Methods: The aim of this study is to evaluate the efficacy and safety of RIRS for managing upper tract stones. The objectives include evaluating SFR in RIRS in relation to stone burden, location and number. Other objectives include evaluating SFR after re RIRS in relation to stone burden, necessity of pre DJ stenting, use of UAS and post operative complication rate. 131 patients operated by single surgeon for single/multiple renal and/or upper ureteric stones were evaluated. Stone size > 3 mm on follow up CT KUB was considered as residual. Re RIRS was required for residual stones. Results: The overall SFR was 76%. SFR were statistically lower with stone burden > 1.5 cm, lower calyceal stones and single stones with stone burden > 1.5 cm. SFR was 90% after 2nd RIRS and 98.5% after 3rd RIRS procedure. No significant difference in SFR was noted between single v/s multiple stones, single calyx v/s multiple calyx stones and renal v/s upper ureteric stones. No major complication was noted. Conclusion: Larger stone burden and lower calyceal location are important factors deciding SFR in RIRS. With auxiliary procedure, RIRS is safe and effective compared to PCNL.
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This challenging procedure has successful outcomes: Laparoscopic nephrectomy in inflammatory renal diseases p. 35
Siddharth Jain, Sudhir K Jain, Ram C.M. Kaza, Yashasvi Singh
DOI:10.4103/UA.UA_9_17  PMID:29416273
In prospective study from November 2011- November 2013, we performed 44 laparoscopic nephrectomies for benign non-functioning kidney diseases. Twenty eight patients underwent laparoscopic transperitoneal nephrectomies (63.6%), ten were laparoscopic assisted (22.7%) and six (13.6%) were converted to open. Patient's age, gender, laterality and etiology of renal failure were noted. Outcomes were measured as operative time, intraoperative and post operative complications, blood loss, pain score and hospital stay. Patients were followed up at one, three and 12 weeks and 6 monthly thereafter. Of the 44, ten (22.7%) were 15-24 years old, 32 (72%) between 25-50 years and two were more than 50 years old. Females were 54.6%. 22 patients had either right or left nephrectomy. Pelviureteric-junction (PUJ) obstruction was the commonest cause, 26 cases (59.0%). Operative time: less than two hours in 30 (68.2%) patients, more than two hours in 14 cases. Blood loss: less than 100 ml in 12 (27.3%), 100-200 ml in 20 (45.4%) and more than 200 ml in 12 (27.3%) patients. All four major complications were converted to open, two had injury to mesocolic veins and two had vascular stapler malfunction. Post-operative complications: surgical site infection (SSI), paralytic ileus and mild grade fever in six cases each and non infected benign intra abdominal collection in two cases. Maximum pain score on POD-1: four in 20 cases (45.7%), two in 24 (54%). Two had pain score between 3-4 three weeks after surgery. Oral intake started by POD-2 in 30 (68.2%) and by POD-4 in 100% cases. 22 (50%) patients were ambulating by POD-2, 16 (36.7%) by POD-4. Our study and randomized and non-randomized published literature report acceptables complication and conversion rates. In conclusion, laparoscopic nephrectomy for benign non functional kidney is a better alternative to open nephrectomy
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Trend analysis of bacterial uropathogens and their susceptibility pattern: A 4-year (2013–2016) study from Aseer region, Saudi Arabia p. 41
Abdulaziz Alamri, Mohamed E Hamid, Muhammad Abid, Abdulrahman M Alwahhabi, Khalid M Alqahtani, Mohammed S Alqarni, Mosleh Abomughaid
DOI:10.4103/UA.UA_68_17  PMID:29416274
Purpose: To analyze the prevalence and resistance rates of bacterial agents causing urinary tract infections (UTIs) in Aseer, Saudi Arabia (2013–2016). Patients and Methods: This was a 4-year (2013–2016) retrospective study undertaken in Aseer Central Hospital, Saudi Arabia. A total of 49,779 urine and other UT specimens obtained from patients suspected of having a UTI were analyzed. Urine specimens were inoculated onto cystine lactose electrolyte deficient agar following standard procedures. Cultures showing significant bacteriuria were subjected to identification and sensitivity testing using VITEK 2 system. Data of patients and uropathogens were assembled, checked, and analyzed using SPSS software. Results: Culture positive samples were 49,779 (59.9% males, 40.1% females; P = 0.000). Year trend showed significant variations (P = 0.000) and the forecast trend line hypothesized a clear rise. Age groups 70–79 years were the most vulnerable group (22.3%). Gram-negative bacilli were 91.8% and the major species were Escherichia coli - 39.7%, Klebsiella pneumoniae - 15.8%; Pseudomonas aeruginosa - 13.8%, Proteus mirabilis - 10.6%, and Acinetobacter baumannii - 5%. Antimicrobials with high sensitivity rate were linezolid (99.1%), daptomycin (89.3%), vancomycin (86.7%), teicoplanin (85.5%), ertapenem (85.1%), fosfomycin (82.1%), and tigecycline (80.2%). High resistant rates to uropathogens were encountered with cephalothin (89.8%), nalidixic acid (86.7%), and ampicillin (81.9%). Conclusions: The majority of uropathogens were resistant to antibiotics commonly used in clinical practice. Linezolid, daptomycin, and vancomycin showed the lowest resistance to all uropathogens; this can be revised for empirical treatment of UTIs. Continuous surveillance of uropathogens and their susceptibility is important.
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Endoscopic urethral realignment of traumatic urethral disruption: A monocentric experience p. 47
Hamed Mohamed El Darawany
DOI:10.4103/UA.UA_151_17  PMID:29416275
Introduction: The optimal management strategy for urethral injuries remains controversial. Suprapubic cystostomy followed by delayed urethral reconstruction or immediate primary urethral injury repair is associated with high complication rate. Early endoscopic realignment for urethral injuries provides early definitive procedure with low complications and avoids the need for further urethral reconstruction. Materials and Methods: Between April 2007 and March 2016, 27 patients with traumatic posterior urethral disruptions were reviewed. All patients were managed by endoscopic urethral realignment. Patients were followed up every 3 months for 18–36 months regarding incontinence, potency, and urine flow. Results: Endoscopic urethral realignment was performed immediately in 21 patients and was delayed in 6 patients. It was successful in 24/27 (88.8%) patients. During the procedure, the proximal urethral end was identified directly in four patients, and by the guidance of methylene blue injection, guidewire or endoscopic light in three, nine, and eight patients, respectively. The Foley catheter was removed after 9 weeks in 17/24 (70.8%) patients and after 12 weeks in 7/24 (29.2%) patients. Six months after realignment, minimal urethral stricture was developed in 4/24 (16.7%) patients. All of them were treated successfully with single session of internal urethrotomy without recurrence after 1-year follow-up. After 18–36-month follow-up period, all patients were potent, continent, and with satisfactory voiding pattern. Conclusions: Endoscopic primary realignment of posterior urethral rupture is less invasive and a safer procedure, without pelvic hemorrhage or additional injuries. It has low incidence of severe urethral stricture and avoids the need for delayed open urethral reconstruction.
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Role of uroflowmetry before and after hypospadias repair p. 52
Rajat Piplani, Satish K Aggarwal, Simmi K Ratan
DOI:10.4103/UA.UA_78_17  PMID:29416276
Aims: To study the role of uroflowmetry in the preoperative and early postoperative period in children undergoing hypospadias repair. Materials and Methods: Twenty-six cases undergoing hypospadias repair over 1 year (tubularized incised plate [TIP] Snodgrass [17 patients], TIP with Snodgraft [5 patients], Duckett's onlay flap [2 patients], and Duckett's tube [2 patients] urethroplasty) were prospectively evaluated with preoperative ultrasound and uroflowmetry and postoperative uroflowmetry at 3 months after the surgery and at 6 and 9 months interval if these dates fell within the study period on follow-up. The parameters studied were maximum flow rate (Qmax), average flow rate (Qav), total voided volume, voiding time, and type of curve. Preoperative and postoperative uroflow data were compared. Results: Twenty-six cases comprised of anterior hypospadias (n = 8), mid penile (n = 11), and posterior hypospadias (n = 7). Fourteen patients had obstructed flow rates preoperatively. While 69% patients (18/26) had obstructed flow rates at 3 months postoperatively, it dropped to 43% at 9 months. Following TIP (Snodgrass) repair, 88% (15/17) had obstructed flow rates postoperatively. Best results were seen in patients undergoing circumferentially epithelialized urethral reconstruction (TIP with Snodgraft, Duckett's onlay flap, and Duckett's tube). Conclusions: Abnormal uroflow is an inherent aspect of hypospadias in 50% of the cases. Both preoperative and postoperative uroflow evaluation is necessary for meaningful conclusion. Patients with preoperative normal flow rates but obstructed postoperative flow rates need clinical evaluation. Obstructive flow rates are more common after TIP (Snodgrass) repair. The urinary flow rates improve with time.
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Epidemiology profile of renal cell carcinoma: A 10-year patients' experience at King Abdulaziz Medical City, National Guard Health Affairs, Saudi Arabia p. 59
Sarah Z Mahasin, Nourah Aloudah, Khaled Al-Surimi, Sultan S Alkhateeb
DOI:10.4103/UA.UA_102_17  PMID:29416277
Purpose: The purpose of this study is to describe the epidemiological profile, histopathological features, and outcomes of patients diagnosed with renal cell carcinoma (RCC) in a tertiary referral center over 10 years. Methodology: This is a retrospective cohort of 219 Saudi patients diagnosed with RCC between June 2003 and May 2013. The variables collected included the sociodemographic details and clinical presentation. The histopathological features investigated include the tumors histological subtype, pathologic staging tumor, node, and metastasis descriptors, and lymph-vascular invasion. Patients were followed until May 2013. Bivariable analysis was calculated using Chi-square test, with level of significance set at P < 0.05. Kaplan–Meier estimate was used to calculate the survival rate. Results: The mean age of patients was 57.18 (±14.68 standard deviation). The trend of patients diagnosed with RCC over the past 10 years was higher among males than females (60.27% vs. 39.73%). Noticeably, more than half (57.58%) were diagnosed incidentally. The most common histological subtype was clear cell (conventional) RCC (70.44%). Patients were usually diagnosed at the pT1 stage (48.1%). The histopathological features associated with worse patient outcome were the stage of the primary tumor (P = 0.01) and lymph-vascular invasion (P = 0.003). The overall mean survival rate was 2.03 years. Conclusion: In the past 10 years, there are more patients diagnosed incidentally with RCC, which is in line with the global trend. Patients were more likely to be male and middle aged. We recommend further population-based studies in this area to establish a national epidemiological data for this common type of cancer.
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An overview of serum prostatic surface antigen cut points for recommendation of prostatic biopsy p. 65
Sujata K Patwardhan, Bhushan P Patil, Umesh Ravikant Shelke, Abhishek G Singh
DOI:10.4103/UA.UA_113_17  PMID:29416278
Introduction: Patients in India frequently present with prostatic surface antigen (PSA) report and request for prostatic biopsy to rule out malignancy. With fear of harboring malignancy set in patient's mind, it becomes difficult to counsel them about absolute indications and need of biopsy. Whether serum PSA has same predictability in symptomatic patients in the Indian context for advising prostatic biopsy at same reference ranges as in western countries, remains to be answered. Materials and Methods: Symptomatic patients between 45 and 70 years of age presenting with either raised serum PSA (>4 ng/ml) reports or abnormal digital rectal examination (DRE) were considered as cases. Standard 12 core transrectal ultrasound-guided prostatic biopsy was done. Statistical analysis using optimal cut points, an R package was done to overview different PSA cut points for the recommendation of prostatic biopsy. Results: A total of 534 patients were included. Mean age was 64 years. Malignancy was detected in total 77 patients (14.42%). Malignancy was identified in 3.59% (10/279) and 30% (63/210) patients at serum PSA ranges 4–10 ng/ml and serum PSA >10 ng/ml, respectively. Both, maximum sensitivity and specificity were found at PSA cut point 9.7 ng/ml. We evaluated these patients to identify the PSA cut point above which unnecessary biopsies will be avoided. We kept power of study maximum, i.e., 1 with confidence interval of 0.95. Conclusion: PSA value 9.7 ng/ml should be considered as the cut point above which prostatic biopsy should be done to avoid unnecessary biopsies. Unless accompanied by abnormal DRE finding at PSA range 4–10 ng/ml, morbidity of prostatic biopsy procedure can be avoided using this cut-point.
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Characteristics of bacterial colonization after indwelling double-J ureteral stents for different time duration p. 71
KS Shabeena, Rahul Bhargava, Muhammed A.P. Manzoor, M Mujeeburahiman
DOI:10.4103/UA.UA_158_17  PMID:29416279
Background: Indwelling Double-J ureteral stenting is commonly used in urological practice and has various complications. This study aimed to assess the frequency of bacterial stent colonization and stent-associated bacteriuria after indwelling it for different time durations and to evaluate the significance of urinary cultures for identification of colonizing microorganisms. Materials and Methods: A prospective cross-sectional study was conducted. Midstream urine from 72 patients undergoing J stent insertion was investigated microbiologically before stent insertion and on the day of stent removal. The stents were removed by aseptic manipulation, and 1–3 cm of the tip located in the bladder was collected for microbiological study. The urine and stent samples were cultured, and the bacterial pathogens were identified using standard microbiological methods followed by Phoenix automated system. Antimicrobial susceptibility testing was performed by Kirby-Bauer disc diffusion method. Results: Bacterial colonies were found in 47.2% (34 of 72) of the stents. Of the multiple pathogens identified, Escherichia coli (20%) was the most common, followed by Streptococcus sp. (17.5%) and Pseudomonas sp. (12.5%). The bacteria did not colonize within the first 2 weeks of stent placement. Results showed that 55% of the isolates were resistant to erythromycin, 52.5% to ampicillin, 42.5% to piperacillin, and least resistant being 17.5% for tetracycline and imipenem. However, 81.3% and 66.7% of the stents were colonized when placed for 90–120 days and 60–90 days, respectively. Conclusion: High prevalence of bacterial isolates and risk of bacteriuria and colonization was found in the DJ stent tips, with E. coli being dominant colonizer. Most of the bacteria were resistant to different classes of antibiotics. Bacteriuria and stent colonization gradually increases with the duration of stent retention in the body.
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STONE score versus Guy's Stone Score - prospective comparative evaluation for success rate and complications in percutaneous nephrolithotomy p. 76
Ujwal Kumar, Vinay Tomar, Sher Singh Yadav, Shivam Priyadarshi, Nachiket Vyas, Neeraj Agarwal, Ram Dayal
DOI:10.4103/UA.UA_119_17  PMID:29416280
Purpose: The aim of the current study was to compare Guy's score and STONE score in predicting the success and complication rate of percutaneous nephrolithotomy (PCNL). Materials and Methods: A total of 445 patients were included in the study between July 2015 and December 2016. The patients were given STONE score and Guy's Stone Score (GSS) grades based on CT scan done preoperatively and intra- and post-operative complications were graded using the modified Clavien grading system. The PCNL were done by a standard technique in prone positions. Results: The success rate in our study was 86.29% and both the GSS and STONE score were significantly associated with a success rate of the procedure. Both the scoring systems correlated with operative time and postoperative hospital stay. Of the total cases, 102 patients (22.92%) experienced complications. A correlation between STONE score stratified into low, moderate, and high nephrolithometry score risk groups (low scores 4–5, moderate scores 6–8, high scores 9–13), and complication was also found (P = 0.04) but not between the GSS and complication rate (P = 0.054). Conclusion: Both GSS and STONE scores are equally effective in predicting success rate of the procedure.
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Comparative efficacy of tamsulosin versus tadalafil as medical expulsive therapy for distal ureteric stones p. 82
Suresh Kumar Goyal, Vikash Singh, Himanshu Pandey, Mahaveer Kumar Chhabra, Satinder Pal Aggarwal, Amilal Bhat
DOI:10.4103/UA.UA_36_17  PMID:29416281
Objective: The objective of this study was to compare the relative efficacy of tamsulosin and tadalafil as medical expulsive therapy for distal ureteric stones. Patients and Methods: This was a prospective study performed between December 2014 and February 2016. A total of 123 adult patients (>18 years of age) presenting with distal ureteric stones sized 6–10 mm were randomized to treatment with tamsulosin 0.4 mg once daily (Group A) or tadalafil10 mg once daily (Group B). Therapy was given for a maximum of 4 weeks. The stone expulsion rate was the primary endpoint. Time to stone expulsion, number of colic episodes, analgesic use, number of hospital visits for pain, endoscopic treatment, and adverse effects of the drugs were noted. Statistical analyses were done using Fisher's exact test and Chi-square test. Results: A total of 61 patients were included in tamsulosin group and 62 patients in tadalafil group. A statistically insignificant difference was found for stone clearance rate between both groups as a whole (Group A-73.77%, Group B-69.35%, P = 0.690) as well as when we considered both subgroups (A1-78.05%, B1-75.0%, P = 0.802; A2-65.0%, B2-55.6%, P = 0.741). All the primary and secondary outcome measures were more in favour of stones ≤8 mm size than stones >8 mm size. No statistical difference was found for adverse drug effects except for retrograde ejaculation, which was significantly high in tamsulosin group (P < 0.001). Conclusion: This study showed that although tamsulosin is more effective for stone clearance than tadalafil, but this difference was not significant (P = 0.690).
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Incidence and characteristics of kidney stones in patients with horseshoe kidney: A systematic review and meta-analysis p. 87
Aditya S Pawar, Charat Thongprayoon, Wisit Cheungpasitporn, Ankit Sakhuja, Michael A Mao, Stephen B Erickson
DOI:10.4103/UA.UA_76_17  PMID:29416282
Introduction: The horseshoe kidney (HSK) is the most common type of renal fusion anomaly. The incidence and characteristics of kidney stones in patients with HSK are not well studied. The aim of this meta-analysis was to evaluate the incidence and types of kidney stones in patients with HSK. Methods: A systematic literature search was performed using MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from the databases' inception through November 2016. Studies assessing the incidence and types of kidney stones in patients with HSK were included. We applied a random-effects model to estimate the incidence of kidney stones. The study protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42016052037). Results: A total of 14 observational studies with 943 patients (522 adults and 421 pediatric) with HSK were enrolled. The estimated pooled incidence of kidney stones was 36% (95% confidence interval [CI], 15%–59%) in adults with the HSK. Kidney stones were less common in pediatric patients with HSK with an estimated pooled incidence of 3% (95% CI, 2%–5%). The mean age of adult stone formers with HSK was 44.9 ± 6.2 years, and 75% were males. Within reported studies, 89.2% of kidney stones were calcium-based stones (64.2% calcium oxalate [CaOx], 18.8% calcium phosphate [CaP], and 6.2% mixed CaOx/CaP), followed by struvite stones (4.2%), uric acid stones (3.8%), and others (2.8%). Conclusions: Kidney stones are very common in adult patients with HSK with an estimated incidence of 36%. Calcium-based stones are the most prevalent kidney stones in adults with HSKs. These findings may impact the prevention and clinical management of kidney stones in patients with HSK.
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Metabolic evaluation of children with urolithiasis p. 94
Vijayabhaskar Reddy Gouru, Vedamurthy Reddy Pogula, Surya Prakash Vaddi, Venu Manne, Ranadheer Byram, Lalith Sagar Kadiyala
DOI:10.4103/UA.UA_98_17  PMID:29416283
Aim: The aim of the study is to identify the prevalence of metabolic abnormalities in children with urolithiasis. Materials and Methods: This is a prospective study; all children below 15 years who are found to have urolithiasis were prospectively evaluated with relevant history, clinical examination, and urine and serum testing. Metabolic workup includes complete urine examination, urine culture and sensitivity, and 24-h urinary analysis (lithorisk profile). Results: A total of 55 patients are included in the study. Forty-two are boys and 13 are girls aged between from 8 months to 15 years. Thirty-three patients underwent stone analysis, primary composition of calcium oxalate stones in 19 (58%), ammonium urate in 4, dahlite in 3 and uric acid in 3, silicon oxide in 2, and struvite in 2 cases. Lithorisk profile was performed in 40 cases (72.7%). The pH range is 5.6–6.2. We noted hypercalciuria in 20 patients (50%), hyperuricosuria in 23 (57.5%), hyperoxaluria in 20 (50%), hypernatriuria in 26 (65%), hypocitraturia in 9 (23%), and hypomagnesuria in 3 (7.5%). Urine calcium-to-creatinine ratio >0.2 was found in 22 (55%) patients. Statistically significant association between hyperoxaluria and hyperuricosuria (P < 0.04, r = 0.32) and hypercalciuria and hyperuricosuria (P < 0.001, r = 0.51) found in this study. Hyperuricosuria is seen in 75% and 73% of patients with hypercalciuria and hyperoxaluria, respectively. Twenty-five children have both lithorisk profile and stone analysis. Hypercalciuria and hyperoxaluria were noted in 60% of calcium oxalate stone formers each. Elevated urinary calcium/creatinine ratio (>0.2) was seen in 73% of calcium oxalate stone formers. Conclusion: Because of high prevalence of metabolic risk factors and the significant risk of lifelong recurrence, all children with urolithiasis need complete evaluation with metabolic workup.
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CASE REPORTS Top

Prolapsed ureterocele in an adult woman after endoscopic incision p. 100
Davide Campobasso, Andrea Lanzi, Gian Luigi Pozzoli, Antonio Frattini
DOI:10.4103/UA.UA_117_17  PMID:29416284
A 44-year-old woman underwent endoscopic incision of a right simple ureterocele with hydronephrosis discovered during gynecological assessment for stress urinary incontinence with Stage I cystocele. At the postoperative visits, she has reported a persistent flap of mucosa coming out from her urethra protruding in the vagina despite manual reduction. An endoscopic resection of the mucosa flap was programmed. After 24 months, she was asymptomatic with no history of renal colic or urinary tract infection. In patients with a history of pelvic organ prolapse, the resection of the ureterocele in the first instance may be the optimal choice.
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A rare case of renal vein thrombosis secondary to Klebsiella pneumoniae pyelonephritis p. 103
Kelly L Lurz, Dany N Hanna, Brian H McGreen, Francis J Schanne
DOI:10.4103/UA.UA_123_17  PMID:29416285
Renal vein thrombosis (RVT) is most often an implication of nephrotic syndrome. Pyelonephritis has been associated at a much lower rate, with the incidence of Klebsiella pneumoniae causation being extremely rare. In our case, a 35-year-old female patient presented with right-sided K. pneumoniae-positive acute pyelonephritis complicated by perinephric abscess and renal vein thrombosis. She was successfully treated with anticoagulation and extended antibiotic therapy. The possibility of RVT in patients with K. pneumoniae-induced pyelonephritis warrants consideration.
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A rare case of prostatic abscess caused by Brucella organisms: First report in Saudi Arabia p. 106
Anwar Hamdi Alenazi, Fahad Mohamed Alfhaidi, Ali Ali Sulaiman Aljumaah, Mohamad Jayed Alenzi, Mubarak M AlOtaibi
DOI:10.4103/UA.UA_67_17  PMID:29416286
Brucellosis is a zoonotic infectious disease that is known endemic infection in Saudi Arabia. Yet, this infection has not been reported as evident cause of prostatic abscess. we present a new case of prostatic abscess caused by brucella organism proven using pus culture and serology. These organisms should be suspected in patients presenting with clinical picture of prostatic abscess especially in endemic areas.
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Hereditary leiomyomatosis and renal cell carcinoma: Case report and review of the literature p. 108
Ferreira Natalia, Oliveira Tiago, Oliveira Pedro, Gaspar Sandro
DOI:10.4103/UA.UA_95_17  PMID:29416287
Hereditary leiomyomatosis and renal cell cancer (HLRCC) is a rare genetic disorder in which the affected individuals tend to develop cutaneous leiomyomas, uterine leiomyomas, and renal cell cancer (RCC). Within the spectrum of this syndromic disease, RCC is the most severe manifestation, occurring at a younger age compared to the sporadic form. Pathological suspicion or diagnosis of HLRCC is critical for appropriate clinical management and genetic counseling of the affected family members. In this study, we report the case of a 27-year-old misdiagnosed carrier of HLRCC phenotype, who presented with a large solitary Type II papillary RCC.
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Intravesical explosion during transurethral resection of prostate: Prevention and management p. 111
Amrendra Pathak, Mahendra Singh, Adarsh Ramappa, Saurabh Jain, Shahnawaz Rasool, Ravi Shankar Kaswan, Bhupesh Patel
DOI:10.4103/UA.UA_8_17  PMID:29416288
The blast during transurethral surgery is a rare but known complication of transurethral resection of prostate (TURP) or transurethral resection of bladder tumors. It may lead to bladder rupture, which can be either extra- or intra-peritoneal requiring urgent laparotomy. It occurs due to the generation and trapping of explosive gases under the dome of the bladder. Even though this complication is rare, but the morbidity associated with this complication is high. Here, we present an interesting case report of an intravesical explosion during TURP leading to bladder rupture to remind urologists of this rare complication with suggestions on how to manage and prevent this complication.
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Multiple bladder diverticula treated with robotic approach-assisted with cystoscopy p. 114
Diego Antonio Preciado-Estrella, Pascual Cortés-Raygoza, Jorge Gustavo Morales-Montor, Carlos Pacheco-Gahbler
DOI:10.4103/UA.UA_108_17  PMID:29416289
A bladder diverticulum (BD) is a herniation of the bladder urothelium through the muscular bladder wall. As a result, BD presents as a thin walled bag, urine filled connected to bladder lumen through a neck or ostium. The clinical problem with bladder diverticula is their poorly empty during micturition which results in multiple lower urinary tract symptoms as well as recurrent urinary tract infections. Bladder diverticula can be grossly classified in two groups as follows: congenital or acquired with different age presentation and etiological factors in each one. Vast majority of BD occur in adults especially in men. Acquired BD, are commonly diagnosed in the setting of neurogenic dysfunction or bladder outlet obstruction, they use to be multiple, associated with trabeculated bladder and prostatic enlargement.
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Omphalocele, exstrophy of cloaca, imperforate anus, and spinal defect complex, multiple major reconstructive surgeries needed p. 118
Nada Neel, Mohmoud Salem Tarabay
DOI:10.4103/UA.UA_193_17  PMID:29416290
OEIS complex is a rare combination of serious birth defects including omphalocele, exstrophy of cloaca, imperforate anus, and spinal defects. The aim of managements has shifted from merely providing survival to improve patient outcomes and quality of life with higher level of physical and social independence. Multiple complicated reconstructive surgeries always needed for achieving the goals of treatment. In this case report, we aimed to present our surgical approach for this rare abnormality to achieve functionally and socially acceptable outcome.
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