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   Table of Contents - Current issue
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January-March 2020
Volume 12 | Issue 1
Page Nos. 1-106

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REVIEW ARTICLES  

The role of robot-assisted radical prostatectomy in high-risk organ-confined prostate cancer Highly accessed article p. 1
Mohamad Waseem Salkini
DOI:10.4103/UA.UA_135_19  PMID:32015608
The traditional open retropubic radical prostatectomy has an established role in the treatment of prostate cancer. However, it is well known to be morbid procedure with high complication rate. This bad reputation prevented utilizing it on a large scale for high risk prostate cancer. Utilizing the da Vinci® to preform radical prostatectomy decreased the morbidity of the procedure. Since the introduction of robotic prostatectomy, there have been hot debates on its role in the treatment of high risk disease. In this article we reviewed the current evidence on utilizing the surgical system in treating high risk organ confined prostate cancer.
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Approach to a woman with urinary incontinence Highly accessed article p. 4
Manidip Pal, Abhijit Halder, Soma Bandyopadhyay
DOI:10.4103/UA.UA_50_19  PMID:32015609
Urinary incontinence is a bothersome situation to the ailing woman. Many times, the woman does not come to medicos due to shyness, and if she comes also she does not reveal all the information. Hence, a sympathetic and structured approach will help to provide judicious management to these women. When a woman with the complaint of urinary incontinence approaches us, we should collect maximum information with the help of structured questionnaire and protocol. Structured questionnaire provides most of the information pertinent to the urinary incontinence. Associated medical disorders are also looked for. Past obstetrical performance can have implication on this ailment. Pelvic organ prolapse, mass lower abdominal, etc., also can lead to urinary incontinence. Adverse effect of some medicines causes urinary incontinence. During general physical examination, attention has to be paid toward body mass index, joint hypermobility, spine, etc. During local examination, stress test, Bonney test, Q-tip test, etc., may help to some extent. The levator ani muscle is assessed of its strength. Neurological evaluation is to be done for all the patients with urinary incontinence. Urinary culture and sensitivity are routinely done. Once urinary infection is ruled out, then the woman is subjected to frequency/volume diary, ultrasonography, urodynamic study, cystoscopy, etc., depending on the necessity. A systematic approach to urinary incontinence will provide the best comfort to these ailing women.
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Burnout of residents: Overview from various medical institutions – A suggested model for improvement p. 9
Jad A Degheili, Aline A Yacoubian, Rana Abu Dargham, Yaser Z El-Hout
DOI:10.4103/UA.UA_107_19  PMID:32015610
Background: Burnout is a common issue among residents across the globe. Although several attempts were made to propose better working hours for residents, burnout is still prevalent as depicted by several studies. Objectives: The aim of the paper is to review several worldwide studies related to burnout in residents and propose potential suggestions. Methods: The following paper summarizes studies pertinent to burnout in residents from different countries categorized into three main regions: North and South America, Europe, and Middle East. The studies were collected from February 2018 to March 2019. Results: Numerous studies across the world have revealed high rates of burnout in residents during the last decades. Conclusions: Various awareness and wellness programs, as well as professional counseling sessions, are proposed to help residents overcome burnout.
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ORIGINAL ARTICLES Top

Penile ring entrapment – A true urologic emergency: Grading, approach, and management p. 15
Omar Dawood, Seena Tabibi, Julia Fiuk, Neil Patel, Ahmed El-Zawahry
DOI:10.4103/UA.UA_16_19  PMID:32015611
Penile rings are used to sustain erection in order to enhance sexual pleasure. They work by reducing the outflow of blood from the cavernosal tissue. However, if left for extended periods of time severe edema, urethral fistula, gangrene, and even complete loss of the distal penis can ensue, this is known as penile ring entrapment (PRE). Management poses particular challenges due to its rarity. Herein, we report our experience with three patients from our institution that presented with PRE and include a review of the approaches others have taken. We also propose a simpler and more effective grading scale to allow for easier communication between providers, as the current grading scales do not do so.
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The learning curve for robotic-assisted pyeloplasty in children: Our initial experience from a single center p. 19
Noor Nabi Junejo, Anwar Alotaibi, Saeed Malwi Alshahrani, Ahmad Alshammari, Craig A Peters, Hamdan Alhazmi, Santiago A Vallasciani
DOI:10.4103/UA.UA_113_19  PMID:32015612
Background: Robotic-assisted pyeloplasty surgery has become the preferred approach of ureteropelvic junction obstruction (UPJO) in pediatrics. However, to our knowledge, there is limited data on the learning curve for robotic-assisted pyeloplasty in children and no similar study from Saudi Arabia. Aims: The objective of the study was to evaluate the progression of the surgical team performing robotic-assisted laparoscopic pyeloplasty (RALP) and to assess the feasibility of the RALP in children, since it is having been recently started in the Kingdom. Settings and Design: Retrospective charts and surgical videos review at the tertiary care centre. Subjects and Methods: After approval from the internal review board (IRB), we reviewed the surgical video recording of the RALP procedure of 15 patients presented with UPJO from January 2016 to October 2017. Statistical analysis was done for the variables includes dissection time, pyelotomy, anastomosis on both sides, and total surgery time and calculated in minutes. Renal ultrasound reviewed to assess any change in grade. Results: Fifteen patients with UPJO underwent RALP. Of 15 cases, nine were primary and six cases as secondary UPJO. The median age was 8 (3–15) years. Out of 15 cases, 13 and 2 patients diagnosed as Society for Fetal Urology grades of 4 and 3, respectively. Total operative time was prolonged in secondary group as compared to primary pyeloplasty group (mean [standard deviation (SD)]: 166.3 [35.1], range: 125–223, P = 0.0028 versus mean (SD): 149.17 (30.4), range: (114–207), P = 0.0008). The success rate was 100% in primary and 84% in secondary cases. The median length of follow-up was 12.0 (7.0–18.0) and 10.0 (8.0–12.5) months in primary and secondary cases, respectively. The overall complication rate was 13% (2/15) (Clavien grade: 1–2). Conclusions: The evaluation of the learning curve of RALP for this group of patients concluded that total operative time for RALP, performed by the pediatric urology team, steadily decreased with collective surgical experience.
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Is cystoscopy follow-up protocol safe for low-risk bladder cancer without muscle invasion? p. 25
Ugur Yucetas, Erdogan Aglamis, Huseyin Aytac Ates, Kemal Behzatoglu, Erkan Erkan, Mahmut Gokhan Toktas, Erdinc Unluer
DOI:10.4103/UA.UA_143_18  PMID:32015613
Objective: The applicability of cystoscopy follow-up protocol that is indicated for low-risk nonmuscle-invasive bladder cancer (NMIBC) in the guidelines was investigated for our population. Materials and Methods: Patients who underwent transurethral resection with a diagnosis of primary bladder tumor in our clinic within 10 years with low grade of pathology pTa and follow-up periods of at least 5 years were retrospectively reviewed. Fifty-one patients (39 males and 12 females) who were diagnosed with a low-risk NMIBC, had no recurrence at the 3-month control cystoscopy, and followed up for the first 2 years on 3-month basis with cystoscopy were included in the study. Results: The mean age of the patients was 57.37 ± 12.21 years (range: 29–80 years), and the mean duration of recurrence was 25.76 ± 32.45 months. In the cystoscopy follow-ups of 51 patients, up to the 6th month, a total of 12 (24%); up to the 9th month, a total of 21 (41%); up to the 12th month, a total of 30 (59%); up to the 15th month, a total of 36 (71%); up to the 18th month, a total of 36 (71%); up to the 21st month, a total of 39 (77%); and up to the 24th month, a total of 41 (80%) patients were reported to have recurrence. In the case of patients with no recurrence at the 9th month cystoscopy, it was determined that 50% of the patients had recurrence in the first 6 months and 67% in the first 2 years. Conclusion: The majority (80%) of recurrences in low-risk NMIBC occurred in the first 2 years. If the follow-up protocol described in the guidelines had been applied, patients with relapses would have a delay of at least 6 months of diagnosis. Therefore, even if there is no recurrence in the low-risk NMIBC at the 3rd and 9th months, it may be more appropriate to follow the cases in the first 2 years with follow-up cystoscopy every 3 months.
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Prospective audit of complications after ultrasonography-guided percutaneous nephrostomy for upper urinary tract obstruction using modified Clavien classification system p. 31
Sunil Kumar, Uma Kant Dutt, Suresh Singh, LN Dorairajan, KS Sreerag, Tepukiel Zaphu, R Manikandan
DOI:10.4103/UA.UA_18_19  PMID:32015614
Introduction: Percutaneous nephrostomy (PCN) is a commonly performed intervention in urology for various benign and malignant conditions causing upper urinary tract obstruction. We present a prospective audit of complications of ultrasonography (USG) guided PCN using modified Clavien classification system (mCCS). Methods: The data were prospectively collected for 368 PCN performed in 344 patients from June 2015 to January 2017, for various benign and malignant diseases causing upper urinary tract obstruction. Patients were followed for 1 month, and complications arisen of PCN were noted. Results: PCN was successful in 356 renal units. The 12 patients in which PCN failed was due to minimal pelvicalyceal dilatation and PCN was successfully performed after 48 h by a senior urologist. 207 patients had malignant disease and 161 patients had benign condition. Most common malignant disease was carcinoma cervix. 238 were noninfected while 130 had infected renal units. 62 (16.84%) patients had Grade I (self-limiting hematuria/cot/debris/fever). 37 (10.0%) patients had Grade II (7 - transfusion and 30 - urinary tract infection). 34 (9.2%) had Grade III a (repositioning/change/reinsertion of PCN tube under local anesthesia) and 4 (1.1%) had Grade III b (repositioning under anesthesia). 8 (2.2%) Grade IV a (Sepsis), 0 Grade IV b, and 0 Grade V complications were observed. Conclusion: USG-guided PCN is a safe, minimally invasive, and effective procedure for upper urinary tract diversion with a low rate of morbidity. Individual complications are within the threshold limits set by the American College of Radiology, the Society of Interventional Radiology. mCCS is well applicable and easily reproducible tool for reporting the complications of PCN.
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The safety of ureteral stenting with the use of potassium citrate for management of renal uric acid stones p. 37
Nawaf Abdulaziz Alenezi, Fouad Zanaty, Amr Hodhod, Mohammed El-Gharabawy, Eid El-Sherif, Atef Badawy, Mohammed El-Shazly
DOI:10.4103/UA.UA_60_19  PMID:32015615
Objectives: The objective is to evaluate the relative risks of ureteric stents application while managing uric acid stones with potassium citrate in terms of stone encrustations and urinary tract infection (UTI). Patients and Methods: We prospectively enrolled patients with renal uric acid stones who received K citrate from 2013 to 2018. Patient's demographics were collected. All patients were evaluated using noncontrast computed tomography (CT) scan to measure the stone size and density. JJ ureteric stent was inserted prior to the initiation of treatment. At follow-up, all patients underwent urine analysis for pH and to detect UTI. CT was repeated at 1 month and those patients who showed incomplete stone resolution underwent another course of treatment for another month. CT was repeated prior to stent removal. The presence of encrustations was inspected and collected. Results: We collected 59 patients with a median age of 36 years (18–73) and median stone burden of 26 mm3 (15–50). The median stone density was 310 HU (175–498). Twenty-one patients (35.6%) received K citrate treatment for 1-month, while the remaining patients had 2 months treatment. Sixteen patients (27.1%) had a complete stone dissolution, 41 patients (69.5%) had more than 50% decrease of stone burden while only 2 patients (3.4%) had stones with poor dissolution. Four patients (6.8%) experienced UTI while 2 patients (3.4%) had visible JJ encrustations. Most of these complications occurred when the treatment was offered for the 2nd month. Conclusion: Short-term use of ureteral stents is safe during the management of uric acid stones with K citrate.
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The effect of the body mass index on the types of urinary tract stones p. 42
Raed M Almannie, Khalid A AL-Nasser, Khalid M Al-Barraq, Muaath M Alsheheli, Hamdan H Al-Hazmi, Saleh A Binsaleh, Abdulaziz M Althunayan, Mohammed A Alomar
DOI:10.4103/UA.UA_161_18  PMID:32015616
Objectives: Urinary tract stones are a common public health problem worldwide. In addition, identifying the composition of stones is important for the further metabolic evaluation of patients. We conducted this study to further correlate the relationship between body mass index (BMI) and different compositions of urinary tract stones. Materials and Methods: A retrospective study of 433 patients who underwent urinary tract stone analysis via Fourier-transform infrared spectroscopy at King Khalid University Hospital in Riyadh from May 2015 to June 2017 was performed. Their BMI at the time of stone analysis was recorded. Results: A total of 433 stones were analyzed by the statistical data analysis software. The BMI was classified according to the WHO classification. We divided our patients into seven age groups. Most patients were between the age group of 35 and 44 years and were overweight. The incidence of calcium oxalate, carbonate apatite, and uric acid stones was higher in patients with a BMI above thirty than in patients with a lower BMI. However, cystine stones were more common in normal-weight patients. Conclusions: In this study, we found that the incidence of certain types of stones, such as calcium oxalate, cystine, and uric acid stones, in Saudi Arabia can be predicted by BMI measurement.
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Outcome of salvage ureteral reimplantation after endoscopic treatment failure for high-grade vesicoureteral reflux compared to primary ureteral reimplantation p. 49
Tariq Burki, Muhammad S Howeiti, Maha K Almadhi, Fayez M Al Modhen, Hamdan Alhazmi, Santiago A Vallasciani, Abdulwahab E Alhams, Shahbaz W Mehmood, Ahmed M Al Shammari
DOI:10.4103/UA.UA_58_19  PMID:32015617
Introduction: Surgical treatment of vesicoureteral reflux is required after conservative treatment has failed. However, there is a controversy if fibrosis related to previous attempts of dextranomer/hyaluronic acid (Dx/Ha) injection increases the risk of surgical difficulty and postoperative complications. Therefore, the purpose of our study was to compare the outcome of salvage ureteral reimplantation (SUR), after failed endoscopic therapy, to that of primary ureteral reimplantation in patients with high-grade primary vesicoureteral reflux (VUR). Materials and Methods: We conducted a retrospective analysis of children, <14 years old, treated for Grade IV or V VUR, between 1998 and 2014. Cases were classified into the SUR or the PUR group. Cases of secondary VUR were excluded. All patients were treated using a cross-trigonal ureteral reimplantation technique by two surgeons. The following demographic and clinical variables were included in the analysis: presentation, reflux severity, scarring on imaging, age at endoscopic injection, total amount of Dx/Ha injected, operative time, postoperative hospital stay, operative complications, incidence of febrile urinary tract infections (UTIs) after surgery, and persistent VUR. Between the groups, differences were evaluated using Fisher's exact test. Results: Twenty-six patients were included, 19 in the SUR and 7 in the primary ureteral reimplantation (PUR) group. In the SUR group, 12 cases had a bilateral VUR and 7 had a unilateral VUR, with 4 bilateral and 3 unilateral VUR cases in the PUR group. In the SUR group, 13 patients had received one Dx/Ha injections, with the other 6 receiving two injections, of 0.5 ml of Dx/Ha (range, 0.5–2.0 ml). A bilateral reimplantation was performed in 14/19 patients in the SUR group and 4/7 in the PUR group. The median age at surgery was 4 years in the SUR group and 3 years in the PUR group (P < 0.02). The median operative time was comparable between the groups (120 and 140 min for the SUR and PUR groups, respectively, P = 0.73), with a comparable length of hospital stay (5 and 6 days, respectively, P = 0.061). Blood loss was generally <10 ml, except in three cases in the SUR group, due to difficult dissection. Over the median follow-up of 1 year, persistent Grade III SUR was identified in only one patient in the SUR group, with no occurrence of febrile UTIs postoperatively. Conclusion: SUR for high-grade primary VUR after failed Dx/Ha injection has the same success rate as PUR, with no significant complication rate, although the necessary dissection may be more difficult.
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Air embolism during percutaneous nephrolithotomy using air pyelogram during initial access: Does it really occur? p. 54
Anshul Garg, Mohd Mubashir Ali Khan, Praveen Singh, Manish Kumar Agarwal
DOI:10.4103/UA.UA_10_19  PMID:32015618
Introduction: In the present era, percutaneous nephrolithotomy (PCNL) is the standard treatment for large (>2 cm) renal or staghorn renal stones. Both air and iodinated contrast has been used to opacify the pelvicalyceal system (PCS) before the dilatation of the tract. There are rare reports of air embolism following air pyelogram on mere presumptions. Materials and Methods: This is a prospective observational study. A total of 164 patients underwent PCNL in which air was used to opacify the PCS by placing a ureteric catheter for initial access. Results: None of our patients developed any complication during the procedure or in the postoperative period, which could be attributed to air embolism. Conclusions: The present study ascertains that using air for opacification of PCS for initial puncture access is a safe and acceptable alternative to iodinated contrast.
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Urolithiasis: Prevalence, risk factors, and public awareness regarding dietary and lifestyle habits in Jeddah, Saudi Arabia in 2017 p. 57
Nada Yasser Baatiah, Raghad Bader Alhazmi, Fatmah Ali Albathi, Esraa Ghazi Albogami, Abdullah Khalid Mohammedkhalil, Basim Saleh Alsaywid
DOI:10.4103/UA.UA_13_19  PMID:32015619
Introduction: Urolithiasis is a public health concern, yet there are limited studies in our community. This study aimed to provide a current estimate of the prevalence of urolithiasis and to evaluate the public's awareness about dietary and lifestyle habits that impact on urolithiasis among the Jeddah population in 2017. Methods: This is an observational cross-sectional study design where a self-administered questionnaire was distributed in two major malls in Jeddah. The total number of participants was 2173, who were Saudis and non-Saudis aged 18 years and above. The questionnaire includes five sections: demographics, general information related to urolithiasis, dietary information related to urolithiasis, lifestyle habits, and medical conditions. Results: The overall prevalence of urolithiasis was 11.2%, 48.8% of which had a family history with a first-degree relative. The odds of urolithiasis among males was 1.8 times higher than in females (odds ratio [OR] =1.8, 95% confidence interval [CI], 1.4–2.4). The median age of stone disease was 33 years (25%–75%: 26–42 years). Diabetic individuals were 3.2 times more likely to have urolithiasis when compared to nondiabetic individuals (OR = 3.2, 95% CI, 2.1–4.9). Low level of awareness was observed in this cohort group with a mean score of 37.7%; 64.1% of the population were in the low awareness level, 35.3% were in the medium level, and only 0.6% participants were in the high level of awareness. Conclusion: This study highlights the lack of public awareness about urolithiasis and knowledge about its causation despite the high prevalence. There is a clear need to inform and educate the public on matters relating to the known risk factors associated with urolithiasis.
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Assessment of posterior urethra in benign prostatic hyperplasia and after its surgery p. 63
Vivek Agrawal, Rahul Khullar, Ashesh Kumar Jha
DOI:10.4103/UA.UA_118_18  PMID:32015620
Introduction: Surgical management of benign prostatic hyperplasia (BPH) primarily consists of transurethral resection of the prostate (TURP). Due to BPH and after surgical intervention, anatomic variations in the posterior urethra are expected. Due to the paucity of information regarding posterior urethral anatomic variations in these conditions and its aftermath, this study was undertaken to evaluate the anatomic variations in the posterior urethra after TURP. Materials and Methods: This prospective observational study was conducted over 2 years at the Department of Surgery and Radiodiagnosis, University College of Medical Sciences, Delhi. All consenting patients undergoing TURP for BPH were included in the study. We assessed the posterior urethral changes in BPH before and 3 months after the procedure. Diagnostic modalities used were urethrocystoscopy, micturating cystourethrogram, and retrograde urethrogram. Furthermore, the prostate volume and postvoid residual volume of urine were compared before and after its surgery using ultrasonography. Urodynamic studies were used to calculate total voided volume (TVV), peak flow rate (PFR), voiding time (VT), and hesitancy. Results: Mean age of the patients was 68.12 ± 7.83 years. Lengthening in posterior urethra was seen in BPH patients with a mean of 4.24 ± 1.012 cm. Postprocedure, there was a mean reduction of 2.6 ± 1.225 cm in length of the posterior urethra (P < 0.0001). Prostatic urethral angle was increased in patients suffering from BPH, and it decreased after undergoing surgical management (P < 0.679). All patients enrolled in our study had prostatic lobes enlargement, and after surgery, this enlargement was reduced in most of the patients with 21 having no prostatic enlargement, and in four patients, bilateral lateral lobe was not completely reduced (P = 1.000). Stricture in prostatic urethra was observed in 2 out of 25 (8%) patients operated for BPH. Evaluation of various parameters of urodynamic studies revealed the net improvement in the TVV of 157.746 ± 120.999 ml, as before the procedure, this value was 176.715 ± 72.272 ml, and after surgery, it was 334.46 ± 78.588 ml (P < 0.001). VT taken by patients before surgery was 57.377 ± 16.858 s, and postprocedure, this value was 33.31 ± 8.807 s. This net reduction of 24.069 ± 14.88 s was statistically significant (P < 0.0001). PFR before the procedure was 6.177 ± 3.5067, and postprocedure, this value was 26.43 ± 7.112 ml/s with a net improvement of 20.253 ± 9.226 ml/s (P < 0.0001). Hesitancy in BPH patients before the procedure was 23.908 ± 15.521 s. Postprocedure, hesitancy decreased to a value of 6.79 ± 4.435 s with a net reduction of mean 17.115 ± 15.817 s (P < 0.002). Conclusion: By our findings, we conclude that BPH is associated with anatomic variations in posterior urethra such as lengthening of the length of the posterior urethra and increased posterior urethral elevation, which is measured by an increase in posterior urethral angle (PUA). Whereas post-TURP, there is a shortening of posterior urethra, decrease in PUA, decrease in prostatic volume, postvoid residual urine volume, and improvement in uroflowmetric parameters.
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Efficacy of follicle-stimulating hormone as a treatment of severe idiopathic oligospermia: A retrospective study p. 69
Ahmed Aljuhayman, Abdulmalik Almardawi, Moayid Fallatah, Naif Alhathal
DOI:10.4103/UA.UA_37_19  PMID:32015621
Introduction: About 15% of couples are infertile, with the male factor being responsible for about 50% of these cases of infertility. Idiopathic oligospermia (IO) is a dilemma that faces every andrologist and yet is one of the most common causes of male infertility. Although studies have shed some light on multiple treatment modalities and their effectiveness, one of the most fascinating ones is follicle-stimulating hormone (FSH). Methodology: This is a single tertiary center retrospective study; all patients with severe IO (sperm count of <5 million/ml) from January 2016 till January 2018 were included in the study. We divided our retrospective population into 2 groups, Group 1 who received FSH 75 IU (Menogon®) twice a week and Group 2 who received FSH 150 IU (Menogon®) twice a week. Semen parameters were recorded pretreatment and posttreatment. Results: Number of the patients included in the study was 32. Group 1 included 16 patients who received FSH 75 IU. Group 2 included 16 patients who received FSH 150 IU. After 4 months of treatment, the mean sperm count in Group 1 increased to 4.745 million/ml (pretreatment was 1.235 million/ml), while in Group 2, it was 1.516 million/ml (pretreatment was 0.578 million/ml). The mean total motility in Group 1 was 20.3%, while Group 2 mean total motility was 27.5%. Conclusion: In conclusion, our study elicited that a dose of FSH as low as 75 IU can improve sperm count significantly in patients with severe IO.
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CASE REPORTS Top

Cystic trophoblastic tumor – The effect of chemotherapy in metastatic testicular germ cell tumor to retroperitoneal lymph nodes p. 73
Swetha Narla, Ann Kurian, Rajarajan Venkatesan, Ajit Pai
DOI:10.4103/UA.UA_131_19  PMID:32015622
Cystic trophoblastic tumor is an uncommon lesion which is occasionally seen after chemotherapy in metastatic retroperitoneal lymph nodes in patients with testicular germ cell tumor. The tumor cell clusters show cystic change lined by single to multiple layers of cells with abundant dense eosinophilic vacuolated cytoplasm, large pleomorphic vesicular nuclei with smudged chromatin, and prominent nucleoli. It is important to identify this lesion as its prognosis is similar to a teratoma and does not require any additional chemotherapy.
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Noninfectious glans gangrene in a diabetic male p. 77
Gyvi Gaurav, Raghubir Bhardwaj, Shahnawaz Alam
DOI:10.4103/UA.UA_65_19  PMID:32015623
Limited glans penis gangrene is a rare subset of penile gangrene and is associated with favorable prognosis as compared to more aggressive course of the similar entity in moribund diabetic end-stage renal disease patients. A 64-year-old diabetic, hypertensive male with a history of tobacco consumption, bilateral great toe amputations, and normal renal function, presented with gangrene of glans penis and lower urinary tract symptoms. Early surgical debridement, glycemic control, and alpha-blocker treatment were successful in controlling the disease. There was no further progress of the gangrene requiring further amputation and no voiding difficulties after 6 months of follow-up.
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Penile cutaneous horn p. 80
Diya Pal, Dilip Kumar Pal
DOI:10.4103/UA.UA_158_18  PMID:32015624
Cutaneous horns are cornified hyperkeratotic lesions on the skin, usually present on photo-exposed areas such as the face and scalp. Its presence on the penis is very rare. Here, we report a 35-year-old male presenting with penile cutaneous horn with successful management with wide local excision along with a review of other modalities of treatment of this rare entity.
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Primary cutaneous mucinous carcinoma of the scrotum: A rare tumor at a rare site – A case report and review of literature p. 83
Olajide Olusegun Abiola, Gbemi H Ano-Edward, Olutunde A Oluwumi, Mathew E Lasisi
DOI:10.4103/UA.UA_126_18  PMID:32015625
Primary cutaneous mucinous carcinoma (PCMC) is a rare malignant adnexal tumor of eccrine origin with a higher incidence in the head and neck region of the body while scrotal skin involvement is rare. We report a case of a 72-year-old man with ulceration of painless scrotal lesions of 10 years' duration. Histology of the wedge biopsies of the lesions was mucinous carcinoma. Clinical workup excluded noncutaneous primary sites of mucinous carcinoma and distant metastasis. He had wide excision of the scrotal skin lesions with histological findings of nests of malignant cells separated from pool of mucin by fibrocollagenous septae. Periodic acid–Schiff stain was positive; however, immunohistochemical stains for estrogen and progesterone receptors were negative. No local recurrence was observed after 12 months of follow-up. Scrotal PCMC is a rare tumor; this may probably be the first reported case of this tumor in the scrotum. Prognosis was good following surgical excision.
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Extended Boari-flap reconstruction in isolated tuberculous pan-ureteral stricture p. 87
Shanmugasundaram Rajaian, Pragatheeswarane Murugavaithianathan, Karrthik Krishnamurthy, Lakshman Murugasen
DOI:10.4103/UA.UA_165_18  PMID:32015626
A 53-year-old female presented with left loin pain and imaging showed left pan-ureteral stricture secondary to tuberculosis. The renal unit was salvaged by percutaneous nephrostomy. She was planned for ileal ureteric replacement. An extended Boari flap was constructed for her as the bladder capacity was good and Boari bladder flap reached the renal pelvis without tension. Follow-up nephrostogram revealed wide pyelovesical junction with prompt drainage. She completed antituberculous treatment. Extended Boari flap is rarely used for upper ureteric reconstruction. It should be considered as an option for complete ureteric reconstruction in the unilateral pan-ureteral stricture in selected cases.
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Ureteroneocystostomy herniation leading to obstructive uropathy 10 years postrenal transplant: A rare case report p. 90
Shailesh Chandra Sahay, Dilip Bhalla, Pawan Kesarwani, Madan Sethi
DOI:10.4103/UA.UA_2_19  PMID:32015627
Herniation of the urinary bladder is observed in around 1%–4% of cases. Bladder herniation rarely presents with obstructive uropathy; however, bladder herniation carrying ureteroneocystostomy and leading to obstructive uropathy of the graft is even rare. Here, we present a case of a 36-year-old male with deranged renal function test who had undergone renal transplant 10 years back. Computed tomography scan revealed bladder herniation with ureteroneocystostomy and hydronephrosis. He was surgically explored by Gibson incision and ureterolysis, and hernioplasty was performed. Although the cause of herniation was ureteroneocystostomy, it was managed immediately without any need for percutaneous nephrostomy.
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Urethral duplication with rectourethral fistula: Review of two cases p. 92
Rama Kishan Saran, Kiran Mirdha, Sanya Saran, Rajendra Prasad Takhar
DOI:10.4103/UA.UA_25_19  PMID:32015628
Urethral duplication is a very rarely observed congenital anomaly, mostly affecting the males. This case report highlights the management of two patients diagnosed with Type II A, Y-type urethral duplication. An 11-year-old boy was diagnosed with Type II A of Y-type urethral duplication, where the dorsal urethra was completely hypoplastic, and the ventral urethra was communicating with rectum. After the failure of a single-stage inner preputial pedicled tube urethroplasty, a perineoscrotal flap urethroplasty was done, and at present, the patient is waiting for the 2nd stage of surgery. Case 2 is a 14-year-old boy diagnosed with Type II A2, Y-type urethral duplication, where the dorsal urethra at proximal part was hypoplastic with normal caliber of penile urethra, and the ventral urethra was communicating with rectum. The boy was treated with end-to-end urethroplasty, and good surgical outcome was observed. The purpose of this case report is to discuss the management of unusual form of Y-type urethral duplication by staging the surgical procedure.
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Antegrade removal of a knotted ureteric stent: Case report and review of literature p. 96
Jennifer Bradshaw, Atif Khan, Ese Adiotomre, Simon Burbidge, Chandra Shekhar Biyani
DOI:10.4103/UA.UA_172_18  PMID:32015629
Ureteral stents are routinely used in urological practice for many indications including obstruction of ureter, ureteral stricture, prior to treatment with extracorporeal shock wave lithotripsy, and to promote healing following ureteral injury. Complications reported with ureteric stents include stent migration, stent rupture, encrustation, ureteral perforation, erosion, and fistulation. Knotting of an indwelling ureteral stent is a very rare complication, with fewer than 30 cases reported in the literature. Techniques for managing this complication include using a holmium laser to cut the knot, percutaneous antegrade removal, and gentle traction. We describe the case of a knotted stent and its removal along with a comprehensive literature review.
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Congenital unilateral absence of vas deferens with contralateral testicular atrophy p. 101
Turki A Alferayan, Saad M Abumelha, Mazen S Al Subayyil, Bader M Al Asmari, Talal M Al Nahas
DOI:10.4103/UA.UA_155_18  PMID:32015630
We present a case report of a 25-year-old obese man complaining of primary infertility for 2 years. After a thorough examination and investigation were done, he had congenital unilateral absence of vas deferens with ipsilateral renal agenesis and a palpable vas deferens in the contralateral side with testicular atrophy. Semen analysis showed low semen volume (0.5 mL) with azoospermia. Hence, a scrotal exploration and a crossover transseptal vasoepididymostomy to relocate the vas deferens were done. After 6 months, the sperm concentration reached 5 × 106/mL with good motility (40%) and volume (1.5 mL).
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High-flow priapism treated with selective embolization of a helicine branch of the penile artery: A case report and selected review of the literature p. 103
Faizanahmed I Munshi, Young Suk Kwon, Douglas T Gibbens, Parvez Mahmood, Mukaram Gazi, Ephrem O Olweny
DOI:10.4103/UA.UA_45_19  PMID:32015631
High-flow, or nonischemic, priapism occurs in <5% of observed clinical presentations of all priapism and is characterized by prolonged, painless erection in the context of pelvic and genitourinary trauma. While conservative management can be safely attempted for many cases of high-flow priapism (HFP), selective embolization is becoming the preferred approach as it allows for rapid resolution. We, herein, present a case of a 42-year-old male patient who presented with trauma-induced HFP treated with selective embolization and briefly review the current literature regarding the management of HFP.
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LETTER TO EDITOR Top

RE: Miniaturized percutaneous nephrolithotomy versus retrograde intrarenal surgery in the treatment of renal stones with a diameter <15 mm: A 3-year open-label prospective study p. 106
Mohd Nazli Kamarulzaman
DOI:10.4103/UA.UA_12_19  PMID:32015632
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