True hermaphrodites have characteristics tissue both sex in the form of presence of vagina uterus, fallopian tubes and ovaries as in female and presence of testis seminiferous tubules but penis as in penoscrotal hypospadias and bifid scrotal sac confuses as well developed labia majora. Determination of sex as per parents view in our social set up. The case was provisionally diagnosed as intersex. Total abdominal hysterectomy, bilateral salphingo-oophorectomy and colpectomy were conducted. A 3-year-old child referred by a pediatrician to Nalanda Medical College, child surgical department for investigation and management of his ambiguous genitalia having following features like, urine was not passing from the tip of penis; penis along with apparently looking female genitalia was taken under treatment. Examination under general anesthesia showed a presence of both male/female internal genitalia and gonads with features of external genitalia of both sexes. After total abdominal hysterectomy and human chorionic gonadotrophin treatment growth of phallus and testicle was noted. The child was made male after extirpation of female genitals. This case illustrates that gender correction can be made as per patients consent in adult but at this stage social customs and parents consent dictated the treatment.

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Ovotesticular disorder of sex development (OT-DSD) is a rare disorder of sexual differentiation characterized by the presence of both ovarian and testicular tissues in the same individual. It's incidence ranges from 3% to 10% of all disorder of DSD's, and the most common presentation is 46, XX followed by 46, XX/46, XY mosaicism and 46, XY. Klinefelter syndrome (KS) mosaicism 46, XX/47, XXY is extremely rare, and its association with the ovotesticular disorder is even rarer. We report an unusual case of 16-year-old with male habitus who presented with complains of cyclic hematuria. On examination, he had bilateral gynecomastia, unilateral left cryptorchidism, absent facial hair, sparse axillary hair growth, and pubic hair distribution of feminine type. The right testis was of normal size located normally in hemiscrotum and was confirmed by radio imaging. Ultrasonography and magnetic resonance imaging revealed a cystic area behind posterior half of urinary bladder. Chromosomal analysis revealed 46, XX/47, XXY mosaicism of female karyotype and KS. Histopathological report of this left side excised specimen confirmed the structures to be ovary, uterus, and fallopian tube, thus confirming our diagnosis of the lateral ovotesticular disorder. Meticulous workup combined interdisciplinary approach will lead to early diagnosis and resolve timely sex reassignment issues and also prevent consequences arising due to gonadal insufficiency.

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For the diagnosis of prostate cancer trans-rectal prostate biopsy (TRPB) is used commonly, the procedure is associated with infective complications. There is evidence that antibiotics (ABx) decrease infective events after TRPB, but different regimens are used. To systematically review different regimens of prophylactic oral ABx in TRPB. MEDLINE, EMBASE, clinical trials site, and Cochrane library were searched, experts were consulted for relevant studies. Randomized clinical trials conducted in the last 20 years, which investigated the different oral antibiotic regimens in TRPB, and compared their efficacy to reduce infectious complications were analyzed. Primary outcomes were bacteriuria, urinary tract infection (UTI), fever, bacteremia, and sepsis. Secondary outcomes were the hospitalization rate and the prevalence of ABx-resistant bacteria. Nine trials were eligible with 3012 patients. ABx prevented bacteriuria (3.5% vs. 9.88%), UTI (4.46% vs. 9.75%), and hospitalization (0.21% vs. 2.13%) significantly in comparison with placebo or no treatment. No significant difference was found in all the outcomes of the review between the single dose regimen and the 3 days. The single dose regimen was as effective as the multiple doses except in bacteriuria (6.75% vs. 3.25%), and the prevalence of ABx-resistant bacteria (1.57% vs. 0.27%). Quinolones reduced only UTI significantly in comparison with other ABx (chloramphenicol, trimethoprim-sulfamethoxazol). It is essential to prescribe prophylactic ABx in TRPB. No conclusive evidence could be claimed about the superiority of the multiple or the 3 days regimens to the single dose regimen. Unexpectedly, ABx-resistant bacteria were identified more often in the single dose cohorts.

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Objective: The objective was to review the impact of transperineal biopsy (TPB) at our institution by assessing rates of cancer detection/grading, treatment outcomes and complications. Patients and Methods: A retrospective review of TPBs between 2009 and 2013 was performed. Variables included reason for TPB, age, prostate-specific antigen, previous histology, TPB histology, and management outcomes. Results: In total, 110 patients underwent 111 TPBs at our institution. On average, 22 cores were taken from each procedure. Disease-upgrade occurred in 37.5% of active surveillance patients, 35% of patients with previous negative transrectal ultrasound, and 58.8% in patients undergoing TPB for other reasons. Of these patients, anterior and/or transition zones were involved in 66%, 79%, and 80%, respectively. Involvement in anterior and/or transition zones only occurred in 40%, 37%, and 10%, respectively. About 77% of patients with disease-upgrading underwent treatment with curative intent. Complications included a 6.3% rate of acute urinary retention and 2.7% of clot retention, with no episodes of urosepsis. Conclusions: Transperineal biopsy at our institution showed a high rate of disease-upgrading, with a large proportion involving anterior and transition zones. A significant amount of patients went on to receive curative treatment. TPB is a valuable diagnostic procedure with minimal risk of developing urosepsis. We believe TBP should be offered as an option for all repeat prostate biopsies and considered as an option for initial prostate biopsy.

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Background: Prostate cancer is a major health problem throughout the developed world. Tumor grade is one of the most important prognostic factors of prostate cancer. At present, adequate prognostic markers for prostate cancer progression are still lacking, in spite of intensive investigation. Accordingly, we studied the role of immunohistochemical (IHC) expression of p53 and Ki-67 as a prognostic factor in carcinoma prostate and correlated their expression with Gleason's grade. Materials and Methods: In this prospective study, a total of 60 cases including 50 cases of prostate carcinoma and 10 of benign prostatic hyperplasia (BPH) were taken. Tumor grade was determined according to Gleason's grading system. p53 and Ki-67 expressions were determined by IHC staining. The obtained results were analyzed and evaluated using Spearman's statistical test (SPSS version 20). Results: In BPH, p53 was expressed in only 2 of 10 (20%) cases while in carcinoma it was expressed in 38 of 50 (76%) cases. Ki-67 was expressed in only 1 of 10 (10%) BPH cases while in carcinoma it was expressed in 32 of 50 (64%) cases. In present study, 1 of 4 (25%) well differentiated, 23 of 31 (74.19%) moderately differentiated and 14 of 15 (93.33%) poorly differentiated tumors revealed p53 immunopositivity and a statistically significant correlation was observed between p53 expression and increased Gleason's grade (P = 0.038). All 4 (100%) cases of well-differentiated carcinoma were negative for Ki-67 expression. Nineteen of 31 (61.29%) moderately differentiated and 13 of 15 (86.66%) poorly differentiated tumors were positive for Ki-67 and a statistically significant correlation was observed between Ki-67 positivity and increased Gleason's grade (P = 0.002). Conclusions: Both p53 and Ki-67 were significantly up-regulated in malignant lesions as compared to benign lesions and a strong relationship with the Gleason's grading was noticed, therefore, we propose that these markers can be applied along with other prostate cancer prognostic factors.

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Objective: The objective of the following study is to evaluate the efficiency of transurethral plasma vaporization of the prostate in saline bipolar plasma vaporization of the prostate (BPVP) using the button electrode and comparing it to the standard transurethral resection of the prostate (TURP). Patients and Methods: During the period of the year between 2007 and 2013, 152 patients with benign prostatic hyperplasia were rolled in our study. Fifty-two patients were underwent BPVP and 100 TURP. All patients were evaluated preoperatively, 24 h and at 3 months postoperatively. International Prostate Symptom Score (I-PSS), quality-of-life (QOL) score, Qmax and Qave and post void residual (PVR) urine. Operative time, hospital stay, catheterization time, and complications were reported. Mean serum Hb, hematocrit and serum sodium changes were reported preoperatively and within 24 h postoperatively in both groups. Statistical analysis is performed using SPSS program version 20 for windows. Results: Mean age at surgery was 60.8 ± 8 (range 63- 92) and 66 ± 8.6 (range 50-83) for BPVP and TURP groups, respectively. Mean prostatic volume was 46 ± 11 (range 30-92) and 43 ± 8 (range 30-80) in both groups, respectively. Patients from both series had similar preoperative characteristics. The mean operative duration 53 ± 21 1 ± 2.1 (range 1-7) versus 3 ± 3.3 (range 3-8) days (P value 0.0001) were significantly (range 20-80) versus 62 ± 16 min (range 30-126) (P value 0.004), catheterization period 2 ± 0.28 ( range 2-4) versus 3 ± 3.2 (range 2-7) days (P value 0.03). Conclusions: BPVP has superior efficacy in short-term results and less complication rates compared with classic TURP.

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Fournier gangrene (FG) is polymicrobial necrotizing infection of subcutaneous tissues and deep fascia, commonly involving the perineum, external genitalia, anterior abdominal wall and medial aspect of thighs. Urethral pathology, although often the inciting factor for FG, extensive involvement with urethral necrosis is very rare. This is the first report in English literature, describing complete sloughing of the bulbar urethra with ischemic necrosis of the bladder mucosa from FG. Such extensive disease is associated with high mortality, despite higher antibiotics, through debridement and intensive care. Urethral involvement needs extensive debridement and temporary or permanent urinary diversion.

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Introduction and Objectives: The management of urolithiasis in patients with horseshoe kidney (HSK) is difficult. Stone formation occurred in 1:5 patients with HSK due to impaired urinary drainage and infections. Percutaneous nephrolithotomy and shock wave lithotripsy can be technically challenging due to altered anatomy. Materials and Methods: We conducted a systematic review of the literature to look at the role of ureteroscopy for stone management in these patients. We searched MEDLINE, PubMed and the Cochrane Library from January 1990 to April 2013 for results of ureteroscopy and stone treatment in HSK patients. Inclusion criteria were all English language articles reporting on ureteroscopy in patients with HSK. Data were extracted on the outcomes and complications. Results: A total of 3 studies was identified during this period. Forty-one patients with HSK underwent flexible ureteroscopy and stone treatment. The mean age was 42 with a male:female ratio nearly 3:1. The mean stone size was 16 mm (range: 3-35 mm). The mean operating time was 86 min with multiple stones seen in 15 patients. All 41 patients had a ureteral access sheath used and flexible ureteroscopy and holmium laser fragmentation done. Thirty-two (78%) patients were stone-free with a mean hospital stay of 1-day. Minor complications (Clavien I or II) were seen in 13 (32%) of which 6 had stent discomfort, 3 needed intravenous antibiotics for <24 h, 3 had hematuria of which 2 needed blood transfusion and one had pyelonephritis needing re-admission and antibiotics. There were no major complications found in the review. Conclusions: Retrograde stone treatment using ureteroscopy and lasertripsy in HSK patients can be performed with good stone clearance rate, but with a slightly higher complication rate. This procedure should, therefore, be done in high volume stone center with an experienced stone surgeon/team.

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Context: Various factors predict recoverability of kidney function preoperatively. Placement of percutaneous nephrostomy (PCN) and measuring the differential creatinine clearance (diff. %CrCl) is still regarded as a simple and reliable method. Aims: The aim was to evaluate correlation between renal cortical thickness (CT), hydronephrosis, intrapelvic pressure (IPP), PCN output, renal morphological factors such as length, width, echogenicity, corticomedullary differentiation (CMD), status of c/l kidney, and presence of infection which can predict recoverable function. Settings and Design: A prospective study done between July 2013 and June 2014 in Urology Department. Subjects and Methods: Hundred and sixty patients of supravesical obstruction for various causes who need PCN either due to chronic renal failure or nonvisualized kidney on contrast study, were included. IPP was measured during PCN placement. After 4 weeks 24 h urine was sent for CrCl and urine pH. Statistical Analysis Used: Correlation of continuous and categorical variables with dependent variable (diff. %CrCl) was formulated using spearman correlation and Mann–Whitney U test. Simple and multiple linear regression analysis were performed. Results: The study includes 160 patients with median age of 65.5 years. Hydronephrosis were due to stone in 76 (47.5%), pelviureteric junction obstruction (PUJO) in 40 (25%), cancer in 32 (20%), others in 12 cases (7.5%). IPP was <10 cm H₂O in 48 (30%); 10–20 cm H₂O in 64 (40%) and >20 cm H₂O in 48 (30%). There was significant correlation between IPP and diff. %CrCl with correlation coefficient ρ = 0.509 (P = 0.0001). Conclusions: CT, parenchymal echogenicity, CMD, pre-PCN creatinine, and status of c/l kidney are the only independent variables which can predict the renal function while other variables like renal size, urine output, infection, hydronephrosis lost their statistical significance in multivariate analysis. Furthermore, IPP measured before PCN directly correlated with daily urine output and diff. %CrCl.

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Introduction: Emphysematous pyelonephritis (EPN) is associated with high mortality rate, up to 25%. There is still conflicting reports regarding the most appropriate management, conservative versus nephrectomy. Objective: To describe the outcome of patients with EPN. Methods: We retrospectively reviewed the medical records of patients diagnosed with EPN by computed tomography from three tertiary institutes in Jeddah, Saudi Arabia. Type of management was classified as conservative and surgical. The conservative includes medical and minimally invasive procedures, such as percutaneous drainage and nephrostomy. The surgical which is nephrectomy. The outcome observed was preservation of the kidney function or patient's life. Results: A total of 10 patients were included (9 females and 1 male), median age was 55 years and 63% were diabetic. The most common presentation was flank pain (100%), fever (75%), and vomiting (63%). The most common organism isolated was Escherichia coli. Nephrectomy was not associated with increased survival rate, while conservative management was associated with a good outcome, less morbidity (not dialysis-dependent). Conclusion: Nephrectomy was not associated with high survival rate. Patients managed conservatively had a better overall performance and better survival. This study will add to other studies, which are encouraging conservative management.

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Circumcision is an easy commonly performed surgical procedure in childhood. However, it is not free of a low number of complications, (1-5-5%). Here we report a case of a 3-year-old boy with glans superficial necrosis after circumcision, managed with topical (nitroglycerin, gentamicin), oral (pentoxifylline) and epidural (urgent caudal block with bupivacaine) treatment. A review of the literature and the different treatments reported by other authors was done. After 7 days of treatment, local signs of ischemia and severe pain disappeared, without adverse events related to treatment. Although the ischemia or necrosis of the glans after circumcision are rare, we may suspect them in case of presence of severe acute pain or dark color. We report the successful management of this complication.

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Introduction: Currently, (multiple) biopsies are taken to obtain histopathological diagnosis of suspicious lesions of the penile skin. Optical coherence tomography (OCT) provides noninvasive in vivo images from which epidermal layer thickness and attenuation coefficient (μ_oct) can be quantified. We hypothesize that qualitative (image assessment) and quantitative (epidermal layer thickness and attenuation coefficient, μ_oct) analysis of penile skin with OCT is possible and may differentiate benign penile tissue from (pre) malignant penile tissue. Materials and Methods: Optical coherence tomography-imaging was performed prior to punch biopsy in 18 consecutive patients with a suspicious lesion at the outpatient clinic of the NKI-AVL. Qualitative analysis consisted of visual assessment of clear layers and a visible lower border of the lesions, quantitative analysis comprised of determination of the epidermal layer thickness and μ_oct. Results were grouped according to histopathology reports. Results: Qualitative analysis showed a statistically significant difference (P = 0.047) between benign and (pre) malignant lesions. Quantitative analysis showed that epidermal layer thickness and attenuation coefficient was significantly different between benign and (pre) malignant tissue, respectively, P = 0.001 and P < 0.001. Conclusion: In this preliminary study, qualitative and quantitative analysis of OCT-images of suspicious penile lesions shows differences between benign lesions and (pre) malignant lesions. These results encourage further research in a larger study population.

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Objective: The aim was to highlight the advantages and the feasibility of treating ureteral stump syndrome (USS) by different minimally invasive procedures. Materials and Methods: Four patients with USS who were treated by different minimally invasive surgery approaches depending on their presentation and findings on radiologic investigations. Results: Three patients had complete resolution of their symptoms, whereas the fourth patient had persistence of urinary tract infection. Conclusion: Minimally invasive surgery is a valid treatment option for patients with USS with possible less morbidity than conventional open surgical excision.

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Context: Partial nephrectomy is becoming the standard of care in management of small renal tumors and excision of the peritumor fat is recommended for accurate staging. During the surgery, the overlying fat may be excised for accurate visualization of margins or maybe inadvertently left behind when performing a partial nephrectomy in an obese patient. We investigated the prevalence of fat involvement in these patients. Aims: The aim was to document the prevalence of peritumor fat involvement discovered after partial nephrectomy performed for radiologic T1 renal cancer. Settings and Design: Between 2005 and 2011, 107 partial nephrectomy procedures were performed for radiologic T1 disease. Statistical Analysis: All analyses were performed using SAS 9.2. Subjects and Methods: Patients were classified as: Group A (n = 88 patients), patients with stage T1a (tumor size ≤4 cm) and Group B (n = 24 patients) patients with stage T1b (tumor size 4-7 cm). Results: The overall prevalence of peritumor fat involvement was 1.86% (n = 2). The two patients had tumor ≤4 cm in size of the papillary subtype and were followed for 61 and 57 months, respectively. Both were living and without recurrence. Patient demographics and tumor characteristics did not differ between the two groups except, Fuhrman Grades 3 and 4 were statistically more prevalent in Group B (<0.01). Tumor grade, clear cell type cancer and stage T1b did not correlate with peritumor fat involvement in the study population. Conclusions: Our study revealed a low prevalence of peritumor fat involvement in radiologic pT1 renal cancer; however, peritumor fat removal is still recommended.

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Objective: Infected obstructed kidney (IOK) is a urological emergency. We wanted to look at the role of serum inflammatory markers in these patients. Materials and Methods: Patients with IOK requiring percutaneous nephrostomy (PCN) at our university hospital were identified, and data were collected on lymphocyte count, C-reactive protein (CRP) and microbiology results. Results: Thirty-nine patients had PCN for IOK. Lymphocytopenia was seen in two-thirds of these patients. Severe lymphocytopenia was associated with a significant rise in CRP in all cases and following PCN, lymphocytopenia improved in the majority of cases. Conclusions: Lymphocytopenia seems to be associated with the severity of infection and could be a surrogate marker on its own or in conjunction with CRP for initial diagnosis and monitoring response to treatment in patients with IOKs.

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Context: The recent advent of bipolar energy in bladder tumor resection has raised many questions regarding density of current and its effect on histopathology of the resected transurethral resection of bladder tumor (TURBT) chips. Aims: The aim of this study is to evaluate the histomorphological features in resected bladder tumors comparing bipolar versus conventional (monopolar) energy. Settings and Design: Inclusion criteria were patients with primary presentation of carcinoma urinary bladder undergoing TURBT. The patients with prior resections were excluded as these could jeopardize the results of cautery artifacts. Materials and Methods: From February 2010 to December 2011, 61 patients with primary carcinoma bladder and meeting our inclusion criteria were compared. Group 1 (n = 31) underwent bipolar-TURBT (B-TURBT) and Group 2 (n = 30) monopolar-TURBT (M-TURBT). Two pathologists, who were blinded to the form of electrocautery used, examined the resected tissue. The degree of cautery artifact in each specimen was recorded. The severity of the cautery artifact was graded as absent, mild, moderate, or severe. The mean age, tumor size, and resection time were recorded in both groups. Statistical Analysis Used: Data were analyzed using SPSS 16. Data were compared in between groups using paired t-test and Pearson's Chi-square test. The significance level was set at 0.05. Results: The mean age, tumor size, and resection time were similar in between the two groups. The pathologists had no obscurity in reaching a correct diagnosis in all cases. The cautery artifacts were graded as absent in 10 (32.2%) and 8 (26.67%), mild in 12 (38.7%) and 11 (36.67%), moderate in 5 (16.1%) and 7 (23.33%) and severe in 4 (12.9%) and 5 (16.66%) cases, respectively in Group 1 and 2. There was no statistically significant histomorphogical dissimilarity between specimens according to the type of cautery used. Conclusions: Bladder tissue obtained from B-TURBT is of equivalent histomorphological feature as that of standard M-TURBT.

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Mucinous cystadenoma of the urinary bladder is a very rare tumor and only a handful of cases have been described in the literature. It can easily be missed on cystoscopic examination as the lesion is not intramucosal. In addition, extensive workup is required to rule out borderline or frank malignant neoplasm elsewhere in the body. Due to its scarcity and diagnostic challenges, we report a mucinous benign cystic lesion arising in the dome of the urinary bladder.

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Testicular plasmacytoma, whether occurring as a primary lesion or as a reflection of underlying multiple myeloma (MM), is a rare disease. We report the case of a 38-year-old male with multiply relapsed MM, who was found to have a testicular plasmacytoma. He presented with a gradually enlarging scrotal mass. Following orchidectomy, pathologic examination of the specimen demonstrated a plasmacytoma. In the context of active MM, the specimen was also sent for cytogenetic analysis but this was unhelpful in guiding a chemotherapy regime, which still continues at time of reporting. Although a rare lesion, there remains no definitive treatment protocol for the management of testicular plasmacytoma representing an extramedullary manifestation of MM.

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Objective: The aim was to determine the prognostic ability of Partin's tables for a patient collective undergoing radical prostatectomy (RP) and to evaluate the association of prostate-specific antigen (PSA) density (PSAD) and postoperative lymph node status. Methods: From 1999 to 2006, 393 consecutive patients underwent RP at our Urology department. Patients with Gleason scores <6, clinical stages >T2c or neoadjuvant hormonal therapy were excluded. Preoperative PSA, biopsy results, digital rectal examination, and prostate size at transrectal ultrasound were recorded. Risk stratification according to the Partin scoring system was performed. Postoperative results were compared with preoperative risk estimation. Univariate and multivariate statistical analysis about prediction of postoperative lymph node status was performed. Results: Lymph node invasion (LNI) was found in 36 patients (9.16%). Kendall's rank correlation analysis revealed a significant association between the number of removed LN and LNI (P = 0.016). Patients with LNI had a significantly higher preoperative PSA and PSAD. Preoperative Gleason score was a significant predictor of LNI. The Partin tables' prediction of organ confined stages, extraprostatic extension, and seminal vesicle invasion was in line with the pathological findings in our collective. PSAD was a significant predictor of LNI in univariate and multivariate analysis. Conclusion: The most widely used nomogram is of high value in therapy decision-making, although it remains an auxiliary means. Considering the performance of lymph node dissection, surgeons should be aware of the specifics of the applied nomogram. PSAD appears as a useful adjunctive parameter for preoperative prostate risk estimation and warrants further evaluation.

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Objective: To prospectively study and identify, the preoperative factors which predict intraoperative difficulty in laparoscopic transperitoneal simple nephrectomy. Patients and Method: Seventy seven patients (41 males and 36 females) with mean age of 43 ± 17 years, undergoing transperitoneal laparoscopic simple nephrectomy at our institute between February 2012 to May 2013 were included in this study. Preoperative patients' characteristics recorded were: Gender of patients, history of intervention, palpable lump, BMI, urine culture, side, size of kidney, fixity of kidney on USG, perinephric fat stranding on preoperative CT scan, periureteral fat stranding, perinephric collection, enlarged hilar lymph nodes, renal vascular anomalies, differential renal function on renogram. Preoperative factors of these patients were noted and intraoperative difficulty in the surgery was scored between 1 (easiest) to 10 (most difficult or open conversion) by a single surgeon (who was a part of all studies either as operating surgeon or assistant). Using SPSS 15.0 software, multivariate and univariate analysis was done. Results: In multivariate analysis presence of pyonephrosis on preoperative evaluation and BMI < 25kg/m² were found to be statistically significant factors predicting intraoperative difficulty during laparoscopic simple nephrectomy.On univariate analysis following factors were associated with increased surgeon's score: Lower BMI, palpable kidney, pyonephrosis, history of renal intervention, perinephric fat stranding, right side, fixity of kidney on USG with surrounding structures. Conclusion: Our findings suggest that presence of pyonephrosis as identified on preoperative imaging and a BMI of less than 25 Kg/m² are the most significant factors predicting intraoperative difficulty during laparoscopic simple nephrectomy.

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Leiomyoma of the urinary bladder is a very rare entity and represents <0.5% of all bladder tumours, with only 250 cases reported worldwide to date. We report a case of leiomyoma of the bladder 55 -year-old female presented with chief complaints lower abdomen pain since 1 year associated with intermittency, burning, frequency and hesitancy in micturation. Bimanual examination of the patient revealed a mass on the right side near the bladder neck. USG suggested a well circumscribed polypoidal soft tissue lesion seen projecting in urinary bladder lumen and attached to the posterior wall and base of bladder with no internal vascularity. On cystoscopic examination, large smooth sessile growth arising from the right postero-lateral wall was noted with right ureteric orifice not visualized. Magnetic resonance imaging showed Large well defined rounded soft tisssue lesion close to anterior surface of the cervix and vagina which was Isointense to the skeletal muscles on T1 and T2 images with small focal irregular cystic areas of necrosis seen. It could be urinary bladder neoplasm or sub serosal cervical fibroid. Transurethral resection of tumor was performed. The pathologic diagnosis was leiomyoma of the bladder. We discuss the diagnosis and management of leiomyoma of the bladder and briefly review the literature.

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Bilateral cryptorchidism is a rare occurrence and seminoma is the most common germ cell tumor found in undescended testes when they occur. We present the case of a patient with bilateral cryptorchidism who presented to our trauma center after a motor vehicle collision and was found incidentally to have a 17-cm intra-abdominal mass. The mass was subsequently biopsied and proven to be seminoma. The patient completed three cycles of bleomycin/etoposide/cisplatin chemotherapy and successfully underwent a postchemo retroperitoneal lymph node dissection with no viable residual tumor or positive lymph nodes found in the surgical specimen. He also had an orchiopexy of the contralateral testicle. The patient recovered fully and has been found to be recurrence-free four months postoperatively. We highlight the importance of cisplatin-based chemotherapy and extensive tumor resection as the mainstay of initial cancer control.

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Emphysematous pyelonephritis is fatal necrotizing infection where life saving emergency nephrectomy is recommended for severe cases, but we performed nephron sparing surgery. Elderly diabetic female presented with left flank pain and fever for 15 days. On examination tender lump was palpable in left lumbar region. Investigations showed hyperglycemia, leucocytosis and creatinine 3.0 mg/dl. NCCT-KUB suggested class 3B-EPN. Following emergency pigtail, a repeat CT-scan suggested upper and lower pole destruction. In open drainage both poles debrided with sparing of middle pole. Follow-up CECT-KUB showed spared kidney with normal function. No literature for nephron sparing surgery in similar cases of EPN was found.

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A 44-year-old female presented to the urology clinic with flank pain and tenderness. After full assessment, the patient was booked for surgery for partial nephrectomy and the patient was diagnosed with renal cell carcinoma (RCC) chromophob type. Six months later, the patient came back for follow-up; a mass was detected on the same kidney. Radical nephrectomy was performed to excise what is thought to be a recurrence of RCC and the tissues were sent to pathology. The postoperative pathology report confirmed the presence of xanthogranulomatous pyelonephritis rather than RCC recurrence.

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We present the first case of a nonmetastasizing renal cell carcinoma (RCC) masquerading as an adrenal mass, in the presence of normal bilateral native kidneys, in a young adult. The possibility of this mass developing in a supernumerary kidney was ruled out, since no identifiable renal tissue, pelvis or ureters was seen within the mass, nor was any separate systemic arterial supply to the mass seen. The diagnosis of extra-renal clear cell RCC was based on cyto-morphological features, further confirmed by immunohistochemistry findings. The origin of this extra-renal clear cell renal cell is proposed to be from the mesodermal embryonic rests.

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Persistent Müllerian duct syndrome is a rare genetic disorder characterized by a male with retained Müllerian structures. Remnant excision must be considered due to the possibility of malignant degeneration. We review a case of delayed diagnosis in a 25-year-old man presenting with hematuria. Preoperative counseling must emphasize the risk of malignancy versus the risks to fertility. The da Vinci robot offers a novel, safe approach for excision of the relevant Müllerian structures. Dissection should be limited to structures superior to the cavernosal neurovascular bundles to preserve the continence and erectile function. A semen analysis is recommended preoperatively to determine effects on fertility.

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Introduction: Although there are many literature examining the possible effects of varicocelectomy on classic semen parameters and recurrence rate, few published articles have examined the effect of conventional laparoscopic varicocelectomy on sperm DNA integrity. Objectives: The objective was to evaluate the effect of extensive laparoscopic venous disconnections on the recurrence rate and sperm DNA damage in varicocele patients. Methods: Totally, 54 patients with varicocele underwent extensive laparoscopic venous disconnections were assessed by clinical evaluation, duplex scan, semen analysis, and sperm DNA fragmentation assay before surgery and after 6 and 12 months following surgery. Results: No intra- or post-operative complications were observed and out of 54 patients preoperatively complained from varicocele 2 (3.7%) patients' have recurrence during the follow-up period for 12 months. Out of 54 patients complaining from male infertility, 14 patients success to get pregnancy after 6 months with pregnancy rates of 25.92% and 22 (40.74%) after 12 months, and 28 patients (51.85%) had a preoperative DNA fragmentation index (DFI) >30%, decreased following surgery below 30% in 19 (35.18%) patients after 6 months, and 11 (20.37%) after 12 months, and the percentage of sperm with DFI > 30% was significantly decreased after 6 and 12 months, respectively (38.4 ± 10.6 vs. 31.3 ± 12.4, [P < 0.001] at 6 months, and 22.9 ± 13.2, [P < 0.001] after 1-year). Other spermatic parameter was significantly improved. Conclusions: An extensive laparoscopic venous disconnection was significantly decreasing the recurrence rate, DFI and improving normal semen parameters and fertility.

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Bladder cancers are the second most common urogenital malignancy, its most common type being urothelial carcinoma. Lymphoepithelioma-like carcinoma (LELC) which is commonly described in the nasopharynx is a very rare presentation in the bladder. Diagnosis of this entity poses a histopathological challenge. Nonetheless, the correct diagnosis is important as it implies a different therapeutic approach with the potential bladder salvage treatment protocol. We here present a case of an 87-year-old man, who was diagnosed as LELC. To the best of our knowledge, this is the first case of LELC reported from India in English literature.

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