Post-enterocystoplasty massive bleeding because of Arteriovenous malformation from bowel arteries : A very Rare Case

A 65 year old man presented to us with frank hematuria of 1 day duration. he was known case of small capacity bladder with hemorrhagic cystitis with no apparent reason.He was operated in 2002 for clam cystoplasty. He was apparently alright for 8 years just to land up in emergency department with gross total hematuria.He is known case coronary artery disease and hypertension on medication.He was on ecosprin when he came for hematuria.Immediately ecosprin was stopped.He was supported with irrigation,tranexa and cystoscopy and evacuation followed by alum irrigation.After this surgery he was fine for 2 days then suddenly he had bout of frank hemturia causing fall of Hb from 13 TO 10 GM% and BP to fall from 130/80 mm Hg to 70/30 mmHg.He was immediate taken up for cystoscopy and clot evacuation again with institution of proper blood support and plasma expander support.The bladder base region had angry looking globular mass? Rest of the bladder mucosa and the intestinal mucosa was normal.The clots were removed with resectoscope and cautery and ellicke evacuator.A three way Foleys catheter was introduced wnd alum irrigation was started..The urine effluent was clear.AFTER THE CLOT EVACUATION WAS DONE BILATERAL ANGIOEMBOLISATION WAS CARRIED OUT SELECTIVELY ON ANTERIOR DIVISION OF INTERNAL ILIAC ARTER USING SELDINGERS TECHNIQUE.

The both iliac arteries anterior divison was blocked with gel foam mixture viscous with the contrast,

The process of Angioembolisation of the internal iliac artery --the end result of the embolisation is seen as the disapperance of the terminal branches of the vesical arteries.The next plan was if the patient bleeds again then abdominal exploration.The patient again bleede after 5 days; again the bleed was torrential causing drop in hematocrit.

The patient was taken up for CT Angiography which showed a big arteriovenous malformation on the dome of the bladder feeded by superior mesenteric arteries.

the mesenteric artery being very crucial one the angioembolisation of it was not taken into consideration thinking of the sequele of catastrophe of mistaken blockage of main trunks.


The exploratotry laparotomy was performed.The adhesiolysis was performed.The dome of the bladder was thickened with multiple serpigenious vessels .This part of the bladder was excised and bladder was closed with Suprapubic tube in situ.

The abdomen was closed in layers with drain in pelvis.The post-operative period was uneventful with no episode of hematuria till 3 weeks post-operatively.

Free camp update

First date of the Free Consultation camp for Male Infertility and Prostatic problems in general population was a great success with 78 patients visiting the Hospital and checked by the experts here.They got investigations at subsidised rates and medications for 15 days free of the cost.
Dr Ramesh Ramayya(CEO and Chairperson),Dr Vishwabhar Nath(Clinical Director),Dr Naveenchandra Acharya(Consultant Urologist),Dr Mahesh Sable(Medical Superitendent) supervised and managed the camp activities.

Press Conference by Dr Ramayyas Urology and Nephrology Hospital

Dr Ramayyas Hospital arranged a press conference to spread awareness about the forthcoming health camp about male infertility and prostate problems in people.

Dr Vishwanbhar Nath(Clinical Director of Dr Ramayyas Hospital) and Dr Naveenchandra Acharya(Urologist and Andrologist)briefed about the male infertility and prostate issues to the conference.

The camp will be held at the Dr Ramayyas Hospital premises on 26 and 27 Th June from 10-4 pm.

Mitomycin C for prevention of bladder tumor recurrence

A 30 year old lady presented with history of hematuria and dysuria. There was no history of comorbidities.

There was no history of prior surgical intervention .

On evaluation her USG showed left lateral wall space occupying lesion 3x2 cm and positive urine cytology for malignancy.

She was taken up for Trans-Urethal Bladder tumor resection with Continuous wave Holmium Laser.The Mitomycin C is a 334-kD alkylating agent that inhibits DNA synthesis. The drug is usually instilled weekly for 6 to 8 weeks at dose ranges from 20 to 60 mg.
One review found a 38% reduction in tumor recurrence with MMC.
Optimization of MMC delivery can result in halving of the recurrence rate in some studies. This can be achieved by eliminating residual urine volume, overnight fasting, using sodium bicarbonate to reduce drug degradation, and increasing concentration to 40 mg in 20 mL.

Check up camp for rnlarged prostate and male infertility

We have arranged camp at Dr Ramayyas Urology and Nephrology Institute and Pramila Hospitals under patronage of Dr Ramesh Ramayya CE and chairman and able guidance of Dr Vishwambhar Nath.It will be kept on two days 26 and 27 th June 2010 from 10 am to 4 pm at the premises of the hospital.The patient can undergo tests worth 2500/- just for 700/- and free medications worth 15 days given.

Following symptoms - poor urine flow,urgency,frequency,night time frequent urinations,burning micturition,blood in the urine,prostate cancer and male infertility.The ejaculation problems will also be assessed and accordingly managed.

Dr Vishwambhar Nath(Clinical Director of the Hospital), Dr Naveenchandra Acharya(Andrologist) and Dr Mahesh Sable(Medical Superitendent) will be rendering their valuable services during the camp.

Post Papavarine Priapism

A 28 year old patient came to us with priapism post papavarine induced for penile Doppler test.He presented to us five hours after the test.

On examination there was pain and considerable rigidity.

The patient was taken up for corporal drainage and instilllation of phenylephrine(1 ml PE in 19 ml Normal Saline).The corporal drainage was done with 21 G Vasofix and when dark blood was initially drained.When bright reddish blood started coming out PE was instilled.The final outcome was good, complete flaccidity was achieved.

The patient was kept on alprazolam and ketoconazole for 2 weeks to prevent erection.

Hypospadias repair

A 10 year old man came with aberrhant opening of the urethra and chordee and small penis.

There were no other developmental anamolies.The testes were normally descended.

On examination there was distal penile hypospadias and chordee.

He was taken up for final single stage repair-after skin degloving the chordee was partially got corrected(this was tested by instilling saline in corpora through the glans).The urethra after degloving fell more proximally.

Tunica albugenia plication was done on lateral side then the chordee was totally corrected.The Tubularised Incised Plate Urethroplasty was done over silicon 10 Fr Foleys catheter.The dartos was used as covering flap and Byars flap was used to place skin coverage.

A 12 Fr Foleys catheter was kept as Supra-pubic tube.

Radical Cystoprostatectomy for bladder tumor

A 60 year old man came to us with hematuria and lower urinary tract symptoms.On evaluation ultrasound revealed a space occupying lesion in bladder which was further evaluated with contrast enhanced CT scan.The CT scan showed huge bladder mass filling the almost bladder with left posterior and lateral wall thickening and the perivesical stranding.There were no obvious lymphadenopathy.

His metastatic work up was normal.He had no comorbidities except diabetes.He was taken up for Trans-urethral Bladder Biopsy which revealed Papillary Urothelial Neoplasm of Low Malignant Potential .As the growth was endoscopically unresectable there was high chance of muscle invasive element;the patient was counselled and taken up for Radical cystectomy and bilateral iliac lympahdenectomy and ileal conduit.The uretero-ileal anastomosis was done with Wallace technique.

Boari Flap reconstruction for upper ureteric stricture

21 year old patient came to us with history of having been operated outside for ? twisted ovarian cyst. The laparoscopy was abandoned because contrary to their expectations they found retroperitoneal mass on the right side of the retroperitoneum.She came to us with a post-operative contrast enhanced CT Scan which revealed urinoma near middle of the right ureter

.

The urinoma was encapsulated in thick capsule (? Chronic process).On clinical examination she was looking ill and frail. She had loose motions(? Pelvic collection induced).Her vitals though were maintained except for tachycardia.She had normal hematological and biochemical parameters. Her abdomen was mildly distended with urinary leakage through one of the ports.She was taken up for Retrograde Pyelography which showed mid-ureteric disruption and dye leaking into a diffuse cavity.The patient was made prone for percutaneous nephrostomy drainage.Right Percutaneous Drainage was performed through a midcalyceal approach for possible antegrade stenting sometimes in future.She started draining around 100 ml of urine per hour through the nephrostomy and her leakage of urine through the port and the abdominal distension subsided.Her loose motions also subsided The very next day she started looking fresh and was back to her normal routine.She was called after a period of 6 weeks thinking that this time is enough for urinoma would subside and the inflammatory reaction would also subside.

She was taken up for laparotomy.A midline infra-umbilical incisiwas given .The bladder was capacious.
The ureter could be traced only till mid part.After that there was a massive fibrosis.The ureter was disconnected there and Boaris flap was raised from the bladder was anastomosed to the upper ureter after adequate spatulation.

The surgery was concluded with putting a stent in neo-ureter and supra-pubic tube in bladder.

Surgery for erectile dysfunction

Surgery
Surgery usually has one of three goals:
to implant a device that can cause the penis to become erect (Penile Implant surgery)
to reconstruct arteries to increase flow of blood to the penis (Penile revascularization surgery for patient with focal arterial stenosis-post-trauma)
to block off veins that allow blood to leak from the penile tissues (penile venous leak-particularly detected on Doppler showing persistence end-diastolic velocity more than 5 cm/sec)
Implanted devices, known as prostheses, can restore erection in many men with ED. Possible problems with implants include mechanical breakdown and infection, although mechanical problems have diminished in recent years because of introduction of Viagra but there are a group of patients who fail with medications and refuse or fail with Vacuum Erection Device. Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis. They also leave the penis in a more natural state when not inflated.
Advantages with the penile impants are:
o Good rigidity
o Freedom from medications
o Outpatient/24HR surgery
o Resume sexual activity 4-6 weeks
o No loss of ability to ejaculate or achieve orgasm

Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to perineum or fracture of the pelvis.Surgery to veins that allow blood to leave the penis usually involves an opposite procedure-intentional blockage. Blocking off veins (ligation) can reduce the leakage of blood that diminishes the rigidity of the penis during erection. However the results are not long lasting so the venous ligation surgery have diminished

Testosterone undeconoate depot:better dosing conveniece

We had one gentleman 56 year old complaining of loss of libido and decreased erection. He also complained about irritative mood and lack of enthusiasm. He was investigated and found to have a low testosterone level(230 ng/dl.)

He was started on testosterone local gel to be applied daily on his shoulder and after a period of 2 weeks; he underwent total and free serum testosterone assay again which was disappointedly low ( 268 ng/dl).

His erection had improved but not strong enough for penetration.He was also taking PDE-5 inhibitors along with hormone replacement.
He was now started on Testosterone undeconoate Depot 1000 mg/4ml deep intramuscularly as some patients have erratic absorption from local application.
The depot preparation would suit many patients as the injections can be placed at a wider intervals.For example we have scheduled the depot injection on 0,6th,18 th and 30 th weeks with Serum PSA and Complete Blood Parameters to be done on 18 th and 30 th weeks.
So there is convenience of administration as well 3-5 times lesser injections to achieve the sufficient testosterone in hypogonadal men.