Forgotten ureteric stent:Avoidable condition

In urology stents have a special place.In almost all cases pertaining to endourology; stent placement is usually assorted to.The stent less surgery is gaining momentum but majority of the urologist including the ones in our centre are very comfortable with stented surgery.The stents have its own complications like stent related pain,dysuria,UTI etc in the immediate post-operative period.But if the stent is kept inadvertently for longer period then stent encrustation,stone formation,stent fragmentation can alos occur.Most of the cases the forgotten stent is due to poor compliance.But still the treating urologist needs to be proactive in pursuing such cases.Stent registry is a good concept as it is practically impossible to follow up each and every patient without systematic dedicated registry services.

Forgotten stents are dealt on the merit of each case.The intervention can be open surgery,URS,PCNL,Cystolithotripsy superadded with the ESWL.With the advent of LASER; almost all the cases can be dealt with endourology.

A 47 year old patient came to us with prior history of stone disease treated with ESWL and stenting 4 years back.She was suffering from recurrent UTIs.She was investigated and we saw a forgotten stent with stone formation at the both ends.She is planned for LASER cystolithotripsy and LASER URS and stent retrieval from below after cutting it at the level of the pelvi-ureteric junction.Then followed by PCNL for the partial staghorn calculus formed at the upper end of the calculus.

GENITO-URINARY TRACT TUBERCULOSIS

A 38 year old lady presented to us with lower urinary tract symptoms and right flank pain for 15 days.She had history of undergoing left nephrectomy in 2002.The histopathological evaluation had shown granulomatous nephritis.After the surgery; she was advsied scrupulous follow-up but she could not regularly visit the surgeon.On presentation to our hospital; she had deranged creatinine(2.7 mg%) with sonographic evidence of right moderate hydroureteronephrosis.Non contrast CT scan evaluation confirmed the sonographic findings.She was taken up for retrograde pyelography and stenting.The findings on RGP were hydroureteronephrosis with a stricture at pelvi-ureteric junction.The bladder capacity was small around 90 ml.She was subjected to bladder biopsy.

GUTB: A REVIEW
Genitourinary tuberculosis is hematogeneous infection of the kidneys. The kidney being a primary organ the rest of the organs are affected by direct extension. The disease progression depends upon the host immune response.
The urologist many a times consider the GUTB as the diagnosis of exclusion. Any longstanding lower urinary tract symptoms with obvious cause detected makes the urologist suspicious about the disease.
Recurrent UTIs, frequency, dysuria, painless hematuria, painful ejaculation, anejaculation etc are the predominant symptoms.
Pathology: Tuberculosis results in development of Caseating granulomas - Langhans giant cells surrounded by lymphocytes and fibroblasts. The course of the infection depends on the virulence of the organism and the resistance of the host.
The healing process results in fibrous tissue and calcium salts being deposited, producing the classic calcified lesion. The disease because of fibrotic/calcific nature results in development of strictures,deformed calyces,small capacity bladder(so called thimble bladder).The irony of the treatment is that the starting of the antiKochs medications results in further fibrosis.This can lead to further narrowing of the strictures and / or further decrease in bladder capacity.
We therefore usually add steroids in initial management to prevent further compromise of the renal functions.
In the present case the disease had already taken a toll of left kidney.(hematogeneous route).The rest of the disease was probably because of direct extension( small bladder capacity and multiple ureteric strictures).
The treatment in our case was –stenting to safeguard the kidney function by stenting,bladder biopsy for getting final histopathological proof.The next strategy would be starting her on AKT and steroids and keep stent for 3-6 months period.Any recurrent stricture/persistence of thimbe bladder would need specific surgery.

Recurrent ovarian cyst causing left ureteric obstruction

A 40 year old lady presented with history of left flank pain of 15 days duration.There was recent exaggeration of the pain intensity.There was no history of fever,dysuria and lower urinary tract symptoms.She gave history of having been operated for ovarian cyst 3 months back.The histopathological report of the cyst was benign.

The biochemical and hematological parameters were normal.CA-125 antigen assay was also normal.The urine analysis didnot reveal any abnormality.The USG abdomen showed left hydroureteronephrosis with cyst in pelvis.The ureter could be traced only to the cyst region.She was subjected to Contrast Enhance CT scan which showed cyst compressing the ureter causing hydroureteronephrosis.

She underwent RGP and DJ stenting followed by aspiration of the cyst under USG guidance.The cytology of the aspirated cyst was essentially normal.Two weeks post-operatively the patient is doing well.We have planned a repeat CT scan after a period of 6 weeks and decide further management.Any recurrence of the cyst would then need laparotomy with cyst removal.

Complication after ileal conduit done for urinary diversion post radical cystectomy

A 65-year-old lady underwent radical cystectomy for TCC bladder 1 year back.The surgery was uneventful.The mode of diversion was ileal conduit.The post-operative histopathology read as TCC T2N0.In the post-operative follow up she had recurrent UTIs and at the end of 1 year post-op her creatinine was around 2.3 mg%.

The imaging showed no local or systemic recurrence and the upper tracts showed changes of hydroureteronephrosis.The EC scan done to reveal the pattern of drainage didnot reveal any prolonged stagnation above uretero-ileal junction.During one such episode of UTI;we decided to put the catheter in the conduit for better drainage and then we realised that there was difficulty in catheterisation because of kinking at parietes.

We perfomed dynamic contrast study under fluoroscopic guidance; it showed adequate draiange.

With every episode of UTI she usually used to get elevated RFTs and the same used to settle down after the institution of the antibiotics and the conduit catheterisation.

We revised the stoma and the conduit was released from the parietes thinking that that would relieve the blockage but it didnot.After the stomal revision also she landed up again in UTI.

We went ahead and did percutaneous nephrostomy for her on both sides for the raised creatinine and the urosepsis.After the PCN her came down and got stabilised at 1.8 mg% and also she was free from UTI for 2 months period.The patient is still on bilateral indwelling PCNs and we are planning to go ahead with nephrostogram.If the nephrostomgram reveals any stagnation then the revision of the uretro-ileal junction will be needed.

The case was brought up here to discuss the long term complication of ileal conduit.The deterioration of kidney function,recurrent urosepsis,stomal complications are possible complications of ileal conduit diversion.

RIRS: Retrograde Intra-renal Surgery ensures complete clearance of renal stone

In this case stenting and ESWL had left one residual fragment in the renal pelvis.



OUR RIRS URETEROSCOPE
In our hospitals;we routinely prestent the patient during ESWL. The reasons being two; one that stenting facilitates the passage of calculus fragments and at the same time safeguards kidney from any obstructive complications. Secondly in the event if the ESWL fails then RIRS during the stent removal can ensure complete clearance.RIRS in presented patient is comparatively easier task as the ureter is dilated and placement of ureteric access sheath becomes easier task.
Review of literature:
In RIRS; a fibre-optic tube is inserted through the urethral meatus into the kidney after passing it through bladder and the ureter. The stone is visualized and is thereafter evaporated by a laser probe. We have a 20 W Holmium LASER(Sphinx). The procedure is usually done under general or spinal anesthesia. Retrograde Intrarenal Surgery (RIRS) allows the surgeon to do surgery inside the kidney without making an incision/ and hole on the body.
The indications for RIRS include:
· Failed previous treatment attempts of ESWL
· Strictures
· Tumors
· Stones in children
· Patients with bleeding disorders
· Patients with gross obesity/KYPHOSCOLIOSIS etc

We combine the two modalities of ESWL and RIRS routinely in all patients and give 100% success rate after the procedure for all patients. The combination of these modalities ensure elimination of the need for more invasive procedures like PCNL.This is a special boon for patients having physical deformities like obesity or kyphosis.

palliative radical nephrectomy:Metastatic Renal cell Carcinoma

A 75-year-old gentleman came to us after he was diagnosed to be having left renal mass.He initially had back pain for which he consulted spine surgeon.After initial conservative therapy failed;he was subjected to MRI spine.MRI revealed metastatic foci in dorsolumbar vertebrae.

His staging work up revealed enhancing midpolar mass in left kidney.The mass appeared to be confined to the kidney only although there was ipsilateral psoas thickening.It also revealed basal metastatic lung lesions.We came to conclusion of metastatic renal cell carcinoma.

As the patient had a good performance index and preserved biochemical and hematological parameters he was advised palliative nephrectomy.

The open radical nephrectomy was performed ; the post-operative course was uneventful.The final Histopathology read as Renal cell Carcinoma -Furhmann Grade 3 with T3 stage.

He is planned for Sunitinib therapy.(Sutent 50 mg cap/day ) along with possible radiation to the spine if needed.

REVIEW OF LITERATURE:

Renal cell carcimoma (RCC) is the third most common genitourinary cancer after prostate and bladder. Majority (80% to 85%) of kidney tumors are malignant. It is the most lethal malignancy of all urological cancers.Unique characteristics of RCC lack of early warning signs,§ diverse clinical§ manifestations, resistance to radiation and chemotherapy, and immunogenic nature and spontaneous regressions.

Pretreatment features associated with shorter survival

There are various studies identifying the pretreatment factors associated with poor survival. These are – Low Karnofsky performance status (< 80%)– High lactate dehydrogenase level (> 1.5 x normal)– Low hemoglobin level– High serum calcium– Absence of nephrectomy• Nephrectomy and resection of metastases has been reported to prolong the survival. Effect is enhanced with long disease-free interval between initial nephrectomy and development of metastases.

Survival also depends on the site of metastasis. Patients with lung metastasis only have better survival than those with other site metastasis. (Flanigan RC, et al. N Engl J Med. 2001; 345: 1655-1659.)

Available treatment modalitiesOptions for chemotherapy and endocrine-based approaches are limited, and no hormonal or chemotherapeutic regimen is accepted as a standard of care. Therefore, various biologic therapies have been evaluated. New agents, such as sorafenib and sunitinib, having anti-angiogenic effects through targeting multiple receptor kinases, and have been investigated in patients failing immunotherapy.

Role of Surgery Palliative nephrectomy should be considered in patients with metastatic disease for alleviation of symptoms such as pain, hemorrhage, malaise. Several randomized studies are now showing improved overall survival in patients presenting with metastatic kidney cancer who have nephrectomy followed by either interferon or IL-2. If the patient has good physiological status, then nephrectomy should be performed prior to immunotherapy. There are anecdotal reports documenting regression of metastatic renal cell carcinoma after removal of the primary tumor but adjuvant nephrectomy is not recommended for inducing spontaneous regression; rather, it is performed to decrease symptoms or to decrease tumor burden for subsequent therapy in carefully controlled environments. About 25-30% of patients have metastatic disease at diagnosis, and fewer than 5% have solitary metastasis. Surgical resection is recommended in selected patients with metastatic renal carcinoma. This procedure may not be curative in all patients but may produce some long-term survivors. The possibility of disease-free survival increases after resection of primary tumor and isolated metastasis excision.

RADIATION THERAPY:Radiation therapy may be considered as the primary therapy for palliation in patients whose clinical condition precludes surgery, either because of extensive disease or poor overall condition. A dose of 4500 centigray (cGy) is delivered, with consideration of a boost up to 5500 cGy. Preoperative radiation therapy has not been found to yield any survival advantage. Controversies exist concerning postoperative radiation therapy, but it may be considered in patients with peri-nephric fat extension, adrenal invasion, or involved margins. A dose of 4500 cGy is delivered, with consideration of a boost. Palliative radiation therapy often is used for local or symptomatic metastatic disease, such as painful osseous lesions or brain metastasis, to halt potential neurological progression. Surgery also should be considered for solitary brain or spine lesions, followed by postoperative radiotherapy. Stereotactic radiosurgery is more effective than surgical extirpation for local control and can be performed on multiple lesions.

Multi-kinase inhibitors:

Sunitinib (Sutent) Sunitinib is another multi-kinase inhibitor approved by the FDA in January 2006 for the treatment of metastatic kidney cancer that has progressed after a trial of immunotherapy. The approval was based on the high response rate (40% partial responses) and a median time to progression of 8.7 months and an overall survival of 16.4 months. The receptor .b and atyrosine kinases inhibited by sunitinib include VEGFR 1-3 and PDGFR Major toxicities (grade II or higher) include fatigue (38%), diarrhea (24%), nausea (19%), dyspepsia (16%), stomatitis (19%), and decline in cardiac ejection fraction (11%). Dermatitis occurred in 8%, and hypertension occurred in 5% of patients. A recent phase 3 study evaluating sunitinib in the first-line setting, , in patients with metastatic RCC demonstrated significantacompared against IFN- improvement in PFS and response rates compared against the control arm. These results are considered to be preliminary, and longer-term follow-up is necessary for conclusive results.Other multi-kinase inhibitors undergoing investigation for RCC Lapatinib is an EGFR and ErbB-2 dual tyrosine kinase inhibitor, which appears to have efficacy in the treatment of tumors, including RCC, which overexpress EGFR. This was recently reported in a phase 3 study in advanced RCC evaluating lapatinib against hormonal therapy in patients who had failed prior therapy.RAD001 (Everolimus) is a serine-threonine kinase inhibitor of mTOR, an important regulatory protein in cell signaling. A recent phase 2 trial in patients with metastatic RCC demonstrated promising preliminary clinical results

MATHIEU REPAIR FOR HYPOSPADIAS CRIPPLE

LOUPE ASSISTED HYPOSPADIAS REPAIR

We did Mathieu repair for hypospadias cripple who had undergone four repairs for proximal hypospadias.As the local flaps on the dorsum(TPIF) and lateral based flap were unavailable the permeatal flap was raised and the repair was done satisfactorily.

Gross prostatomegaly with seminal vesicle hematoma presenting as acute retention of urine

MORCELLATED PROSTATIC CHIPS


MRI SHOWING PROSTATOMEGALY WITH GROSS SEMINAL VESICLE DILATATION WITH MASS WITHIN

A 65 year old gentleman came with acute retention of urine.He was catheterised with 18 Fr Foleys catheter; around 1.2 litres of urine drained out.His imaging showed gross prostatomegaly with seminal vesicle dilatation and mass in the seminal vesicle.He further underwent MRI pelvis which demonstrated prostatomegaly with seminal vesicular cyst and hematoma/mass inside.His PSA value was normal and his previous TURPs(he underwent two TURPswithin a span of 2 years for acute retention of urine).The Histopathological analysis showed benign prostatomegaly only.He was taken up for laser prostatectomy and was planned for review imaging after 3 weks for seminal vesicular hematoma/mass.The catheter was removed on second day post-operatively and he passed urine in good stream with low residual urine volume.His histopathological analysis was again benign.In the post-operative period he presented with seconary bleeding on 7 Th day; so was taken up for cystoscopy and clot evacuation.There was organised clot in the prostatic fossa measuring around 6X6 cm.The mass had to be morcellated with the morcellator.After the procedure he was comfortable with clear urine.He was given catheter free trial two days later and passed urine freely.Review Imaging showed no seminal vesicular mass/dilatation.The prostatic mass was probably decompressed seminal vesicular hematoma which probably would have resulted in resolution of seminal vesicular dilatation.

LAPAROSCOPIC RADICAL NEPHRECTOMY FOR EXOPHYTIC MIDPOLAR RENAL MASSA

A 70-year old gentleman came with incidentally detected right renal mass( on USG scan done for urinary retention).He was investigated with staging work up including triphasic CT Scan which revealed enhancing mass around 5 cm in midpolar region with both exophytic and endophytic component.

After explaining to the patient the options of both laparoscopic partial nephrectomy and radical nephrectomy he opted for laparoscopic radical nephrectomy.

Laparoscopic surgery was done with 5 port approach and the specimen was removed by a small right iliac fossa incision.