Laparoscopic partial cystectomy for the urachal cyst

A 25 year old lady was diagnosed to be a case of urachal cyst after cystoscopic biopsy.The mass was cystic situtaed on left dome of the bladder.She was taken up for laparoscopic surgery.The mass along with adjacent detrusor muscle(detrusor myectomy) with urachal ligament were taken down and removed in toto.The patient is doing well and polanned for discharge on 3rd post-operative period.

Retrocaval ureter: a rare anamoly presenting with pain

A 23 year old patient presented with pain in right flank on and off for more than 3 months duration.He was investigated with ultrasound of KUB region which revealed right sided moderate hydronephrosis with prominent upper ureter.He underwent IVP which showed right moderate hydronephrosis with kinked upper ureter.He was taken up for CT scan for further demonstration of the anamoly which showed retrocaval ureter.The DTPA scan revealed left obstructed system.The patient is planned for laparoscopic uretero-ureterostomy.

PCNL in a partial staghorn calculus

A 50 year lady was taken up for PCNL for left partial staghorn calculus.She was a diabetic patient and had a obese body predisposition.


She was taken up for PCNL ; with two punctures one in mid-posterior calyx and the other one in the lower anterior calyx.Near complete clerance was given The plan is to perform a secondary RIRS after a period of 3 weeks for any residula calculi.

PCNL in a complete staghorn calculus

A 40 year old lady presented to us with flank pain on left side on and off for a period of 6 months.On investigations she was found to have calculus -a complete staghorn variety in the left renal pelvis.
She was taken up for PCNL.A total of 4 punctures in different calyces had to be made.The surgery was carried out in 3 sessions.At the end we could give a complete endoscopic and fluoroscopic clearance.

Interstitial cystitis/Painful bladder syndrome: A review

A 45 year old lady came to us with recurrent complaints of pain while passing urine,suprapubic discomfort,urgency lasting for more than 1 years.She had been investigated extensively and was given antibiotics/bladder spasmolytics/antimuscarinic agents/NSAIDs with no relief.Her all the investigations were normal.She was taken up for cystoscopy which revealed bladder capacity of 250 ml with glomerulations on emptying the bladder.The bladder biopsy was done after a therapeutic distension for 8-10 minutes.The patient was started on amitryptiline,Comfora(sodium pentosan polysulphate 100 mg three times a day)and gabapentin(TRIPLE THERAPY).She had temporary remission after the institution of the therapy and now relatively free of the symptoms.We are planning to repeat the distension after a period of 6 months.

REVIEW OF LITERATURE:
The interstitial cystitis is a chronic condition which comprimses of a constellation of symptoms-bladder pain, suprapubic/pelvic pressure, urgency, dysuria etc. The all above symptoms may occur together or the patient may suffer each one of them in isolation.
This is diagnosis of exclusion and requires a high level of suspicion on the part of the treating urologist. Any patient having unexplained irritative bladder symptoms without relief and the all investigations showing no culprit then we must doubt painful bladder syndrome.
The condition has been seen as debility because its effect on patients quality of life. A Harvard medical scholl guide states that the impact of this condition on the patient can be compared with chronic cancer pain /or renal dialysis.
The International Continence Society (ICS) reserves the diagnosis of IC for patients with “typical cystoscopic and histological features,” without further specifying these. In the absence of clear criteria for “IC,” this chapter will refer to PBS/IC and IC interchangeably, because all but recent literature terms the syndrome “IC.”(Campbells Book of Urology)
National Institute of Diabetes and kidney Diseases(NIDDK) diagnostic criteria:It’s a cystoscopic and histological diagnosis.Cystoscopy should demonstrate glomerulations(with or without Hunners ulcer)-diffuse on distension of bladder.

There are some conditions which must be excluded:-UTI/vaginitis/prostatitis
-Urinary tuberculosis
-Stone disease
-Radiation/cyclophosphamide cystitis
-malignancy
-herpetic affections(less than 3 months duration)
-urethral instrumentation(recent)
-stricture urethra
Urodynamically-the pain should be elicited after filling the bladder for 100-150 ml and the capacity should not be more than 350 ml.There should be any presence of uninhibited bladder contractions.
The typically age of the patient should be more than 18 years and the symptoms should be present for more than 9 months. There should not be a relief on institution of anticholinergics /antibiotics.
A patient who fulfills these criteria can be termed to be a patient of interstitial cystitis.
This condition is more common in women especially menopausal women. Although all the people irrespective of age, socioeconomic status, menopausal status do suffer from this syndrome.

The patient of IC/PBS may have associated illnesses like-allergic conditions,Inflammatory bowel diseases,Fibromyalgia and focal vulvitis etc.
Aetiology:The IC as such is a complex condition with no direct etiological agent to attribute this condition to. Neurological/allergic/autoimmune/stress-psychological conditions have been supposed to be playing a role in these conditions. Presence of MAST cells in the bladder is supposed to be a pathognomonic marker of the disease. The association of mastocytosis, IC and inflammatory bowel disorders is intriguing. The bladder permeability defect due to lack of surface bladder glycosaminoglycans can lead to aggravation of the condition. The treatment now also is aimed at restoring this protective layer of the bladder.

Diagnosis:
The cystoscopic visualization of glomerulations is not a specific for diagnosis. Potassium chloride sensitivity test although not a specific again but can hint to success of pentosan polysulphate.
Management:
1. Behavioural modification: May help in patients having predominant frequency but less pain.

2. Diet: Certain foods can aggravate the condition like banana, cranberries, tea, coffee, alcoholic beverages, ketchups, Mayonnaise, carbonated drinks, junk foods, onion etc..


3.Medications: Antihistaminics to control mast cell proliferations,amitryptiline to fight with neurogenic inflammation,oral pentosan polysulphate to restore the protective layer of the bladder have been used in this condition with variable success rates.In india it is available as Comfora 100 mg three times a day for 3 months and then re-evaluate the patient.The side effects like nausea,diarrhea,rashes and reversible alopecia have been reported.Tachyphylaxis is also reported.
4.Bladder instillation therapies:DMSO – a wood pulp extract is the only agent FDA approved for the instillation.25% or 50% solutions have been used for the instillation.
With its ease of administration, lack of side effects, and dependable symptomatic results, DMSO has been a treatment of choice with many treating doctors. Some people add triamcinolone, 40,000 units of heparin, and sodium bicarbonate for better success.
5. Bladder distension:
Bladder distension stretches the bladder and gives a temporary relief for few months. It is done under general anesthesia. The bladder is distended for 2 minutes with 80 cm of H20 and then deflated again to see the glomerulations. Once it is done a therapeutic distension is done for 8 minutes followed by bladder biopsy for mast cells detection.
6. Radical surgical options are sometimes chosen like subtotal cystectomy with augmentation or ileal diversion with or without cystectomy. The results are somewhat positive. But as the underlying condition of neurogenic inflammation may not go -phantom bladder pain may persist.

LASER BLADDER NECK INCISION: SMALL FIBROTIC PROSTATE WITH BLADDER OUTLET OBSTRUCTION

A 60 year old gentleman came with complaints of weak stream,frequency,nocturia over a period of 1 year.He was tried on alpha blockers before but didnot respond.He was a known case of asthma in remission not on any brochodilators.His ultrasound has shown 20 cc prostate with 90 cc post-void residual urine and increased bladder wall thickness(6 mm).

His PSA was 1.77 ng/ml,urine culture was sterile and other hematological and biochemical parameters were normal.His uroflowmetry showed obstructive pattern.He was taken up for LASER BNI surgery.The bladder showed grade 2 trabeculations with high bladder neck.The prostate and the anterior urethra was grossly normal.The Bladder neck incision was carried out with continuous wave Thulium laser ( 2 micron) with 70 w power.The incision was carried out from the level of ureteric orifices till the level of verumontanum reaching to the depths of the capsule.At the end of the procedure the bladder neck region was widely open as seen with stopping the irrigation.The hemostasis was achieved and 18 Fr foleys catheter ( a 2 -way catheter) with no traction and irrigation.The plan is to remove catheter after 24 hours and give him a catheter free trial.

PCNL in complete staghorn calculus

A 45 year old lady came with left flank dull in nature since 6 months.She underwent a battery of tests including ultrasound KUB region and IVP which revealed a complete staghorn calculus on left side.Her other hematological and biochemical work up was essentially normal.She was taken up for PCNL.The patient and the attendants were explained about multiple settings and ESWL adjuvant therapy if need arises.
Today,PCNL was carried out with postero-inferior calyceal approach and around 70% bulk of the stone was cleared.The nephrostomy tube was left in the pelvis.The plan is to second session of PCNL after 48 hours with the same tract and using the flexible nephroscope for access to all calyces.

SEMEN BANKING: MUST BEFORE CHEMO/RADIOTHERPY IN YOUNG ADULTS

A 30 year old gentleman came to us with primary infertility.He had a very good educational background and belonged to banking sector.He was found to have severe oligospermia on evaluation.He was a known case of testicular carcinoma -Non seminomatous having undergone adjuvant chemotherapy.He was never counselled about sperm banking before the institution of chemotherapy.
One 1999 survey conducted by the Cleveland Clinic Foundation found that only about 50% of cancer patients receive adequate information about their post-treatment reproductive options, and that only about 25% of men eligible to bank sperm do. Given that the survival rate for testicular cancer is so high, quality of life issues such as family building are relevant to literally millions of cancer survivors like the one in our case.
The patient has just to visit the sperm bank and deposit the semen.The initial semen analyiss is done and then the semen is cropreserved.Even if the patient has undergone orchiectomny initially it is worth visiting the sperm bank and store whatever sperms he has now.With the advances in Assisted Reproductive Technologies and ICSI even a single sperm cell can be utilised for the successive IVF.
What is sperm bankingThe sperms are cryopreserved.With the induction of cooling the metabolic rate of the sperm is brought to a minimum level and they are halted in a state of suspended animation till they are thawed.The cooling and thawing can damage the sperms if done repeatedly but the sperms so obtained doesnot appear to altered genetic material.

FINASTERIDE GIVEN FOR HAIR REGROWTH MAY LEAD TO MALE INFERTILITY

Recently a 27 year old gentleman came to us with severe oligospermia.He was a case of hair transplant on finast low dose.There was no other cause discernible for oligospermia.He was asked to stop finast and at the same time advised to take anti-oxidnats to increase the sperm count.He was requested to come after a period of 3 months with fresh report of semen analysis.

Androgenetic alopecia (male pattern hair loss) is caused by androgen-dependent miniaturization of scalp hair follicles, with scalp dihydrotestosterone (DHT) implicated as a contributing cause. Finasteride, an inhibitor of type II 5alpha-reductase, decreases serum and scalp DHT by inhibiting conversion of testosterone to DHT.It is usually given in the low dose of 1 mg/day for accentuating the hair growth in the male pattern baldness.It has been argued that the finasteride doesnot affect spermatogenesis in normal health men in low dosage.But it might affect if the person who is taking the medications has already compromised spermatogenesis.
As most of the patients undegoing treatment for hair regrowth are in the younger age group.The treating surgeon/physician/dermatologist should take into his/her account his fertility status.

LASER EPILATION OF THE NEOURETHRAL HAIR

A 57 year old gentleman -case of urethroplasty with scrotal flap for anterior urethral stricture- had complaints of unabated dysuria and recurrent UTIs.There was no relief with the antibiotic therapy(both curative and suprressive).His urethroscopy had revealed adequate lumen(with diverticulae) with plenty of hair arising out of the scrotal flap area used for urethroplasty.He is presently planned for LASER(continuous 2 micron Thulium LASER) epilation.The hair might be acting as reservoir for the recurrent infections and also could result in dysuria.

Bladder mass in a young patient

A 27 year old patient came with complaints of lower urinary tract symptoms mainly irritative in nature.The patient was treated outside with multiple courses of antibiotic therapy without relief.The sonography done further showed the bladder mass.The other investigations- including the urine culture,urine for malignant cytology,blood biochemistry and haemtology were essentially normal.

We evaluated her further with triphasic CT scan which revealed cystic enhancing mass in the left superolateral wall of the urinary bladder with no iliac lymphadenopathy.The other intra-abdominal organs were normal.



She was taken up for cystoscopy and biopsy.The mass was extravesical.Adequate biopsy was taken with resectoscope.Hemostasis was achieved.The histopathological report is awaited.

Thulium laser prostatectomy: Tangerine technique-safe way of prostatectomy

In our hospital we follow -tangerine technique of laser prostatectomy. We use 2-μm -continuous wave thulium laser to dissect whole prostatic lobes off the surgical capsule, similar to peeling a tangerine. A 70-W, (thulium) laser was used in continuous-wave mode. We joined the incision by making a transverse cut from the level of the verumontanum to the bladder neck, making the resection sufficiently deep to reach the surgical capsule, and resected the prostate into small pieces, just like peeling a tangerine. The prostatic pieces were pushed into the bladder and later removed with the morcellation. We have rarely encountered bleeding. Saline was used for irrigation and hence no TUR syndrome occurs. Blood transfusion rate is less than 0.5%.We have even done patients on antiplatelet agents and patients with cardiac comorbdities.Recently we operated a 90-year old man with retention. The procedure was uneventful and the patient voided well after the surgery.
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Giant Pyonephrotic kidney: A lesson learnt

A 35 year old gentleman came to us with the left flank pain of 15 days duration.He was also complaining of generalised malaise.There was no complaint of fever or lower urinary tract complaints.He was complaining of dull ache in flank region previously also on and off.But the intensity as per the patient was not significant enough to seek consultation from doctor.He didnt have any comorbdities.There was no prior history of undergoing urological/ surgical interevention.Physical examination revealed a large mass in the left flank. Imaging showed a large hydronephrotic kidney with papery thin parenchyma.IVP showed a non excreting kidney even after 24 hours.Urine examination was unremarkable.

We explained the patient about non functioning status of the kidney and need for nephrectomy.Initial on table drainage then followed by laparoscopic nephrectomy vis-a-vis open nephrectomy options were considered.Finally we decided to go for open surgery.The kidney intra-operatively was grossly enlarged and full of thick creamy pus.A total of 3litres of pus was drained and then subcapsular nephrectomy was performed.

The pyonephrotic kidney removal is difficult surgery in view of loss of planes with the surrounding structures.Many times we are misled by the symptoms.We assumed that this would be a simple hydronephrotic kidney and thus surgery will be easier because of maintained planes.Absence of fever or absence of perinephric stranding on CT scan led us to assume so.Laparoscopy is pyonephrotic kidney would be a difficult task and waste of time; which can add to patients morbidity.Initial drainage (before surgery) would add a lot to our management strategy. If a clear urine drains out a laparoscopic surgery would be the treatment of choice.If pus is drained then open surgery can be assorted to.

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.

Seminal Vesiculoscopy:recent case in prostatic utricular cyst

MRI SHOWING SEMINAL VESICULAR DILATATION

We operated a total 8 cases of seminal vesicle obstcruction over last year.

All had low volume ejaculate,azoospermia or severe oligospermia or hematospermia.Out of them;two cases of hematospermia totally resolved after the surgery.

Out of six cases of azoospermia(out of six); four improved- one couple even concieved.Two patients didnot improve.

This shows a great future for seminal vesiculoscopy in obstructive azoopsermia and also hematospermia.It helps in hematospermia.In one case it abated as we did removal of the seminal vesicle calculus in other case there was only congestive hematospermia.It probably helps in idiopathic hematospermia by decreasing the intraseminal vesicular pressures.

Ureterosigmoidostomy Follow up

We had operated 45 year old lady - radical cystectomy and ureterosigmoidostomy for TCC bladder.She underwent the surgery uneventfully.

Post-operatively on 1 year follow up she underwent CECT urogram.Here is the scan photograph showing the ureteral anatomy.

Her hematological/biochemical and VBG analysis was essentially normal.She was passing urine every 1 hourly as per our instrcutions and was leading a very good quality of life.

The ureterosigmoidostomy had fallen out of favour recently due to advent of newer continent diversions like orthotopic diversions.But in select cases ureterosigmoidostomy can offer equal quality of life like orthotopic diversion.

transitional cell carcinoma with staghorn calculus

We operated a case of renal tumor invading the descending colon .He underwent left radical nephrectomy with En Bloc Resection of the intestinal segment.

The patient was having staghorn calculus and nonfunctioning kidney.He was asymptomatic.

He underwent periodic imaging and blood biochemistry studies.This time he presented with signs of constitutional symptoms and dull continuous pain in the left flank.

His ultrasound showed mass in the kidney.He was further evaluated with Triphasic CT scan which revealed left renal mass with obscured planes with the descending colon and staghorn calculus.

He was taken up for surgery in view of his metastatic work up was essentially normal.

In 2 months postoperative period he is doing well and planned for palliative chemo/radiotherapy.