Aggressive primary urethral malignancy masquerading as stricture urethra: Unusual presentation of a rare malignancy

Bladder outlet obstruction in an elderly male patient is most of the time diagnosed as prostatomegaly or stricture urethra unless there is a high index of suspicion for other differential diagnoses. Rare tumors like urethral malignancy may be misdiagnosed due to their varied and delayed mode of presentation. Here, we present a case of a patient who presented with acute urinary retention and was suspected to be a stricture urethra which ultimately turned out to be an aggressive urethral tumor. Investigations such as retrograde urethrogram, ultrasound, or cystoscopy which are the most common diagnostic modalities in a patient with lower urinary tract symptoms may not diagnose urethral tumors. Delayed diagnosis is common in these tumors resulting in a lesser chance for curative treatment. A high index of suspicion with a lesser threshold for investigations like MRI is pivotal for early diagnosis in these patients.

Early Outcome of Cold Knife Ablation and Diathermy Fulguration of Posterior Urethral Valve; A Comparative Study

Background: Posterior urethral valve (PUV) is the most common obstructive anomaly of the urethra. Urethral valves have a wide range of clinical and anatomical presentations and today most patients are diagnosed in the prenatal or early neonatal period. Cold knife and diathermy fulguration are two of the technique of PUV ablation. Objective: To find out early outcome of posterior urethral valve ablation between cold knife and diathermy fulguration. Methodology: This prospective comparative interventional study was conducted in the Department of Pediatric surgery in Dhaka Shishu Hospital (DSH), Dhaka. 54 patients with PUV, admitted for valve ablation during study period were included in this study. Patients were divided in to two group. Among them, 27 were in Group-A, whose PUV ablation were done by cold knife and 27 were in Group-B whose PUV ablation were done by diathermy fulguration. Successful ablation was confirmed under endoscopic vision as well as with the demonstration of good stream following supra pubic compression, at the end of the procedure. All patients were kept with 72 hours of urethral catheterization (All silicon self retaining Foley’s catheter according to body texture ) .Post PUV ablation pt. were given discharged with prophylactic antibiotics on 4th POD. Results: The mean age was found 18.37±16.13 months in cold knife ablation group and 12.70±11.03 months in diathermy fulguration group. Significant number (06/22.2%) of cases were associated with residual valve in diathermy fulguration group and non signicant number (301/3.7%) cases in cold knife ablation group . Significant number (04/14.8%) of cases were associated with post PUV ablation stricture urethra also in diathermy fulguration group and no stricture was found in cold knife ablation group . Significant hematuria. was present in 2(7.4%) in cold knife ablation group and 1(3.7%) in diathermy fulguration group. Conclusion: This study concludes that use of cold knife in case of ablation of PUV causes less post ablation obstruction (residual valve and stricture urethra) than using diathermy fulguration and can be regarded a safe and better option for PUV treatment.

Evaluation of the Extent of Primary Buccal Mucosal Graft Contracture in Augmentation Urethroplasty for Stricture Urethra: A Prospective Observational Study at a Tertiary Healthcare Centre

Introduction. Buccal mucosal graft (BMG) urethroplasty is considered as gold standard in the treatment of urethral stricture disease. The successful outcome after BMG urethroplasty varies between 66 and 99%. One of the possible causes for failure is BMG contracture. Primary BMG contracture rate is poorly understood and unreported. The present study aimed to evaluate the extent of contracture of buccal mucosa immediately after harvesting. Materials and Methods. This was a prospective observational study conducted in the Department of Urology at our institute between January 2016 and December 2019. All patients with urethral stricture disease undergoing BMG urethroplasty for the first time were enrolled in the study after obtaining informed consent. Demographic and patient clinical profile was noted. Based on the intraoperative urethral stricture size, the preharvest graft was marked on the buccal mucosa and the size was calculated. Postharvest unstretched size of the graft was measured immediately after graft removal from the oral cavity. Alteration in BMG size was analysed using paired t-test. Results. Forty-four patients were included in the study. Mean age of the patient was 53.6 years. Mean stricture length was 7.45 cm (range 4–12 cm). Mean pre- and postharvest BMG size was 8.3 × 1.5 cm and 7.6 × 1.3 cm, respectively. There was a 8.4% decrease in length and 9.5% decrease in width of the buccal mucosal graft. Conclusion. Primary buccal mucosal graft contracture is around 8.4% in length and 9.5% in width. It would be better to mark wider than necessary while harvesting buccal mucosa so that tension-free anastomosis is performed.

Bipolar TURP in high-risk patients with large prostate gland: our experience

Background: The present gold standard monopolar-TURP is associated with a number of complications and has less safety margin in comorbid patients. Bipolar TURP is a modification of conventional M-TURP and has the potential to overcome its most prominent shortcomings with better safety profile in patients with comorbidities. Aim of the study was to evaluate the efficacy of bipolar-TURP in terms of operative and postoperative parameters.Methods: This prospective study was conducted in the department of urology SKIMS Srinagar, from April-2019 to October 2020. Forty-five patients with one or more comorbidities and BHP, with a prostate weight ≥60 gm was evaluated. Operative and postoperative parameters were recorded and patients followed with IPSS and uroflowmetry for a period of 6-months.Results: Of 45 patients who underwent B-TURP, pre-operative parameters were mean age(years) 66.59±9.88, mean prostate size (gm) 77.42±18.4, mean IPSS of 26.3±2.9, mean serum PSA (ng/dl) of 2.32±0.88, mean Qmax (ml/s)of 7.71±2.41 and PVRU of 113.45±16.5 ml. Operative and post-operative parameters were, mean operative time(min) of 68.14±29.6, TUR syndrome in none, mean change in Na+ of -0.98±0.75 meq/l, mean change in Hb of -1.66±0.68 g/dL, mean irrigation time (hours) 24.53±5.46, clot retention in 3 (6.66%) patients, transfusion in 2 (4.44%) patients, mean postoperative catheter time(hours) 69.5±10.5 and mean hospital stay 3.6±1.61 days. Two (4.44%) patients developed stricture urethra and were managed with urethral dilatation. IPSS and Qmax at 6-weeks were 10.2±2.18 and 16.22±2.31 ml and at 6-months were 6.43±1.16 and 19.12±3.14 ml respectively.Conclusions: B-TURP seems to be a more sensible choice for patients with underlying comorbidities or implanted cardiac devices.

An insight into the management of urinary bladder diverticulum: a retrospective observational study

Background: The aim of the study is to retrospectively analyse the best mode of treatment for patients presenting with urinary bladder diverticulum. Methods: This study includes 46 patients who presented to the outpatient department between January of 2018 to March of 2020. They had lower urinary tract symptoms (LUTS) and were later found on investigations with imaging like ultrasound and voiding cystourethrogram (VCUG) as having bladder diverticulum with some cases associated with bladder outlet obstruction. Secondary causes were treated surgically or conservatively with clean intermittent catheterisation (CIC). Diverticulum was addressed with diverticulectomy when conservative management failed with recurrent LUTS or if the diverticulum was of a large size with significant post void residual urine. Results: Most of the patients with diverticulum associated with prostatomegaly or stricture urethra fared well after treatment of the underlying cause except one who underwent subsequent diverticulectomy. Four out of 5 patients with neurogenic bladder did well with CIC alone barring one who underwent diverticulectomy for a large sized diverticulum and refractory LUTS. Two patients with bladder growth involving the neck of diverticulum underwent partial cystectomy along with diverticulectomy. Four out of the remaining 8 patients with primary diverticulum were taken up for diverticulectomy directly and one underwent subsequent diverticulectomy for failed CIC. Conclusions: Not all urinary bladder diverticulum required surgical management per se. Most fared well with treatment of the underlying cause. So only those with large size, recurrent LUTS and failed management with CIC should be considered for diverticulectomy.

Outcome of Laser Urethrotomy in Comparison with Optical Internal Urethrotomy in Recurrent Stricture Urethra Following Perineal Anastomotic Urethroplasty for PUDD

Objective: To compare the outcome of laser urethrotomy and optical internal urethrotomy(OIU) for the treatment of recurrent stricture urethra following perineal anastomotic urethroplasty for posterior urethral distraction defect. Materials and methods: The study was conducted in Dhaka Medical College Hospital from January 2013 to December 2014.Male patients presented with obstructed voiding symptoms following perineal anastomotic urethroplasty were evaluated by their history, physical findings and investigations (urinalysis, uroflowmetry, retrograde urethrogram and micturiting cystourethrogram ) & primarily 64 patients are selected by purposive sampling. Patients are divieded again by random allocation into group A and group B and underwent for OIU and laser urethrotomy respectively. Results: Comparison was made to find out the better method between optical urethrotomy and laser urethrotomy. Overall per-operative complications (bleeding, extravasations of irrigating fluid, false passage and broken knife) in the former group were 31.3% compared to none in the latter group. Post-operative complications like bleeding, haematoma, penile oedema and erectile dysfunction were found only in Group-A (p=0.002). The mean duration of postoperative catheterization and average hospital stay were observed to be much higher in Group-A than that in Group-B (p=0.000008; p=0.0006). Comparison of final outcome (development of stricture) between groups at 1 year of evaluation in Group-A and Group-B was not significant (p= 0.320). Conclusion: Laser urethrotomy is better than optical urethrotmy in regards of peroperative and post-operative complications. Bangladesh Journal of Urology, Vol. 23, No. 2, July 2020 p.181-187

The Profile of Patients Presented at Nephrology Opd With Obstructive Nephropathy; Single Centre Experience

Introduction: Obstructive Uropathy which refers to the structural and functional change impeding the normal urine flow is one of the common cause of renal failure . It has diverse effect on normal renal function as well as there is also diversity on its etiology and outcome Material & methods: Total 108 patients who came to Nephrology OPD with various degree of renal dysfunction resulting from Obstruction of Urinary tract was included in the study. Result : Among the patients 65% were male and their mean age was 51±13.5 years . Common clinical features were loin pain (41%) ; vomiting (30%) ; edema (26%) ; Oligourea (46%) & LUTS (19%). Common etiologies of Obstruction was BEP (28.7%);Urolithiasis(24%); Cervical malignancies(11%); Congenital abnormalities (13%) & stricture urethra(12%). About 37% patients had to under go RRT. Conclusion : Specific strategies to target improvements in early diagnosis renal recovery and patients survival are needed in this patient group. Bangladesh Journal of Urology, Vol. 22, No. 2, July 2019 p.132-135

Tubularized Incised Plate Urethroplasty for the Repair of Distal Hypospadias: A Simple Versatile Technique

Objective: To observe the outcomes of tubularized incised plate urethroplasty in the primary management of distal hypospadias Materials and Methods: Total 70 patients of age group 2 to 10 years with distal hypospadias were selected for this study from January 2008 to December 2015. They were treated with tubularized incised plate urethroplasty. All patients were followed up immediately and at 4th, 8th and 12th weeks after operation. Results: The satisfactory cosmetic and functional outcomes were observed in 58 patients (82.85%).Urethrocutaneous fistula developed in 10 patients (14.70%) patients and 6 patients (8.82%) were found to develop meatal stenosis. Two patients (2.94%) developed stricture urethra. Overall complications occurred in 20 patients (29.41%). Conclusions: This study demonstrates that tubularized incised plate urethroplasty had excellent cosmetic and functional outcomes and fewer complications in the primary management of distal hypospadias. Bangladesh Journal of Urology, Vol. 20, No. 2, July 2017 p.65-69

Comparative Study Between Outcomes of Tubularized Incised Plate Urethroplasty and Modified Tubularized Incised Plate Urethroplasty in the Management of Distal Hypospadias

Objective: To compare the outcomes of tubularized incised plate urethroplasty and modified tubularized incised plate urethroplasty in the primary management of distal hypospadias Materials and Methods: Total 70 patients of age group 2 to 10 years with distal hypospadias were selected for this study from January 2008 to December 2010. They were divided into Group-A (n=35) treated by the tubularized incised plate urethroplasty and Group-B (n=35) treated by the modified tubularized incised plate urethroplasty.The modification was performed by using inner preputial skin on the incised plate before tubularization. All patients were followed up immediately and at 4th, 8th and 12th weeks after operation. Results: The satisfactory cosmetic and functional outcomes were observed in 29 patients (82.85%) of Group-A and all families of Group-B were happy with aesthetic and functional outcomes. Urethrocutaneous fistula developed in 5 patients (14.70%) patients of Group- A and 1 (2.94%) patient in Group-B. Three patients (8.82%) in group-A and one patient (2.94%) in group-B were found to develop meatal stenosis. One patient (2.94%) developed stricture urethra in group A but no patient in group-B developed urethral stricture. Overall complications occurred in 10 patients (29.41%) in Group-A and 2 patients (5.88%) in Group-B. Conclusions: This study demonstrates that modified tubularized incised plate urethroplasty had excellent cosmetic and functional outcomes and fewer complications than that of tubularized incised plate urethroplasty in the primary management of distal hypospadias. Bangladesh Journal of Urology, Vol. 17, No. 2, July 2014 p.75-81