Evaluation of Galdakao-modified Valdivia Position in Combined Simultaneous Access to Upper and Lower Urinary Tract Pathologies

Background Simultaneous retrograde and antegrade endoscopic combined intrarenal surgery in modified supine lithotomy positions offer significant progress in the endoscopic management of urolithiasis. The operative time has been significantly reduced. Aim of the Work To evaluate the Galdakao-modified Valdivia position in simultaneous handling of upper and lower urological pathologies in the same units. Patients and Methods The evaluation for the Galdakao-modified Valdivia position regarding the benefits in different upper and lower urological diseases was the aim of our prospective randomized clinical trial that will started on April 2017 and ended by April 2019. Results The study has included 60 patients comprising males and females. Conclusion We believe that GMSV provided a great versatility in the treatment for urolithiasis along the whole urinary tract, ante-retrograde access, treatment of uretero-ileal strictures in patients with urinary diversions or neobladders, missed double j stent, bilharizoma of the ureter and bladder mass involving the ureteric orifice. Also, the advantage provided by this approach to the surgeon, patient and anesthetist may lead to widespread adaptability of this technique in the management of complex urolithiasis.

Journey of a fish from the vagina to the bladder: a case report

Foreign bodies in the genitourinary tracts are not uncommon and is often a challenge to remove them from the bladder. This case is a peculiar one where there was a migration of a live fish from the vagina to the bladder. A 60- year- old post-menopausal woman while taking bath in a pond felt that there was an entry of fish into the vagina. Her complaints were pain and bleeding per vagina and there was no leakage of urine. At the peripheral health facility, she underwent exploration of the vagina under local anesthesia after placing the foley catheter which was draining blood-stained urine. The patient was then referred to us. There was a laceration at the right anterolateral fornix. Fish could be palpated with the finger. She underwent routine blood tests and CT KUB which revealed a foreign body at the right anterolateral side of the vagina. Cystoscopy showed a laceration of 1×1 cm noted in the posterior wall of bladder approximately 1cm above right ureteric orifice, through which the fish was seen. Through speculum examination, the rent was visible and the remnants of the fish were removed vaginally. Laparotomy and rent repair was done because of the rent in the bladder. Foreign bodies into the bladder are common and invariably seen among children, women who have psychiatric problems. Common foreign bodies seen are broomsticks, toothbrushes, pencils, gauze, sutures, clips, IUCD, etc. Fish as a foreign body is a very rare condition. The unusual entry of a fish into the vagina has eroded and entered the bladder. Prompt investigations like CT scans and cystoscopy can help in the removal of foreign bodies.

Predictors for Retrograde Ureteral Stenting Failure as an Initial Drainage Method for Emergent Complicated Acute Calculus Obstructive Uropathy

Objective: To define predictors for initial retrograde ureteral stenting (RUS) failure with the need for the percutaneous nephrostomy (PCN) insertion as a drainage method in patients with complicated acute calculus obstructive uropathy. Methods: We undertook a retrospective evaluation of patients who presented with complicated obstructive calculus uropathy (acute renal failure or obstructive pyelonephritis) between January 2016 and January 2020. Patients in whom there was failure to visualize ipsilateral ureteric orifice and those with extrinsic ureteral obstruction were excluded. Patient demographics and radiological data including stone site, hydronephrosis grade, maximum transverse stone diameter, periureteral density (PUD) and pericalcular ureteric thickness (P-CUT) at the maximum transverse stone diameter were assessed using non-contrast computed tomography at the time of admission. Results: The study included 256 patients who were managed initially by RUS trial. Of them, 48 (18.8 %) had RUS failure. The presence of acute pyelonephritis, increased maximum transverse stone diameter ≥ 9.5 mm, P-CUT ≥ 7.5 mm, and PUD at stone level ≥ 17.5 HU were risk factors associated with RUS failure (P = 0.007, 0.002, < 0.001, and < 0.001, respectively). Conclusion: Initial radiological stone and ureteric characteristics, in addition to the clinical diagnosis of obstructive pyelonephritis, can be used to determine PCN insertion as the preferred option over RUS for urinary drainage.

OUTCOME OF PRIMARY REPAIR OF VESICOVAGINAL FISTULA (VVF)

BACKGROUND & OBJECTIVE: Vesicovaginal fistula is one of the common gynecological problems faced by ladies in developing countries on account of certain significant lacunas in the healthcare delivery system and lack of awareness. The purpose of this study is to highlight our experience of primary vesicovaginal fistula repair. METHODOLOGY: It is a cross-sectional experimental study from February 2019 to February 2020. Nineteen consecutive patients having vesicovaginal fistulas up to 3 cm in size, single in number were included in the study while those having fistulas more than 3 cm, involving urethra, bladder neck, and ureteric orifice were excluded. After a detailed history, physical examination, laboratory workup, and cystoscopic examination under anesthesia, the fistulas were repaired. All information was noted on the pre-planned questionnaire for this purpose. RESULTS: There are around 63% of patients having fistula infratrigonal and the rest percentage on the supratrigonal area of the urinary bladder. The risk factor found hysterectomy in 32% of patients, unsupervised home delivery in 16% of patients, C-Section in 12% of patients, delivery by an untrained person in 26% of patients, induced miscarriages in 5% of patients, and other risk factors found in 12% patients. The 68% of patients managed through transabdominal and the rest 32% patients operated through the transvaginal approach. The surgery, either transabdominal or transvaginal, was successfully done in 84% of patients and failed in the rest of 16% of patients. CONCLUSION: Fistulas due to obstetric trauma were mostly preventable. The success of surgical repair was due to health professionals' expertise, the suitable decision about approach, method of repair, proper preoperative evaluation, and careful postoperative management.

A Prospective Comparative Study to Evaluate the Effect of Alpha Blocker on Ureteric Orifice for Ease of Ureteroscopy in Patients of Ureteric Calculus and BPH

BACKGROUND The selective alpha-blockers are widely used in the clinical treatment for ureteral stones as MET (Medical Expulsive Therapy). American Urological Association and European Association of Urology, strongly recommend that patients with ureteral stones be alpha-blockers to promote stone passage. Due to the physiological effect of alpha-blockers on the ureter, researchers hypothesized that the use of alphablockers before ureteroscopy may help during the Ureteroscopic procedures, making it easier and safer. One critical step in doing ureteroscopy is directing scope into vesicoureteral junction as most of the time its non-dilated and this is place injury and later stricture chances are high which lead to failure of treatment.3 But in literature, there is a discrepancy with this hypothesis as some studies have failed to demonstrate the benefits of technical ease and lower complication rate with alpha-blocker being used in the preoperative period. METHODS We conducted a cross sectional study in the department of urology from January 2019 to January 2020. 30 patients of ureteric calculus on alpha-blocker therapy and 30 patients of BPH on alpha-blocker ± 5 alpha reductase therapy were included for study. During URSL (Ureteroscopic Lithotripsy) we used 6 / 7.5 fr URS (Ureterorenoscope), ease of admitting URS in vesicoureteral junction noted. The need for ureteral dilator for admitting URS, presence of mucosal injury, and bleeding or false passage noted as difficulty in instrumentation. And documentation of finding done in excel. RESULTS Out of 60 patients, 24 (40 %) patients didn’t need dilatation of ureteric orifice and Ureteroscopy was done easily among which 8 (33.33 %) were BPH patient and 16 (66.66 %) were ureteric calculus patient this difference is statistically significant with p-value 0.010. 36 (60 %) patients needed dilatation of ureteric orifice to facilitate URS of which 22 (61.11 %) patients were from the BPH group and 14 (38.88 %) are ureteric calculus group. The study shows a statistically significant difference with p-value 0.029. CONCLUSIONS Our study demonstrates that alpha-blockers failed to show a statistically significant difference in relaxation of the ureteric orifice in non-ureteric calculus patients. Further large group, multi-centric studies are required to find a definitive role for alpha blockers prior to URS. KEYWORDS BPH, Silodosin, Ureteroscopy, Ureteric Orifice, Alpha Blocker, Alpha 1a, Medical Expulsion Therapy

Surgical strategies for placenta percreta invading the bladder and review of literature

Background Major obstetric hemorrhage is the leading cause of maternal morbidity and mortality. In rare cases, life-threatening hematuria in pregnant women may result from invasion of the bladder by the placenta. We present our experience with 18 cases of placenta percreta with suspected bladder invasion. Methods It is a retrospective single-center study conducted over a period of 3 years. Total 18 patients of radiologically diagnosed placenta percreta were included in the study. All patients who are at risk for placenta percreta underwent prenatal sonograms. Patients of Placenta Accreta Spectrum presenting electively also underwent MRI pelvis. Elective patients who were high risk of placenta percreta underwent bilateral placement of the balloon catheter in internal iliac artery. In case of doubt regarding bladder invasion, patient underwent anterior cystotomy and posterior wall of the bladder was examined and proximity of the ureteric orifice to the placenta and amount of involvement of bladder wall was assessed. Ureteric catheter placement was used as adjuncts depending on the proximity of placental invasion with ureteric orifice. Postoperative outcomes in the form of maternal morbidity, maternal mortality, fetal mortality, postoperative bleeding, bladder status, vesicovaginal fistula, bladder capacity were all evaluated. Results In our series, 17 cases all cases were diagnosed preoperatively by antenatal ultrasound and MRI. Only one patient presented with hematuria. Only in one patient, we attempted separation of placenta from bladder wall, and it resulted in profuse bleeding, and in rest, we excised the involved bladder. Partial cystectomy was done in 33.4% patients, 27% patients required bilateral placement of ureteric catheter due to proximity to the ureteric orifice. 33.4% patient underwent bilateral internal iliac artery ligation or balloon placement. Clot evaluation was needed in one patient. Intraoperatively—39% patients had uterus adhered to the bladder but no placental invasion into the bladder. One patient was managed with obstetric hysterectomy and methotrexate followed by clot evacuation and bilateral internal iliac artery ligation at a later date. One (5.6%) patient developed vesicovaginal fistula in postoperative period. There was one (5.6%) maternal mortality with no fetal mortality. On follow-up, patient had good bladder capacity, 3 weeks after the surgery. Conclusion MRI done preoperatively can help us guide regarding the extent or severity of placental invasion. Intraoperatively, anterior cystostomy should be done in suspected placenta percreta. Grade I or II accrete/percreta patients can be managed conservatively. Partial cystectomy with placement of bilateral ureteric catheter is safer and less morbid approach in tackling placenta percreta invading the bladder with mucosal involvement.

Effectiveness of Single Dose Povidone Iodine Sclerotherapy for the Treatment of Chyluria

Objective: To evaluate the effectiveness of single dose 5 % povidone iodine renal pelvic instillation sclerotherapy for the treatment for chyluria. Methods: In a prospective study from January 2009 and till June 2013, 47 patients presenting with milky urine (chyluria and hematochyluria) were included. Patients with other co-morbid illness like diabetes, urinary infection, renal stone disease, chronic pyelonehritis were excluded from the study. Apart from ether test, the presence of lymphocytes in urine and urine triglycerides levels were also done to confirm chyluria. Under local anesthesia, cystoscopic evaluation revealed right-sided efflux in 11 (23.4%), left-sided in 36 (76.6%), and no bilateral involvement was detected. 5F open-ended ureteric catheter was introduced in the ureteric orifice of affected side. Freshly prepared 10 ml of 5 % povidone iodine solution was instilled over a minute with the patient in Trendelenburg position. Results: Total of 47 patients were enrolled (26 males and 21 females; mean age 41 years, SD 8.4, range 29–71) with a mean follow-up of 12 months. Immediate clearance was seen in all patients and recurrence in 9 (19.15 %). Overall success rate 80.85%. Mean diseasefree duration was 12 months. Three patients had moderate to severe flank pain. Conclusion: Single dose 5 % povidone iodine sclerotherapy is a effective treatment for chyluria. As the patients discharged on the next day after procedure, it can be offered as a day care basis, so continuous ureteral and urethral catheterizations can be avoided. Bangladesh Journal of Urology, Vol. 18, No. 2, July 2015 p.74-78