Large Ejaculatory Duct Cyst in 48years old man: Open Surgery and Fertility Issues

Pelvic cyst originated from Mullerian or Wolffian duct are reported frequently but ejaculatory duct cysts are very rare. Here we present a rare case of large ejaculatory duct cyst in a diabetic man. In Bangladesh no such case has yet reported. This will be the first case reported in our country. This man was 48 years old presented with post ejaculatory pain, haematospermia, low ejaculatory volume and infertility. On trans rectal ultrasonogram (TRUS) there was 70ml volume retro prostatic midline cyst was found. MRI pelvis confirms the diagnosis. There are different modalities of treatment ranging from observation to open surgery. We chose to open excision with good post operative outcome. Ejaculatory duct cyst is a rare entity. Malignant transformation also reported in ejaculatory duct cyst. Trans rectal ultra sonogram (TRUS) and MRI of pelvic organs are diagnostic. Treatment depends on size of cyst and fertility. Total excision result in complete recovery from symptoms and disease. Transurethral surgery may conserve natural fertility but persistence in complications. Fertility issue in our case depends on intra-cytoplasmic sperm injection which outcome will be seen in future follow up. Bangladesh Journal of Urology, Vol. 23, No. 1, January 2020 p.107-111

Laparoscopic Urological Surgery: Our Initial Experiences

Introduction and Objective: Laparoscopic surgery is increasingly exercised in urology due to improvements in technical capabilities and experience. It comes with many advantages compared to open surgery such as lesser degree of pain and haemorrhage, shorter hospital stay and better cosmetic results. This study is carried out to evaluate the outcomes and complications of urological laparoscopic surgery cases performed Chittagong Medical College Hospital, Chattogram, Bangladesh. Methods: This was a hospital based prospective observational study of total 29 patients, who received laparoscopic surgery of different kinds between January 2017 and September 2019 for urological causes with a minimum one month follow-up. Included patients were assessed in terms of demographic characteristics, preoperative diagnosis, type of laparoscopic approach, duration of surgery and hospitalization, complications after surgery and need for conversion to open surgery. Results: The mean age was 45.03 years where 12 patients were women and 17 were male. All patients underwent trans-peritoneal procedures where2 patients received renal cyst excision, 4 simple nephrectomy, 5 ureterolithotomy, 9 radical nephrectomy, 1 radical cystectomy, 2 adrenalectomy, 3 pyelolithotomy and 3 pyeloplasty. Three of the 29 patients required conversion to open surgery. Except these patients, no major complication or mortality was encountered. The mean duration of surgery for the most commonly applied procedures were as follows: renal cyst excision 87.5 (70-105) min, simple nephrectomy 141.25 (120-170) min, ureterolithotomy 120 (100-140) min, radical nephrectomy 215.56 (180-260) min, pyelolithotomy 120 (100-140) min, and pyeloplasty 156.67 (130-190) min. The mean hospital stay was 4.59±1.7 (2-8) days. Conclusions: The success and complications rate of the laparoscopic urological surgeries performed in our hospital were consistent with those reported in the literature. In the light of technological advances and increasing experience, we believe that laparoscopic surgery is an effective technique with excellent outcome along with a safe and feasible alternative to open surgery in the field of urology. Bangladesh Journal of Urology, Vol. 23, No. 1, January 2020 p.17-23

An Early Experience of Retrograde Intrarenal Surgery (RIRS) in National Institute of Kidney Diseases and Urology

Background: Advancements in the endoscopic armamentarium, retrograde intrarenal surgery has become a viable and attractive option for the treatment of renal stones because of its high stone-free rates (SFRs) and low morbidity. Objective: To describe our experience and outcome of RIRS for the treatment of renal stones and to assess its effectiveness and safety. Design, setting, and participants: A retrospective analysis of 60 patients who underwent RIRS for renal stones at our institute between January 2018 to December 2018 was performed. Surgical procedure: Flexible ureteroscopy and laser lithotripsy using a standardized technique with last-generation flexible ureteroscopes (Flex-Xc) using Holmium-YAG laser. Outcome measurements and statistical analysis: Clinical data were collected and intraoperative and postoperative outcomes were assessed (Ureteral access sheath placement, operation time, hospital stay, stone free rate, post-operative blood transfusion & fever, need for second session of RIRS. A descriptive statistical analysis was performed. Results and limitations: The mean overall stone size was 13±3 mm. Pre stenting done in all cases. Ureteral access sheath placement was possible in 54(90%) patients. At 1 month follow-up, the overall primary SFR was 86.67%(52 cases), the secondary SFR was 96.67%(58 cases).The mean operative time was 91.96±18.7 min. Mean hospital stay was 1.86±1.02 days. Complications were reported in 8 (13.33%) patients overall, with fever in 6 patients (10%), steinstrasse in 2(3.33%) patients need for second session RIRS in 6 patients (10%).No patient needed blood transfusion. The main limitation of the study is the retrospective nature. Conclusions: RIRS performed using a flexible ureterorenoscope marked the beginning of a new era in urology. It is safe and effective procedure and an alternative to extracorporeal shock wave lithotripsy (ESWL) and Percutaneous nephrolithotomy (PCNL) in the treatment of selected renal stones. Bangladesh Journal of Urology, Vol. 23, No. 1, January 2020 p.3-10

Extracorporeal Shockwave Lithotripsy with Tamsulosin in Clearance of Upper Ureteral Calculi- A Randomized Control Clinical Trial

Background of the study: Urolithiasis has an incidence in the world of about 5% and the probability of a recurrence within 5–7 years is 50% (Parmar, 2004). Exact data about its prevalence is not known in Bangladesh but it is quite common as seen in outpatient department. It is more common in northern part of the country, male suffer more than female (M:F: 3:1) (Salam, 2002). Symptomatic ureteral calculi represent the most common condition encountered by an urologist in an emergency setting (Pak, 1998). Intervention is recommended for individuals with larger stones, especially greater than 5 mm (Kupeli et al., 1998). The treatment of this pathology was revolutionized with the introduction, in the late 1980s, of extracorporeal shock wave lithotripsy (ESWL), a non-invasive technology that has become one of the primary treatments for urinary stones. Its success rates vary depending on stone size and location and by the type of lithotripter employed. Medical expulsion therapy (MET) can play a key role in support of ESWL: specifically, expulsion is done by diuretics, calcium antagonists, anti-edema agents, and alpha-blockers. A few studies have reported their effectiveness (Borghi et al., 1994, Cervenakov et al., 2002, Porpiglia et al., 2002,Dellabella et al., 2003). Objective: This study is carried out to find out the role of Tamsulos in stone clearance in patientswith upper ureteral stone after extracorporeal shock wave lithotripsy (ESWL). Methods & Material: This randomized control clinical trialwas performed in Department of Urology, National Institute of Kidney Diseases and Urology, Sher-EBangla Nagar, Dhaka during the period from July 2015 to June 2017. A total of 70 cases with upper ureteric stone were included during the study period. Patients were selected randomly in every alternate sequence, odd numbers for experimental group, Tamsulosin+ ESWL, group A & even numbers for control group, only ESWL, group B. Stone clearance rate, number of ESWL session and stone expulsion time were evaluated. Results: In this study showed complete stone clearance one month after ESWL in Group A was 16(89%) and Group B was 16(84.21%) for stone size 6 to 10 mm. Comparison of clearance rate between two groups in stone size 6 to 10 mm was not statistically significant (p value >.05). Complete stone clearance one month after ESWL in Group A was 13(76%) and Group B was 07(43.75%) for stone size 11 to 15 mm. Comparison of clearance rate between two groups in stone size 11 to 15 mm was statistically significant (p value <.05). In this study requirement of number of ESWL sessions according to the stone size showed, in case of 6 to 10 mm stone size, average ESWL sessions 1.28±0.5 in Group A and 1.53±0.7 in Group B and in case of 11to 15 mm stone size, average ESWL sessions 1.29±0.5 in Group A and 1.62±0.7 in Group B. Comparison of ESWL sessions between two groups were statistically significant (p value <.05). In this study mean expulsion time of stone in Group A was 22.34±12.23 days and in Group B was 32.34±21.96 days. Comparison of stone expulsion time between two groups were statistically significant (p value <.05). Conclusion: Tamsulosin results in increased stone-free rates and in lower percentages of patients requiring re-treatment. Tamsulosin can be self-administered and can play a key role in the choice between tamsulosin after ESWL and only ESWL for upper ureteric stone disease treatment. Use of tamsulosin makes the expulsive medical therapy suitable for improving overall outcomes of ESWL treatment for upper ureteral stones. Tamsulosin helps in clearance of upper ureteral stones after ESWL. Bangladesh Journal of Urology, Vol. 23, No. 1, January 2020 p.36-42

To Compare the Efficacy of Tamsulosin, Solifenacin and Combination of Both in the Treatment of Double-J Stent Related Irritative Lower Urinary Tract Symptoms and Low Back Pain

Background: Stent-associated symptoms can have a significant impact on patient quality of life. Hematuria, urgency, frequency, dysuria, and both bladder and flank pain are the most prevalent symptoms related to indwelling ureteral stents. Among them irritative lower urinary tract symptoms and low back pain are more frequent. Despite the stent related symptoms, because of its importance stent is being kept in situ with varieties of medication. Several alpha-adrenergic blocker and antimuscarinic drugs are used to relief these symptoms like Tamsulosin, Solifenacin, Alphazosin etc. Both Tamsulosin and Solifenacin are not costly as use daily single dose. So combination of Tamsulosin and Solifenacin may act as a reliever of stent related symptoms and also cost effective. Methods and materials: For this purpose, a total of 126 patients having unilateral double-J ureteral stent for 7 days with stent related irritative LUTS and low back pain were included in this study. This hospital based prospective randomized clinical trial was carried out in Urology department of Bangabandhu Sheikh Mujib Medical University, Dhaka, during January 2014 to June 2015, to compare the irritative IPSS, improvement of quality of life score component of IPSS ,the low back pain score for double-J ureteral stent using Tamsulosin, Solifenacin and combination of both (Tamsulosin and Solifenacin) Results: Regarding the irritative sub group of International Prostate Symptom Score (IPSS) was observed during 2nd and 4th weeks follow up IPSS was significantly (p<0.05) higher in solifenacin and Tamsulosin group with compared to Tamsulosin+Solifenacin group. During 4th weeks follow up the mean quality of life (QOL) score was significantly (p<0.05) higher in solifenacin group and Tamsulosin group with compared to Tamsulosin+Solifenacin group.During 2nd weeks and 4th weeks follow up visual Analogue Pain Scale (VAPS) was significantly (p<0.05) higher in solifenacin group followed by Tamsulosin group and Tamsulosin+Solifenacin group. Conclusion: Combined use of Tamsulosin and Solifenacin is more effective than use of single drug (either Tamsulosin or Solifenacin) in the treatment of ureteral double-J stent related irritative LUTS and low back pain. Bangladesh Journal of Urology, Vol. 23, No. 1, January 2020 p.48-51

Flexible Cystoscopy a Valuable Diagnostic Lool for Lower Urinary Tract Pathology

Objective: To assess the role of flexible cystoscopy in the diagnosis of lower urinary tract pathology and its suitability as a routine diagnostic protocol in outdoor patients. Methods: The cross sectional study was conducted at the advanced centre of kidney diseases and urology, Dhaka central international medical college, Dhaka from Jan 2016 to jan2019. All adult patients presenting with lower urinary symptoms to outdoor department were included. Flexible Cystoscopy was performed as a outdoor based procedure without sedation. Results: Of the 249 patients in the study,198(79%) were male and 51(21%) were female. Lower urinary tract pathologies were found in 192(72%) patients. The most common pathology among males was enlarged prostate 56(31%) patients. Urethral stricture, bladder neck high were found 23(11%),21(10%) respectively. Among females, urethral stenosis was the most common pathology in 23(32%)patients. Transitional cell carcinoma was seen in 11(4.4%) patients having hematuria with inconclusive ultrasound and intravenous urography. .All patients tolerated the procedure well with no procedure related complaints. Conclusion: Flexible cystoscopy is an effective, well tolerated and easy way of detecting lower urinary tract pathologies. It can alter the management as well as support the diagnosis and management. It is also helpful in routine surveillance of bladder tumours of low grade and low stage. Flexible cystoscopy should therefore be used as routine diagnostic protocol in outdoor practice. Bangladesh Journal of Urology, Vol. 23, No. 2, July 2020 p.151-153

Comparative Study Between Mini PCNL and RIRS in the Treatment of Renal Stones <20mm : Our Experience in CMH Dhaka

Aim: The aim of this study is to compare the outcomes of miniaturized percutaneous nephrolithotomy (mini-perc) and retrograde intrarenal surgery (RIRS) in management of renal stones with a diameter <15 mm. Materials and Methods: This was an open-label prospective study that included a total of 80 cases underwent mini-perc (n = 40) and RIRS (n = 40) between July 2014 and August 2017. The primary outcome objective was stone-free rate, retreatment rate, complications, hospital stay, operative time, and reduction in hemoglobin level. Data were analyzed using SPSS version 16.0 Software. Results: Overall, 80 patients were enrolled in this study. The mean age was 40.12 and 38.20 years, and the mean stone size was 1.15 and 1.30 cm in mini-perc and RIRS group, respectively. Majority of the study participants were males. Overall, mini-perc and RIRS had stone clearance rates of 100% and 95.4%, respectively. Two patients required retreatment in RIRS group. The duration of hospital stay and the rate of complication was similar in both the groups. Operative duration was more in RIRS group. Decrease in hemoglobin level was more in mini-perc group. Conclusions: Results demonstrated that both modalities were associated with high stone clearance rates with minimal complications. RIRS was associated with less reduction in hemoglobin and could be used as standard treatment modality for small renal calculi. Bangladesh Journal of Urology, Vol. 23, No. 2, July 2020 p.199-204

A Case Report on Bilateral Adrenal Histoplasmosis

Disseminated histoplasmosis affecting the adrenal glands is a very rare infection and an uncommon cause of adrenal insufficiency. We present a case of bilateral adrenal histoplasmosis in a 77 years old immunosuppressed patient who presented with bilateral adrenal masses. The fine needle aspiration cytology of the adrenal mass was positive for Histoplasma capsulatum. Bangladesh Journal of Urology, Vol. 23, No. 2, July 2020 p.210-212

Low intensity Extra Corporeal Shock Wave Therapy in Patients with Erectile Dysfunction: Our experience in ACKU

Introduction: Oral 5-phosphodiesterase inhibitors (PDE5-I) is the main therapeutical options in erectile dysfunction (ED). It shows good results, but non-responders lack other effective options and its effect is also not long lasting. Since last few years, low-intensity extracorporeal shockwave therapy (Li-ESWT) in the corpora cavernosa showing promising results. This article presents our early experiences in Advanced Center of Kidney disease and Urology (ACKU) with the aim to evaluate clinical efficacy of Li-ESWT. Materials and methods: Thirty four patients with ED were prospectively included in the study during the period of January 2018 to Jun 2019.Treatment was performed using the PiezoWave2 (Richard Wolf, Germany) device with a linear probe. Treatment protocol included a weekly session for four weeks. Each session delivered 2000 shocks on the perineum plus 4000 shocks on dorsum penis with an energy flux density (EFD) of 0.160 mJ/mm2. Every patient has been re-evaluated 1.5 and 3 months after the last session. Pre- and post-procedure International Index Erectile Function – Erectile function domain (IIEF-EF) score, Erection Hardness Score (EHS) and Global Assessment Questionnaire-Question 1 (GAQ-Q1) answers were obtained. Results: Mean age of the study population was 39.4 (±12.9) years, 35.29% diabetic, 20.59% with hypertension and 55.85% smokers. Mean baseline IIEF-EF was 14.6, at 6 week post LiSWT was 16.4 (p >0.05) and at 3 months post LiSWT was 19.2 (p < 0.05). EHS was significantly improved at 3 month in comparison to baseline (p<0.05). 20.59% patients answered positively to GAQ-Q1 at 6 week and 61.76% at 3 months. IIEF-EF score change of >5 and increase of EHS >2 were observed in 62.88% and 70.59% study subjects respectively. Conclusions: Li-ESWT is a safe, harmless and repeatable treatment tool for ED with good outcomes reported. Bangladesh Journal of Urology, Vol. 23, No. 2, July 2020 p.176-180

Female Urethroplasty: A new hope for better quality of life

Introduction: Female urethral stricture is a difficult issue in Urology. Many of the times it may follow any sort of urethral instrumentation but in other cases no definite precipitating causes are unidentified. Methods: This was a prospective study. The sample size was n – 50. All cases were recurrent with the history of urethral dilatations, urethrotomies in multiple sessions. The diagnostic investigations in VCUG (voiding cystourethrogram), Ultrasound scan of kidney Ureter, bladder with post void residues, Uroflometry etc. Due to limitations, Urodynamic study was done in limited cases. Urethral augmentation was done using dorsal substitution of OMG (oral mucosal graft). Urethral catheter was left for 03 – 04 weeks. Results: After removal of catheter, urinary flow was observed; excellent in all the cases. It remain satisfactory in 06 months of follow-up. Overall result is excellent. Conclusions: Female urethral stricture is a difficult issue in Urology, Urethral dilatation, urethrotomies, clean intermittent catheterization are good options but need frequent procedures. Urethral augmentation with dorsal substitution of oral mucosal graft is a curative approach in long-run. Bangladesh Journal of Urology, Vol. 23, No. 2, July 2020 p.158-163