Significance of inflammatory biomarkers and urethral histology in patients with urethral stricture disease in relation to treatment outcome—a single centre prospective study in the north-eastern part of India

Background Inflammation plays a very important role in defining the urethral stricture. Inflammatory biomarkers may play an important role in predicting the underlying pathophysiology as well as outcome of surgery. Histology of urethral strictures along with histology of urethra proximal and distal to stricture segment may have a role in predicting the outcome of the surgery. The literature discussing this aspect is rare; thus, this novel study aimed to find out the role of inflammatory biomarkers and urethral histology in predicting the outcome of surgery in urethral stricture disease. Methods This prospective study had 105 patients with age more than 15 years with urethral stricture. Baseline characteristics, routine blood tests including inflammatory blood markers (CRP, ESR, HbA1C, fasting insulin, serum ferritin, etc.) were recorded. They underwent various types of surgery, and first biopsy was taken from stricture segment and second biopsy from proximal to stricture segment and third biopsy from distal to stricture segment and evaluated for the presence of features of lichen sclerosus and inflammation. Primary endpoint was to diagnose the role of inflammatory biomarkers and histology of stricture in stricture recurrence. Results Their mean age was 43.3 ± 13.46 years. Mean CRP of 11.54 ± 3.64 in patients with failure and 9.59 ± 2.77 in patients with successful outcome (p 0.025). Other inflammatory biomarkers like HbA1C, fasting insulin, ESR, serum ferritin, NLR had no significant correlation with the outcome. The presence of features of lichen sclerosus like hyperkeratosis and severe inflammation in stricture segment predicted higher likelihood of failure. Histology of proximal and distal segment of urethral stricture had no significant relationship in predicting outcome. Staged urethroplasty with buccal mucosal graft outperformed single-stage urethroplasty in biopsy-proven LS strictures. Conclusions The present study found a negative impact of increased CRP and the presence of features of lichen sclerosus in urethral histology with the outcome of urethral stricture disease. Thus, our study confirms that inflammatory biomarkers (CRP) and histology of stricture segment play a significant role predicting the outcome of surgery.

The efficacy of fosfomycin trometamol in prevention of postoperative urinary tract infection in pregnant women after endoscopic procedures: open clinical trial

Background Fosfomycin tromethamine is recommended (category B) for the treatment of urinary tract infections in pregnant women. We aimed to evaluate the efficacy of single-dose preoperative fosfomycin tromethamine in the prevention of urinary tract infection in pregnant women who underwent lower urinary tract endoscopic surgeries. Methodology The subjects of this study were pregnant women who underwent lower urinary tract endoscopic procedures. All patients received Fosfomycin tromethamine1 packet (3 g) dissolved in water the day before surgery. Routine pre- and postoperative urine analysis and urine cultures were performed when needed. Patients were monitored for urinary tract infections and the side effects of the drug. Moreover, maternal and fetal complications were monitored. Results The study was conducted on 31 pregnant women with a mean age of 24.48 ± 5.35 years. The endoscopic procedures were as follows: 28 (90.3%) DJ ureteric insertions for hydronephrosis, 2 (6.5%) urinary bladder stones, and cystoscopy (3.2%) for gross hematuria. Two (6.5%) patients had postoperative asymptomatic bacteriuria that resolved with oral antibiotic therapy. Conclusion Fosfomycin tromethamine is safe in preventing urinary tract infection and decreases the need for postoperative parenteral antibiotics in pregnant women who require lower urinary tract endoscopic procedures.

Scrotal reconstruction with pedicled gracilis muscle flap following Fournier’s gangrene: a case report and literature review

Background Fournier’s gangrene is an acute soft tissue necrotizing infection involving the perineum and the external genitalia which can result in a major loss of the scrotal wall with exposure of the testicles. Reconstruction of such major defect is quite challenging; the use of pedicled gracilis muscle flap helps to create an aesthetically acceptable scrotum with minimal donor site morbidity. Case presentation We described the case of a 60-year-old man with a large scrotal loss from Fournier’s gangrene following bladder outlet obstruction and perineal abscess. He had multiple debridement and reconstruction with pedicled left gracilis muscle flap with a good aesthetic and functional post-operative outcome. The major challenge encountered was the loss of the skin graft as a result of the retraction of the muscle flap due to too early ambulation; this can thus be avoided by adequate pre-operative counseling and enforcing bed rest. Conclusions The use of gracilis muscle flap in the reconstruction of large scrotal defect described in this report has the additional advantage of creating a pliable and soft feel like that of the original scrotum with minimal donor site morbidity.

Primary adenocarcinoma of renal pelvis or ureter: an uncommon histopathological entity seen in three cases

Background Primary adenocarcinoma of renal pelvis or ureter is rarest (< 1%) among all urothelial tumors. Regrettably, no characteristic symptoms, radiological features and treatment for this tumor are reported. We report three cases of adenocarcinoma of renal pelvis and ureter. Case presentation Case 1 had grossly hydronephrotic non-functional right kidney and underwent percutaneous nephrostomy followed by laparoscopic simple nephrectomy. Incidentally, histopathological examination reported adenocarcinoma of renal pelvis. Whole-body positron emission tomography-CT (PET-CT) ruled out malignancy at other sites. Patient refused adjuvant chemotherapy. Case 2 presented with previous history of right pyelolithotomy, right ureteroscopic lithotripsy and right flank pain with intermittent discharge via previous percutaneous site. On biochemical and radiological investigations, right poorly functioning pyonephrotic kidney was confirmed. Patient underwent right open nephrectomy which incidentally reported adenocarcinoma of renal pelvis. Patient is disease-free at 18 months of follow-up. Case 3 had left ureteric wall thickening on CT scan when evaluated for hematuria. Ureteroscopic-guided biopsy showed villous adenoma. Laparoscopic left nephroureterectomy with bladder cuff excision specimen showed well-differentiated adenocarcinoma in ureter with extension into periureteric fat. Patient died 32 months after surgery. Conclusion Primary adenocarcinoma of renal pelvis or ureter is very rare and urologists should suspect it in patients with mucinous material in nephrostomy tube. We should have a low threshold for performing radical nephrectomy with complete ureterectomy in these unusual cases to improve the prognosis.

Exercise-induced ruptured renal tumour in a young patient with hereditary leiomyomata-associated renal cell carcinoma (HLRCC): a case report

Background Hereditary leiomyomatosis-associated renal cell carcinoma (HLRCC) is rare with only 300 families reported to date worldwide. Despite highlighting renal malignancy, it is infamous for its cutaneous and leiomyomatosis component as the more common cause of presentation. This report is to highlight the rare presentation of HLRCC which occurs in a teenager which is unfortunately complicated with exercise-induced renal tumour rupture. Case presentation A 22-year-old gentleman presented with severe right lower abdominal pain for 4 days, associated with fever and nausea following a session of strenuous exercise. He has first-degree relatives and second-degree relatives from his maternal side who were genetically tested positive for HLRCC. Clinical examination revealed a tender right lumbar and right iliac fossa region. A computed tomography of the kidneys demonstrated a ruptured right renal tumour with a large right renal subcapsular and contained right retroperitoneal hematoma. An emergency right radical nephrectomy was performed, and he recovered well. The histopathological examination was consistent with HLRCC associated ruptured right renal cell carcinoma. Conclusion Identification of this underreported familial malignancy is paramount as the onset of neoplasia occurs much earlier in life. This necessitates screening of family members at a younger age, and the management is followed by life-long surveillance.

Prophylactic role of ciprofloxacin and ceftriaxone in prostate biopsy-related infection: randomized comparative study of bacterial spectrum and antibiotic sensitivities

Background The mainstay for the diagnosis of prostate cancer is transrectal ultrasound-guided prostate biopsy. However, prostate biopsy is associated with a significant risk of complications including urinary tract infection. This study aims to compare the bacterial profile and antibiotic susceptibility pattern in urinary tract infection after prostate biopsy between patients on 2 different antimicrobial prophylactic regimens. Methods This was a comparative cross-sectional study done at the urology unit of our institution, over 13 months. Fifty-six patients who met the inclusion criteria made up the study population and were randomly assigned to two groups. Those in group 1 (28) received intravenous ciprofloxacin (Juhel) 400 mg at induction of anesthesia, while those in group 2 (28) received intravenous ceftriaxone (Rocephin) 1 g at induction of anesthesia. All patients received bisacodyl (dulcolax) rectal suppositories 20 mg nocte starting 2 nights before the procedure as well as intravenous metronidazole (Juhel) at induction of anesthesia. Urine samples were taken for urine culture and sensitivity three days after biopsy. Isolated organisms and their antibiotics sensitivities were documented. Statistical analysis was done using SPSS version 21.0 with the level of significance set at P < 0.05. Results In group 1 the prevalence of urinary tract infection was 61%. Escherichia coli was isolated in 11(64.71%) cases, Klebsiella species in 3(17.65%), staphylococcus aureus in 1(5.88%), Proteus species in 1(5.88%), and non-hemolytic streptococcus species in 1(5.88%). In this group, all isolated bacterial organisms were resistant to ciprofloxacin. In group 2 the prevalence of urinary tract infection was 43%. Klebsiella spp was isolated in 6(50%) cases, Pseudomonas aeruginosa in 3(25%), E. coli in 2(16.67%), Staphylococcus in 1(8.33%). In group 2 all isolated bacterial organisms were resistant to ceftriaxone. Conclusion Ciprofloxacin and ceftriaxone are both associated with a high rate of urinary tract infection when used as prophylaxis for prostate biopsy. The bacterial etiology of prostate biopsy-related urinary tract infection is dependent on the prophylactic antibiotics used. Based on the high rate of urinary tract infection associated with the use of either ciprofloxacin or ceftriaxone, we recommend a combination of both drugs as prophylaxis for prostate biopsy.

Impact of surgical intervention on progression to end-stage renal disease in patients with posterior urethral valve

Background Posterior urethral valve patients present with varied presentations at any age of life and have significant associated morbidity and require long-term follow-up and care. Methods This was a single-center ambispective cohort study carried out over a period of 2 years. Patient data regarding the symptoms, investigations, interventions, secondary complications were recorded and were followed up regularly during the study till either normalization of their creatinine level which was maintained up to one-year post-fulguration (non-CKD) or progression to end-stage renal disease (ESRD) requiring renal transplant. Various clinical factors were then compared between these groups. Results The age of presentation varies from 6 months antenatal period to a maximum of 34 years. Most common symptom was of lower urinary tract obstruction, followed by recurrent febrile UTI. The interval between disease presentation detection and PU valve fulguration ranged from 6 days to more than 5 years, median duration being 1 month. 85.7% patients had hydroureteronephrosis on initial USG. In VCUG, there was no significant difference found between the presence of reflux and poor renal outcome. Age of presentation greater than 2 years was seen in 52% of patients with CKD compared to only 10% patients in non-CKD group (significant, p value 0.02). Among patients who developed CKD, 60% of patients had PU valve fulguration after one month of disease presentation, while in contrast, among the non-CKD group, 80% of patients had it done within one month of disease presentation. (significant, p value 0.03). Conclusions Late age of presentation, delayed fulguration with high initial creatinine, and failure of serum creatinine to return to normal after one-month post-fulguration are important risk factors in the progression of the disease to ESRD. Symptomatic improvement after interventions does not correlate with progression to ESRD. The number of interventions also does not predict progression to ESRD. Interventions should be chosen wisely on case to restore near-normal physiology and delay progression to ESRD.

Laser lithotripsy using dusting technique (low energy, high frequency) for symptomatic upper urinary tract stones

Background A prospective study to assess the feasibility of stone dusting technique (low energy and high frequency) during laser lithotripsy in symptomatic upper urinary tract |(UUT) stones. Methods Sixty patients with symptomatic single or multiple UUT stones less than 3 cm in diameter were included. Patients with coagulation disorders and active UTIs were excluded. All patients were clinically evaluated and underwent non-contrast spiral CT (NCSCT) to detect stone site, size, number, Hounsfield unit. A rigid or flexible ureteroscope was used with stone dusting using the Ho: YAG laser at low-energy and high-frequency (0.5 J & 20 Hz) set. Operative and fluoroscopy time, total energy delivered, type of stent, hospitalization time, complications and its grade, and stone-free rate using NCSCT after 4 weeks were recorded. Results The mean stone size ± SD (range) was 1.55 ± 0.55 (0.5–3) cm; out of sixty patients (50 with single stone and 10 with multiple stones), fifty-five patients were stone-free at 4 weeks. Complications had occurred in 11 patients (eight with grade I, one with grade II, and two with grade IIIa) according to Clavien–Dindo grading of surgical complications. Stone size was the only parameter which correlated significantly with stone-free rate. No significant correlation was found between incidence of complications and other parameters (stone size, site, BMI, age and operative time). Conclusions Stone dusting technique is feasible, safe and effective in management of UUT stones.

Robotic excision of interaortocaval paraganglioma: a case report with the literature review

Background Paragangliomas are rare neuroendocrine tumors of extra adrenal origin. The symptomatic paragangliomas require multimodal treatment approach. Case Presentation We report a case of 34-year-old female who presented with complains of headache and blurring of vision. Examination revealed Hypertensive crisis with grade 3 retinopathy. The patient was diagnosed as a case of extra-adrenal paraganglioma during evaluation for secondary hypertension. Magnetic Resonance Imaging of the abdomen revealed 23*28*28 mm mass lesion in the inter-aortocaval region at the level of L3–L4. The patient was started on medical management for hypertension and was managed safely with robot-assisted surgery, owing to enhanced visualization of feeding vessels and avoidance of excessive manipulation of tumor. Conclusions Our case report emphasizes on the robot assisted surgical technique for the removal of tumor in a vulnerable anatomical position and presents a review of the literature.

Presentation and management of pheochromocytomas and paragangliomas: about 40 cases

Background Pheochromocytoma and paraganglioma are rare neuroendocrine tumors of the chromaffin tissue, which may produce catecholamines. The aim of our study was to analyze the clinical and para-clinical aspects as well as the therapeutic and evolutionary aspects of pheocromocytomas and paragangliomas based on a series of 40 cases. Methods Our retrospective population-based research study includes 40 patients. Then, a statistical analysis was carried out using the SPSS software (version21). Results Our study involves 40 patients, including 23 women (57, 5%) and 17 men (42,5%). The mean age at the time of the diagnosis was 43.8 ± 16.8 years. The circumstances of the discovery were mainly characterized by adrenal incidentaloma and hypertension. The biological diagnosis was based on the dosage of urinary metanephrines and plasma-free metanephrines in, respectively, 61.5% and 18% of cases. A computerized tomography scan and/or a magnetic resonance imaging scan could help to locate the tumor in 100% of cases. Our series includes 3 cases of bilateral pheochromocytoma, 3 cases of paragangliomas and 1 case of malignant pheochromocytoma, while a hereditary form was retained in 3 patients. In fact, thirty-two patients were operated; cure was clinically labeled in 100% and biologically in 87.5% of patients. Conclusions The main points for improvement that our study has revealed are; a patient follow-up after surgery, which was not always regular, and an insufficient screening for genetic diseases associated with pheochromocytomas and paragangliomas.