Biomedical subjects
Publications and source records attributed to Ganesh Gopalakrishnan.
We describe the use of a pedicled tunica vaginalis flap to cover the anastomotic area after progressive elaborated perineal bulboprostatic anastomotic urethroplasty. Urethroplasty is completed in the standard technique. The tunica is opened longitudinally and dissected away as a rectangular flap from the testis and wrapped around the urethra.
OBJECTIVE: To present our experience with three cases of rectoprostatic fistula with special emphasis on diagnosis and conservative management. PATIENTS AND METHODS: Three middle-aged men presented to us differently. All had spontaneous rectoprostatic fistulas. Biopsy showed tuberculosis though three consecutive urine samples for acid-fast bacilli were negative. None of the patients were immunocompromised. Their upper tracts were normal and all had a past history of pulmonary tuberculosis. They were started on antitubercular drugs and urinary diversion with or without faecal diversion. RESULTS: All fistulae healed completely within 6 weeks of starting antitubercular treatment. One patient healed with bladder neck stenosis that required bladder neck incision. Voiding was normal on 1-year follow-up. CONCLUSION: Spontaneous tubercular rectoprostatic fistulae are rare. There should be a strong clinical suspicion in endemic areas. Prostatic biopsy proves the diagnosis. Conservative management with antitubercular drugs and urinary diversion with or without faecal diversion has a high success rate and should be the first line of treatment even if urine is negative for acid-fast bacilli.
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OBJECTIVE: Use of shock-wave lithotripsy (SWL) for lower caliceal calculus is associated with a relatively high rate of residual fragments. Various radiographic anatomical factors of the lower calix predicting the outcome of lithotripsy have been described and have generated considerable discussion. We aimed to reassess the role of these factors in predicting clearance of lower caliceal stones by SWL. MATERIAL AND METHODS: Between January 1998 and December 2001, 148 patients underwent SWL for solitary lower caliceal stones using a Dornier Compact S lithotripter. The infundibular length, infundibular width, caliceopelvic height and infundibulopelvic angle were measured. Success was defined as either complete clearance or clearance with insignificant residual fragments <4 mm in size at 3 months follow-up. The results were analysed using the chi2 test and logistic regression analysis. RESULTS: Complete clearance was seen in 69% of cases and clearance with residual fragments <4 mm in size at 3 months was seen in 5%. The overall clearance rate at 3 months was 74%. Infundibular length, infundibular width, caliceopelvic height and stone size were not found to be statistically significant in predicting clearance. None of the patients had an infundibulopelvic angle of >90 degrees. Contrary to most previous studies, univariate and multivariate analysis revealed that an infundibulopelvic angle of <70 degrees was statistically significant in predicting clearance in the stone-free group. CONCLUSIONS: The use of radiographic anatomical factors to predict clearance of lower caliceal stones following SWL is an attractive concept. However, based on this study, we feel that these factors do not merit the attention they have attracted. In routine practice, regardless of the radiological anatomy, SWL continues to be the initial treatment option, given its non-invasive nature and ease of administration.
OBJECTIVE: To compare the efficacy of fine-needle aspiration cytology (FNAC) with that of open biopsy in the evaluation of chronic epididymal lesions. MATERIAL AND METHODS: Forty men evaluated for chronic epididymal lesions were studied. Men aged >25 years who did not intend to father any more children and had had local symptoms for >6 weeks were included. Of these 40 men, 23 who satisfied the above criteria were subjected to FNAC and open biopsy. The slides were reviewed by two independent pathologists. The sensitivity, specificity and positive predictive value of FNAC were compared with the results of open biopsy. RESULTS: Tuberculous epididymitis was the commonest cause of chronic epididymal lesions, followed by non-specific epididymitis, sperm granuloma, epdidymal cyst and normal epididymis. The sensitivity and specificity of FNAC for the diagnosis of tuberculous epididymitis were 87% and 93%, respectively. For the diagnosis of non-specific epididymitis, FNAC was 100% sensitive and 100% specific. The positive predictive value was 87% for the diagnosis of both tuberculous and non-specific epididymitis. CONCLUSIONS: FNAC has an overall sensitivity and specificity of 90% for diagnosing chronic epididymal lesions, with a positive predictive value of 87.5%. It is a valuable tool for evaluating chronic epididymal lesions. We suggest that FNAC should be the first-choice investigation for establishing the histopathological diagnosis of epididymal lesions.
OBJECTIVE: To evaluate potential donor kidneys with asymptomatic calculi detected during screening, and the management of the calculus before, during and after transplantation, as with fewer live donors, marginal kidneys and donors are a significant subgroup in renal transplantation. PATIENTS AND METHODS: Five live-related donors, with one incidentally detected calculus during their routine evaluation, were accepted for transplantation. Of these, three were detected only on spiral computed angiography. There was no biochemical evidence of a metabolic abnormality or history of stone disease. One donor had elective lithotripsy and another nephrolithotomy under ultrasonographic control immediately after perfusion. The others were transplanted with the calculus in situ. Ureteric reimplantation was by the Leadbetter-Politano technique over a JJ stent. RESULTS: One recipient patient passed the calculus within 4 h of stent removal. The follow-up ultrasonogram at 3 months showed a stone in only one recipient. In the others, the calculus could not be seen after stent removal. The maximum follow-up was 2 years and graft function has remained normal in all. CONCLUSIONS: Voluntary kidney donors with one calculus incidentally detected on routine evaluation form a unique group and can be accepted for transplantation in selected cases. Careful follow-up of the donor and recipient is essential, with early intervention if necessary.
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OBJECTIVE: To review the presentation of tubercular ureteric strictures and assesses the role of balloon dilatation and open surgical repair in their management. METHODS: This was a retrospective review of tubercular ureteric strictures managed between January 1993 and December 2002. The records were analyzed to assess clinical presentation and compare the results of balloon dilatation with open surgical repair. Success was defined as adequate drainage on imaging, no worsening of renal function, no recurrence of symptoms and no requirement of intervention on further follow up. The long term success rates were compared using the t-test for proportion. RESULTS: Of 73 strictures, 88% had lower urinary tract symptoms. Genital abnormalities suggestive of tuberculosis was observed in 40% male patients. Urine examination yielded aseptic pyuria in 85%, positive AFB smears in 36% and positive AFB cultures in 32%. A small capacity bladder and non-functioning renal units were the only consistent findings on intravenous urogram. Nephrectomy was performed in 37% cases due to non salvageable kidneys at presentation. The success rate of stenting fell from 93% on immediate follow up to 59% on a follow-up of 12 months. At 90% success rates on a follow-up of 7 months open surgical repair was superior (p 0.03). Long term success following balloon dilatation in renal units with good function was 78% compared to 25% for poorly functioning units. (p= 0.01) CONCLUSION: Open surgical repair is superior to balloon dilatation in the management of tubercular ureteric strictures. Renal function may predict the success of balloon dilatation.
During evaluation for loin pain a 54-year-old man was found to have bilateral upper ureteric strictures with hydroureteronephrosis on imaging. Renal function tests were normal. There was no peripheral eosinophilia but an excision biopsy of the stricture revealed eosinophilic ureteritis. As the patient had a previous history of cellulitis with epididymitis and came from an endemic area, filariasis should be considered as a possible triggering etiology.
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We report the CT and MRI appearances of dilated retroperitoneal lymphatic channels in six patients. In two patients, these dilated channels resembled a mass of confluent low-density lymph nodes on CT. On MR urography the lymphatic channels in all six patients were seen as a meshwork of multiple tubular, tortuous, fluid-filled structures in the retroperitoneum of the abdomen and pelvis. On axial T1W images, these channels were seen as numerous, interconnected small, nodular and streaky intensities and as a cloak of diffuse homogenous hyperintensity on T2W axial images. The lymphatic nature of these abnormalities was confirmed at surgery in one patient. In another patient, the calibre and number of the dilated retroperitoneal channels reduced following anti-filarial therapy. The remaining four patients presented with chyluria.
BACKGROUND: Tuberculous epididymitis is one of the causes of chronic epididymal lesions. It is difficult to diagnose in the absence of renal involvement. AIM: To profile isolated tuberculous epididymitis and to assess our approach in the evaluation of this group of patients. SETTING AND DESIGN: Retrospective study done at Christian Medical College, Vellore, South India. METHODS AND MATERIALS: Between 1992 and 2002, 156 fine needle aspiration cytology specimens and 108 epididymal biopsies were carried out in 187 men for evaluation of chronic epididymal nodules. Isolated epididymal tuberculosis was defined as "tuberculous infection affecting the epididymis without evidence of renal involvement as documented by the absence of acid fast bacilli in the urine sample and on imaging". The age, laterality, mode of presentation and method of histological diagnosis were studied with the objective of profiling isolated tuberculous epididymitis. RESULTS: Fifty-four of the 187 men (median age 32 years; interquartile range: 21-37 years) had tuberculous epididymitis. Fourteen were excluded from the analysis (10 had associated urinary tract tuberculosis and 4 were lost to follow-up). None of the 40 men with isolated tuberculous epididymitis had urinary symptoms. Bilateral involvement was seen in five (12.5%) cases. The salient presenting features included painful swelling (16 subjects, 40%), scrotal sinus (4, 20%) and acute epididymitis (2, 10%). Past history or concomitant presence of tuberculosis was noted in three subjects each. Anti TB treatment resulted in a complete response in 10 and partial response in 18. Five subjects underwent epididymectomy. Tuberculous epididymitis was found incidentally in 5 (10%) cases on high orchiectomy specimen done for suspected testicular tumour. CONCLUSIONS: Tuberculous epididymitis can be the sole presentation of genitourinary tuberculosis.
BACKGROUND: Intracavernosal injection of vasoactive drugs is an established method of evaluating erectile dysfunction. However, it is invasive and may be associated with pain and priapism. We investigated the use of oral sildenafil as a possible substitute for intracavernosal agents. METHODS: Men with erectile dysfunction were randomized into two groups of 25 each. One group of 25 men received injection papaverine initially followed by oral sildenafil, and another 25 received oral sildenafil followed by injection papaverine. Genital self-stimulation was used in both the groups. Penile length and circumference as well as angle of erection, before and after each medication, were recorded. Two days later, the intervention arms were crossed over. Subjective responses were obtained. The effect of medication on each outcome variable was studied by using analysis of variance models in relation to patient, period and medication. RESULTS: There was statistically significant improvement from the baseline value in both the arms, i.e injection papaverine and oral sildenafil (p<0.001, p<0.001, respectively) for both penile length and circumference. No significant difference was observed between the two medications in the outcome measures. CONCLCUSION: Oral sildenafil was as effective as injection papaverine in evaluating erectile dysfunction.