Biomedical subjects
Publications and source records attributed to P N Dogra.
Lymphangiomas are benign tumors of unknown etiology often seen in children, involving the neck (75%), and axillary (20%) region, but rarely the kidney [Zapzalka et al. (2002) Lymphangioma of the renal capsule. J Urol 168:220.]. We report a case of unilateral renal lymphangiectasia, where the diagnosis was made on imaging.
Congenital absence of uterus and vagina, Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, is mullerian agenesis and is the second most frequent cause of primary amenorrhea. Only atypical form of MRKH (type B) is associated with renal skeletal and ovarian abnormalities. We report the management of an unusual case of atypical MRKH, unilateral gonadal agenesis, and solitary ectopic pelvic kidney with pelviureteric junction obstruction (PUJO). After doing thorough Medline search, to the best of our knowledge, this is the first case reported with this combination.
PURPOSE: We evaluated the role of surgery for genitourinary tuberculosis with special emphasis on reconstructive procedures. MATERIALS AND METHODS: Case records of 241 patients with genitourinary tuberculosis who underwent surgery at our center during a period of 17 years were reviewed. Clinical features, organ involvement, investigations, treatment and outcome of therapy were studied. RESULTS: There were 129 males and 112 females with a mean age of 34.6 years. The most common presentation was irritative voiding symptoms. Azotemia was seen in 54 (22.4%) cases. The most commonly involved organ was the kidney in 130 (53.94%) cases. Preoperative bacteriologic diagnosis was confirmed in 70 (29%) cases. All patients received antitubercular drug therapy for 9 months. A total of 248 procedures, including 33 endoscopic, 87 ablative and 128 reconstructive, were performed with some patients requiring more than 1 procedure. Early complications, which mainly involved the bowel, were seen in 19 (7.88%) cases. Bacteriologic cure was achieved in all culture positive cases. Renal functional parameters stabilized or improved in 44 of 54 patients (81.5%) in whom they were deranged at presentation. CONCLUSIONS: Genitourinary tuberculosis is common in developing countries. Diagnosis is often delayed because of late presentation and many patients present with cicatrization sequelae. A combination of antitubercular drug therapy and judicious surgery achieves satisfactory results in the majority of cases. With improved antitubercular drug therapy and experience with the use of bowel segments in the urinary tract, more reconstructive procedures are being performed with satisfactory outcomes. In patients who undergo reconstructive procedures, a rigorous and prolonged followup is necessary.
Foreign body granulomas and pseudotumors due to retained surgical linen are well known in surgical practice. These lesions usually correspond to the actual size of residual foreign body and have characteristic presentation according to the anatomy involved. Renal suture granuloma is a rare postoperative complication of renal surgery due to persistence of sutures used to close the pelvicalyceal system/nephrotomy incisions and usually present as incidentally detected small mass lesions. This case of a suture foreign body granuloma presenting with hematuria, large peripheral mass lesion and characteristic computed tomography picture of renal cell carcinoma confounded the diagnosis and underwent laparoscopic radical nephrectomy. In retrospect, such lesions warrant the use of selective needle biopsy and intraoperative frozen section confirmation to clinch diagnosis. Mass lesions occurring in a previously operated kidney should have granuloma as a differential diagnosis.
Spinning top urethra (STU) denotes a particular urethral configuration that is a dilated posterior urethra mainly seen in young girls or women. STU deformity arises secondary to detrusor instability, leading to a rise the intravesical pressure against a closed sphincter. We describe a case of spinning top urethra in a 30-year-old woman who presented with lower urinary tract symptoms and left flank pain.
INTRODUCTION: Clinical results of radical cystectomy performed on elderly bladder cancer patients over 70 years old were assessed to determine whether age is one of the critical points for the application of this type of surgery. MATERIALS: From January 1992 to December 2002, 41 radical cystectomy performed in septuagenarian population were compared with 197 performed in patients less than 70 years of age. RESULTS: The early and late complication rate for septuagenarians was 29.7% and 12%, compared with 26.9% and 9.6% for patients younger than 70 years respectively. The overall mortality rate for septuagenarians was 4.9%, compared with 8.6% for patients younger than 70 years. There was no significant difference between the two groups with regard to pathologic stage or length of hospital stay. The 5-year overall survival rate for septuagenarians was 53% compared with 59% for patients younger than 70 years. CONCLUSIONS: When indicated after adequate preoperative assessment and optimization of the patient, radical cystectomy is a safe procedure in the septuagenarians and patient should not be denied surgery dependent on chronologic age.
We report a case of 20-year-old farmer with penile amputation and emasculation secondary to crushing injury inflicted by agricultural machinery. His entire penis, scrotum and both the testis had been avulsed after falling onto a rotating axel wheel of an electronically driven thrashing machine. After resuscitation the wound was thoroughly washed with saline, hemostasis achieved and a perineal urethrostomy was made from the remnant urethra.
A patient with urethral stricture presented to us with acute retention. Sequential dilatation over a guidewire was done and a suprapubic catheter was placed percutaneously. Guide wire broke during the procedure, which came to our notice on micturating urethrogram. Laser core through for the stricture and endoscopic removal of the guidewire were done.
Skeletal metastases from genitourinary tract are common, but metastatic tumors involving the hand and foot are rare. We herein present a case of 55-year-old man who presented with painful swelling of right foot and no urological complaints. Investigations revealed left renal mass and fine needle aspiration cytology from the swelling revealed findings consistent with metastatic clear cell carcinoma.
OBJECTIVES: To determine the safety and efficacy of holmium laser core-through urethrotomy (HolCTU) for the treatment of post-traumatic obliterative stricture of the urethra. METHODS: From June 2002 to March 2003, 29 men underwent the core-through procedure. All the patients had obliterative strictures of the bulbomembranous urethra. The length of the stricture was 2.5 cm or less, with good alignment between the two urethral ends. The holmium laser was used to vaporize the obliterative fibrotic tissue. The procedure was guided by a metal sound introduced through the suprapubic tract. Catheter removal and voiding cystourethrography were done at 6 weeks after the procedure and urethroscopy 1 month after catheter removal. RESULTS: At a mean follow-up of 15 months (range 10 to 19), the results were excellent in 19 (65.51%) of 29 patients. Nine (31.03%) had acceptable results; these patients failed to maintain good flow after HolCTU and required internal urethrotomy/endoscopic dilation once or twice for stabilization (maximal flow rate 15 mL/s or greater). Failure was seen in 1 patient (3.44%) who had recurrent obstruction despite repeated internal urethrotomy and finally required formal transpubic urethroplasty. The mean operating time was 40 minutes (range 30 to 90), with mean hospital stay of 8 hours (range 6 to 48). No perioperative complications occurred, except in 1 patient who developed small extravasation of fluid locally. All the patients were continent, and potency status was unaffected by HolCTU. CONCLUSIONS: HolCTU is a safe and simple treatment for obliterative urethral strictures. The procedure is less morbid than open repair with a slightly greater failure rate.
We report two unusual cases of spontaneous nephrocutaneous fistulas. They were discovered to be the cases of neglected calculous disease in a poorly functioning kidney and tuberculous pyelonephritis respectively. A timely nephrectomy cured their debilitating condition and prevented further morbidity. We have discussed the etio-pathogenesis, clinical and diagnostic approach towards the cases of nephrocutaneous fistula. The literature regarding nephrocutaneous fistula has been reviewed and discussed. A stepwise algorithm has been proposed to manage cases of nephrocutaneous fistulas.
PURPOSE: Laparoscopic nephrectomy has become a routine procedure at specialized centers with the advantages of less postoperative pain, minimal scars, rapid recovery and short convalescence. We report our experience with the establishment of retroperitoneoscopic nephrectomy as the standard of care for benign nonfunctioning kidneys. MATERIALS AND METHODS: We retrospectively compared the records of patients who underwent simple nephrectomy retroperitoneoscopically or by open surgery from January 1998 to October 2003 at our center. RESULTS: A total of 351 simple nephrectomies were done retroperitoneoscopically, while 83 were done as an open procedure. Mean operative time was significantly longer in the retroperitoneoscopic group. However, mean blood loss, complication rate, hospital stay and convalescence were significantly less in the retroperitoneoscopic group. CONCLUSIONS: Retroperitoneoscopic nephrectomy has become a standardized procedure. It should be offered as the primary treatment modality to patients with benign renal disease scheduled for elective nephrectomy except in those in whom it is contraindicated.
OBJECTIVE: To present the technique of dorsal buccal mucosal graft urethroplasty through a ventral sagittal urethrotomy and minimal access perineal approach for anterior urethral stricture. PATIENTS AND METHODS: From July 2001 to December 2002, 12 patients with a long anterior urethral stricture had the anterior urethra reconstructed, using a one-stage urethroplasty with a dorsal onlay buccal mucosal graft through a ventral sagittal urethrotomy. The urethra was approached via a small perineal incision irrespective of the site and length of the stricture. The penis was everted through the perineal wound. No urethral dissection was used on laterally or dorsally, so as not to jeopardize the blood supply. RESULTS: The mean (range) length of the stricture was 5 (3-16) cm and the follow-up 12 (10-16) months. The results were good in 11 of the 12 patients. One patient developed a stricture at the proximal anastomotic site and required optical internal urethrotomy. CONCLUSION: Dorsal buccal mucosal graft urethroplasty via a minimal access perineal approach is a simple technique with a good surgical outcome; it does not require urethral dissection and mobilization and hence preserves the blood supply.
OBJECTIVES: To evaluate the role of newer imaging modalities in the diagnosis and evaluation of management according to extent of renal vein (RV) or inferior vena cava (IVC) thrombi in patients with renal cell carcinoma. MATERIAL AND METHODS: Fifty-nine patients with renal cell carcinoma and tumor thrombus extension into the RV or IVC were studied. Diagnosis was based on contrast-enhanced CT, magnetic resonance imaging or color-Doppler ultrasonography. Surgical treatment was contemplated in 42 suitable patients and complete resection could be done in all but 3 cases. RESULTS: There were 48 males and 11 females with mean age of 51.8 years. Isolated RV involvement was seen in 27 cases whereas IVC extension was present in 32 cases. The thrombus extent was infrahepatic in 62.5% (20/32) patients with IVC extension. With the newer imaging modalities like contrast-enhanced CT, color-Doppler ultrasound and/or magnetic resonance imaging, correct diagnosis of the extent of the thrombus was possible in 95% of the patients. The accuracy of color-Doppler ultrasound was same as magnetic resonance imaging in the evaluation of the extent of the thrombus. In the present series a median follow-up of 4 years revealed a high incidence of local and distant recurrences and decreased survival in patients presenting with advanced disease, who had venous wall invasion. CONCLUSIONS: The extent of RV or IVC thrombi can be accurately diagnosed with contrast-enhanced CT scan and in case of doubt color-Doppler ultrasound is a good alternative to magnetic resonance imaging. Management can be planned according to the level of the tumor thrombus. Invasion of the venous wall was found to be a bad prognostic factor affecting survival.
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This study analysed the feasibility and effectiveness of Nd-YAG laser core-through urethrotomy in the management of obliterative posttraumatic urethral strictures in children. Between May 1997 and April 2000, 61 patients underwent core-through urethrotomy in posttraumatic urethral strictures, ten of whom were children (ages 5-15 years). Three patients had had previous railroading procedures, two attempted core-through urethrotomy, and two underwent end-to-end urethroplasties. Patients were on suprapubic cystostomy for a mean period of 12 months with mean stricture length of 2 cm. Nd-YAG laser core-through urethrotomy was carried out using 600- micro m bare-contact fibre as a day care procedure. There were no intraoperative or postoperative complications. Micturating cystourethrography was performed 6 weeks following urethral catheter removal. Urethroscopy and uroflowmetry were carried out after 3 months. Mean follow-up was 24 months.Nd-YAG laser core-through urethrotomy was seen to be successful in all patients without any complications. All patients are voiding without obstructive symptoms. Four required optical urethrotomy/endoscopic dilatation at least twice. Nd-YAG laser core-through urethrotomy is a safe and effective procedure for the management of obliterative posttraumatic urethral strictures in children
OBJECTIVES: To evaluate the efficacy of different imaging modalities for visualization of small poorly functioning hypoplastic and dysplastic kidneys and to assess the role of laparoscopy in localization and treatment. METHODS: Between 1998 and 2002, 10 female patients who presented with urinary incontinence, flank pain, or hypertension secondary to small, poorly functioning hypoplastic or dysplastic kidneys were treated at our institute. We reviewed the results of the imaging studies, cystoscopy, and evaluation under anesthesia for these patients. After the diagnosis, all patients were treated with laparoscopic retroperitoneal or transperitoneal nephroureterectomy or nephrectomy. RESULTS: Intravenous urography and ultrasonography failed to visualize the affected renal units in all 10 cases. Computed tomography could locate small dysplastic renal units in only 5 patients (50%). Dimercaptosuccinic acid renal scintigraphy was diagnostic in all 10 cases (100%). Magnetic resonance urography was done in 2 cases only, and the affected renal units were identified in both. Cystoscopy and vaginoscopy were inconclusive in all but 2 cases. Laparoscopy efficiently located the offending renal units in all 10 cases. In 9 cases, the affected renal units were located in the lumbar region, and in 1 case it was situated ectopically in the pelvis. All 10 patients underwent laparoscopic retroperitoneal or transperitoneal nephroureterectomy or nephrectomy and were asymptomatic after surgery. CONCLUSIONS: Dimercaptosuccinic acid scintigraphy is an accurate and specific imaging modality for visualization of small hypoplastic renal units that are not visualized by conventional radiologic imaging techniques. Laparoscopy can be recommended as the ideal method of management, because it provides a minimally invasive technique for detecting the kidney and simultaneously correcting the problem.
BACKGROUND AND OBJECTIVE: Patients with carcinoma urinary bladder with metastasis to the lymph nodes have been believed to have a poor prognosis. The various factors affecting survival in this subset of patients are not well understood. To analyze, these factors, we retrospectively analyzed patients who had undergone radical cystectomy at our center in the last 10 years. METHODS: From Jan. 1991 to May 2001, 158 patients underwent radical cystectomy at our center. 38 of these were found to have metastasis in the regional lymph nodes (i.e. stage D). A multivariate regression analysis was done to look for factors, which predict a better survival in this group of patients. Patients were studied for age, sex, morphology of tumour (papillary or nodular), grade of tumour, local extent of the disease (T1 T3A OR T3B), lymph nodal involvement, chemotherapy (whether received or not) and no. of TUR resection before radical cystectomy. SPSS software was used and the actuarial disease specific survival calculated for each variable. RESULTS: There were 33 males and 5 females with an age range of 34-75 years (mean 56). Overall survival was 7 months to 84 months with mean of 32 months. Patients with polypoidal disease had better survival (66 months vs 15 months). Also patients with organ-confined disease (T2, T3a) had better survival than those with perivesical spread (T3b). The mean survival in N1 and N2 disease was 36 and 10 months respectively. The benefits of adjuvant chemotherapy (methotrexate and cisplatin) could not be assessed as most of the patients received chemotherapy. CONCLUSION: Patients with positive lymph nodes for metastases have fairly good survival with radical cystectomy especially those who have a lower T stage (organ confined), papillary morphology and N1 disease.