Defining the "Cutoff" on the Urethral Caliber in Diagnosing a Female Urethral Stricture

Introduction The rarity in detecting female urethral stricture (FUS) backed by the inconsistency regarding the cutoff on the caliber to direct any treatment for its increase poses a challenge to its existence. Therefore, the present study was conducted to determine the caliber of the urethra that clearly identifies a FUS. Materials and method In this prospective observational study conducted between November 2015 and July 2017, women with obstructive lower urinary tract symptoms (LUTS) and a history of relief on at least a single urethral dilatation were included if the American Urological Association (AUA) score was more than seven and the maximum flow rate (Qmax) was less than 20 mL/sec. Of the 71 women recruited, 10 women had recognizable external causes: caruncle (five), mucosal prolapse (three), and meatal stenosis (two). The remaining 61 underwent voiding cystourethrogram (VCUG) and urodynamics followed by urethrocystoscopy, if the findings suggested a stricture. A definitive diagnosis was sought in those without stricture disease. We categorized all patients as either having a "true" stricture or an alternate etiology. Categorical variables were presented in number and percentage (%) and continuous variables as mean ± standard deviation (SD). Results The mean dilatation ranged between one and six; the mean AUA score, ~17.82 ± 3.59; mean Qmax, ~10.21 ± 3.39 mL/sec; and the mean post-void residue (PVR), 106.65 ± 51 mL. A total of 29 patients were diagnosed to have stricture (dense = 17; flimsy = 12). None of the patients in this group had a urethral caliber of more than 14 French (Fr). Other etiologies were dysfunctional voiding (17), underactive bladder (seven), cystocele (four), and primary bladder neck obstruction (PBNO) (four). Conclusion Women with voiding LUTS should be screened for FUS only if the urethral caliber is ≤14 Fr.

Incidence, management and treatment outcomes of renal malignancy in a post-transplant recipient at a tertiary care centre: A 16-year experience

Introduction and Objective:

Although the incidence of malignancy in renal transplant recipients is on the rise owing to boom in the post-transplant immunosuppressive therapy, there is paucity of literature regarding their reporting and management. In this study, we report the incidence of de novo renal malignancies, post-renal transplantation at our centre over a 16-year period and discuss their management.

Methods:

All patients who underwent renal transplantation at our department between March 2004 and February 2020 were included and retrospectively reviewed. We analysed the incidence of renal malignancy both in the native kidney and the graft, histological subtype, time to and type of treatment.

Results:

A total of 376 patients underwent renal transplantation. Mean age of recipients was 48.2 and 52.15 years among those who developed cancer. 13 (2.93%) of 376 recipients developed urogenital malignancy, of whom 8 had renal cell carcinoma (RCC) in their native kidneys and 1 in the allograft. Transitional cell carcinoma (TCC) of renal pelvis was noted in three patients with one concomitant TCC of bladder. No treatment-related graft losses occurred in the native kidney malignancy. Patients with RCC underwent nephrectomy while TCC of renal pelvis underwent nephroureterectomy with bladder cuff excision. Transurethral resection was done for bladder tumour. All patients were followed up as per standard protocol.

Conclusion:

A rise in urological post-transplant malignancies mandates regular surveillance after renal transplantation to ensure early detection of de novo malignancies and early initiation of treatment. Goal should be to minimise adverse graft outcomes with no compromise on oncological outcomes.

Level of evidence:

Not applicable

Evaluating outcomes of combined bladder neck and supramontanal sparing ejaculatory preserving transurethral resection of the prostate: Results from a prospective, randomised study

Introduction

Although conventional transurethral resection of the prostate (TURP) is highly successful in improving urinary symptoms and flow rates, a higher incidence of loss of antegrade ejaculation has been reported. Therefore, we aimed at prospectively comparing the efficacy and outcomes of a novel dual bladder neck and supramontanal sparing TURP to conventional TURP to improve voiding and ejaculation.

Material and methods

Between January 2019 and November 2020, all patients with benign prostatic hyperplasia (BPH) satisfying the eligibility criteria underwent either conventional TURP (Group 1) or combined bladder neck and supramontanal sparing TURP (Group 2) after randomisation. The groups were compared for functional outcomes including International Prostate Symptom Score (IPSS), peak flow rates, post-void residual urine, perioperative variables and postoperative complications. Ejaculation was assessed with International Index of Erectile Function-Question 9 (IIEF-9) and Ejaculation Projection score (EPS).

Results

A total of 90 patients were randomised, 45 each to Group 1 and 2 respectively. The demographic profiles across both groups were comparable. Retrograde ejaculation and bladder neck contracture were significantly higher in Group 1. Both groups demonstrated significant improvement in the IPSS (26.12 ±2.88 to 4.69 ±0.87 (Group 1) vs 26.60 ±3.45 to 4.36 ±1.74 in Group 2) and Qmax (7.03 ±2.71 to 24.36 ±3.82 mL/s in Group 1 vs 6.29 ±2.64 to 25.28 ±4.33 mL/s in Group 2) at 3 months. However, a significant difference in IPSS and Qmax were recorded at 6 months. IIEF-9 score in Group 2 remained similar to preoperative profile (4.18 ±0.75) vs 2.58 ±0.86 (Group 1). EPS significantly decreased in Group 1 but remained similar to preoperative EPS in Group 2. Antegrade ejaculation was preserved in 88.89% in Group 2 as compared to 22.22% in Group 1.

Conclusions

Dual bladder neck and supramontanal ejaculation preserving TURP is superior to conventional TURP in preventing retrograde ejaculation and bladder neck contractures in prostates <50 cc with comparable functional results, perioperative and postoperative morbidity.

A prospective study comparing side-firing KTP laser enucleation vs bipolar transurethral resection of bladder tumor for small bladder tumors in an outpatient setting

Introduction

Laser therapy provides an alternative option for treating non-muscle-invasive bladder cancer. The clinical evidence for potassium-titanyl-phosphate (KTP) laser en bloc resection is still limited. Here, we evaluated the efficacy, safety profile, and outcomes of side-firing KTP laser enucleation with bipolar transurethral resection of bladder tumor (TURBT) in carefully selected patients with small bladder tumors in an office setting.

Material and methods

A total of 83 patients with small bladder tumors were treated with either side-firing KTP laser enucleation (Group A; n = 40) or bipolar TURBT (Group B; n = 43). Intraoperative and postoperative parameters of interest were recorded and analyzed as per the study so as to evaluate the efficacy, safety profile, and outcome of KTP laser enucleation.

Results

The mean enucleation time was 23 ±5.24 min in Group A and the mean operative time was 21.98 ±4.77 min in Group B (p = 0.207). Group A had a lower risk of obturator reflex (0 vs 8; p = 0.005) and lesser amount of irrigation used intraoperatively as compared to Group B (6.2 ±0.61 L vs 7.65 ±0.75 L; p <0.0001). There were no perioperative complications. The recurrence rate at 6 months was none in Group A and 2.3% in Group B.

Conclusions

The present study shows that, in patients with small bladder tumors (<3 cm), KTP laser enucleation is an effective and feasible alternative to bipolar TURBT in an office setting and can be carried out safely with comparable treatment outcomes, lesser use of irrigation fluid and lower risk of obturator reflex. However, further studies in larger cohorts are warranted.

Stepwise approach in the management of penile strangulation and penile preservation: 15-year experience in a tertiary care hospital

Objective: To present our stepwise approach to the management of penile strangulation and penile preservation with 15 years’ experience in a tertiary care hospital, as penile strangulation is a rare urological emergency that requires immediate attention.

Patients and methods: A prospective observational study was performed from March 2003 to December 2018 of patients presenting with penile strangulation to our hospital.

Results: Nine patients with penile strangulation presented to us between March 2003 and December 2018. The most common motive for the application of a foreign body was sexual gratification (four patients). Three of the nine patients had a mental disorder. Objects used for strangulation included: metallic nut (three), metallic ring (two), plastic bottle (two), wooden hole (one), hammer head (one), and horse hair to control bleeding during circumcision (one). Most of the foreign bodies were located in the proximal penile region. The mean operative time was 38 min and three of the nine patients had complications.

Conclusions: Penile strangulation is one of the rare urological emergencies experienced by a urologist. Removal of the foreign body can be difficult and there is no universal method of removal, as each case differs. So, following our stepwise approach can aid in removal of foreign body quickly and preserve the penis from fatal outcomes. Urologist should be aware of all the available armamentarium used for the removal of such foreign bodies.

Abbreviation: SPC: suprapubic cystostomy

Dorsal onlay graft urethroplasty for female urethral stricture improves sexual function: Short-term results of a prospective study using vaginal graft

Introduction:

Both dorsal and ventral approaches are acceptable options for the surgical reconstruction of female urethral strictures (FUS), but damage to the sphincter and the clitoral nerves resulting in sexual dysfunction is the chief argument against the dorsal approach. Most of the reported case series are retrospective and none has evaluated sexual functions. This study prospectively evaluates the early sexual and functional results after dorsal onlay vaginal graft urethroplasty (DVGU) for FUS.

Materials and Methods:

All women with a history of obstructive voiding symptoms and previous urethral dilatation were evaluated with urodynamic study, voiding cystourethrography, and cystoscopy for the presence of FUS, which was defined as visual demonstration of anatomical narrowing on urethro-cystoscopy. DVGU was offered as a definitive management for all those identified with FUS. Surgical outcomes were assessed at 3 and 6 months with the International Prostate Symptom Score (IPSS), uroflowmetry, and postvoid residual (PVR) estimation. For sexually active females, sexual function was assessed using the Female Sexual Function Inventory (FSFI) score both preoperatively and at 3 months following surgery.

Results:

Seventy-one women were evaluated. FUS was identified in 29 women (flimsy in 12 and dense in 17). Thirteen women with dense strictures underwent DVGU. The mean improvement in the IPSS score, Q_max, and PVR was 12.6, 16.64 ml/s, and 103.08 ml at 3 months, respectively. The FSFI score improved with a mean of 6.42 points after urethroplasty. None of the patients developed incontinence. There were three failures after a mean follow-up of 8.5 months.

Conclusion:

The early functional results after DVGU are good without any negative impact on the continence or the sexual functions.

Pediatric pelvic fracture urethral distraction defect causing complete urethrovaginal avulsion

Pelvic fracture with urethral injury in girls is an uncommon entity that is usually associated with concomitant vaginal lacerations. Management options vary from immediate exploration and urethral anastomosis to delayed urethroplasty. We report our experience of managing a 10-year old girl presenting 6 months after a pelvic fracture with urethrovaginal injury and a completely obliterated urethral meatus managed successfully with a single-stage bladder tube repair.

Can androgen-deprivation therapy obviate the need of channel transurethral resection of the prostate in advanced prostate cancer with urinary retention? A prospective study

Objective

To evaluate the efficacy of androgen-deprivation therapy (ADT) in relieving urinary retention in patients with advanced prostate cancer presenting with urinary retention or a high post-void residual urine volume (PVR).

Patients and methods

Patients with advanced prostate cancer with an indwelling catheter for acute/chronic urinary retention, or with a high PVR (>200 mL) who had not received any previous treatment were included in the study. Patients with localised prostate cancer eligible for receiving any therapy aimed at cure were excluded. All enrolled patients were managed by ADT (LHRH antagonist/agonist or orchidectomy) combined with α-adrenoceptor antagonist/combined therapy for at least 1 month to a maximum of 3 months; they were given their first trial of voiding without catheter after 1 month, and monthly thereafter.

Results

A total of 101 patients received ADT of which 97 were able to void successfully at the end of 3 months. In all, 27 patients could void in the first month, followed by 50 in the second month, and an additional 20 in the third month. There was a significant decrease in prostate volume, PVR, and International Prostate Symptom Score, and maximum urinary flow rates improved with normalisation of renal functions and resolution of upper tract changes noted on ultrasonography.

Conclusion

ADT can relieve retention and decrease PVR over a period of time obviating the need for channel transurethral resection of the prostate.

Day care bipolar transurethral resection vs photoselective vaporisation under sedoanalgesia: A prospective, randomised study of the management of benign prostatic hyperplasia

Objective

To conduct a prospective randomised study comparing the safety, effectiveness and treatment outcomes in patients undergoing bipolar transurethral resection of the prostate (bTURP) and photoselective vaporisation of the prostate (PVP) under sedoanalgesia, as sedoanalgesia is a safe and effective technique suitable for minimally invasive endourological procedures and although studies have confirmed that both TURP and PVP are feasible under sedoanalgesia there are none comparing the two.

Patients and methods

Between November 2014 and April 2016, all patients satisfying the eligibility criteria underwent either bTURP or PVP under sedoanalgesia after randomisation. The groups were compared for functional outcomes, visual analogue scale (VAS) pain scores (range 0–10), perioperative variables and complications, with a follow-up of 3 months.

Results

In all, 42 and 36 patients underwent bTURP and PVP under sedoanalgesia, respectively. The mean VAS pain score was <2 at any time during the procedure, with no conversions to general anaesthesia. PVP patients had a shorter operating time [mean (SD) 55.64 (12.8) vs 61.79 (14.2) min, P = 0.035], shorter duration of hospitalisation [mean (SD) 14.58 (2.81) vs 19.21 (2.82) h, P < 0.001] and a higher dysuria rate when compared to bTURP patients. However, the catheterisation time was similar and both intraoperative and postoperative complications were minimal and comparable. Improvements in the International Prostate Symptom Score, quality of life, prostate volume, maximum urinary flow rate and post-void residual urine volume at 3 months were similar in both groups. None of our patients required re-admission or re-operation.

Conclusion

Both PVP and bTURP can be carried out safely under sedoanalgesia with excellent treatment outcomes.