Impact of COVID-19 pandemic on non-COVID patient's management in urology: a public hospital experience in Mumbai

Background

To evaluate the impact of COVID-19 lockdown on non-COVID urological patient’s management in tertiary care urology centres.

Methods

This is an observational study in which data of patients visiting the urology department of all the MCGM run tertiary care hospitals were recorded for the duration of 1 April 2020 to 31 July 2020 and were compared to data of pre-COVID-19 period of similar duration.

Results

There was a decrease of 93.86% in indoor admissions of urology patients during the COVID-19 lockdown. Indoor admissions for stone disease, haematuria, malignancy accounted for 53.65%, 15.85%, 9.75%, respectively. Elective surgeries had the highest percentage decrease followed by emergency and semi-emergency procedures. There was a reduction of more than 80% in patients attending outpatient clinics. Stone disease and its consequences were the main reasons for visiting outdoor clinics (39%). A substantial number of patients presented with flank and abdominal pain (14.8%) and benign enlargement of the prostate (10.23%). Malignancy accounted for a very small number of patients visiting outdoor clinics (1.58%).

Conclusions

COVID-19 pandemic has a profound impact on patient care and education in Urology. There was more than ninety percent reduction in indoor admissions, operative procedures, and outpatient clinics attendance. Once the pandemic is controlled, there will be a large number of patients seeking consultation and management for urological conditions and we should be prepared for it. Surgical training of urology residents needs to be compensated in near future. Long-term impact on urological patient outcome remains to be defined.

Predictors for severe hemorrhage requiring angioembolization post percutaneous nephrolithotomy: A single-center experience over 3 years

Context and Aim

About 1% of the patients undergoing percutaneous nephrolithotomy (PCNL) have bleeding severe enough to require angioembolization. We identified factors which could predict severe bleeding post-PCNL and reviewed patients who underwent angioembolization for the same.

Settings and Design

This is a single-institutional, retrospective study over a period of 3 years.

Subjects and Methods

We retrospectively studied 583 patients undergoing PCNL at our institute from 2013 to 2016. We analyzed nine patients (three from our institute and six referred patients) who underwent angioembolization for severe bleeding post-PCNL. We analyzed the preoperative characteristics, intraoperative findings, and postoperative course of these patients and compared this with those patients who did not have a severe post-PCNL bleeding.

Statistical Analysis Used

Fischer's exact test and Chi-square test were used in univariate analysis. Logistic regression analysis was used in multivariate analysis with a value of P < 0.05 considered statistically significant.

Results

Three of the 583 patients (0.51%) who underwent PCNL at our institute required embolization to control bleeding. Preoperative characteristics that were significant risk factors for severe bleeding were a history of ipsilateral renal surgery (P = 0.0025) and increased stone complexity (P = 0.006), while significant intraoperative factors were injury to the pelvicalyceal system (P = 0.0005) and multiple access tracts (P = 0.022). Angiography revealed arteriovenous fistula in two patients and a pseudoaneurysm in seven patients. All patients underwent successful superselective angioembolization with preserved renal perfusion in six patients on control angiography postembolization.

Conclusions

History of ipsilateral renal surgery, increased stone complexity, multiple access tracts, and injury to the pelvicalyceal system are risk factors predicting severe renal hemorrhage post-PCNL. Early angiography followed by angioembolization should be performed in patients with severe post-PCNL bleeding who fail to respond to conservative measures.

A Case Report of Largest Documented Multilocular Cystic Nephroma Removed by Thoracoabdominal Approach

Large renal tumours are not uncommon in developing countries. Enhancing renal tumours are considered to be malignant unless proved otherwise and radical surgical resection remains the mainstay of treatment of such tumours. A giant renal tumour, especially on right side, poses a big challenge for the operating team and requires a thoracoabdominal approach for successful excision. We report successful removal of the largest documented Multilocular Cystic Nephroma (MLCN, 5.5 kg) from a 28-year-old female who presented with right abdomen lump since two years. The surgery was done through a 9th intercostal thoracoabdominal incision as the mass (31 x 19 x 19.6 cm) extended from right sub-diaphragmatic space up to the dome of the bladder. We discuss here the technique of removing such a huge renal mass and the challenges an operating surgeon may encounter.

Fractured Penis: Not So Rare!

INTRODUCTION

Penile fracture is a relatively common phenomenon. The main problem associated with this condition is the lack of patients' awareness on the urgency of the situation. This study reports the different modes of presentations and treatment results.

MATERIALS AND METHODS

We reviewed 21 cases of penile fracture over 5 years. Parameters were mode of injury, age group, time interval before presentation, management, site of injury, urethral involvement, results, complications and erectile function at follow-up.

RESULTS

The mean age of patients was 34 years, the mean time interval until presentation was 26 h. Cases involving the right corpus cavernosum comprised 57.14% and 42.85% were cases involving the left corpus cavernosum. Two patients had full circumferential urethral tear. Two patients developed wound infections and 2 patients developed mild penile curvature (<30°). These 4 patients had all presented late for treatment (>40 h).

CONCLUSION

Urologists need to consider penile fracture a urological emergency and atypical presentations need to be considered when deciding on management.

Transperitoneal laparoscopic repair of retrocaval ureter: Our experience and review of literature

Context and Aim:

Retrocaval ureter (RCU), also known as circumcaval ureter, occurs due to anomalous development of inferior vena cava (IVC) and not ureter. The surgical approach for this entity has shifted from open to laparoscopic and robotic surgery. This is a relatively new line of management with very few case reports. Herein, we describe the etiopathology, our experience with six cases of transperitoneal laparoscopic repair of RCU operated at tertiary care center in India and have reviewed different management options.

Methods:

From 2013 to 2016, we operated total six cases of transperitoneal laparoscopic repair of RCU. All were male patients with average age of 29.6 years (14–50). Pain was their only complaint with normal renal function and no complications. After diagnosis with CT Urography, they underwent radionuclide scan and were operated on. Postoperative follow-up was done with ultrasonography every 3 months and repeat radionuclide scan at 6 months. The maximum follow-up was for 2.5 years.

Results:

All cases were completed laparoscopically. Average operating time was 163.2 min. Blood loss varied from 50 to 100 cc. Ureteroureterostomy was done in all patients. None developed urinary leak or recurrent obstruction postoperatively. Maximum time for the requirement of external drainage was for 4 days (2-4 days). Average postoperative time for hospitalization was 3.8 days. Follow-up ultrasound and renal scan showed unobstructed drainage.

Conclusions:

Transperitoneal or retroperitoneal approach can be considered equivalent as parameters like operative time, results are comparable for these two modalities. We preferred transperitoneal approach as it provides good working space for intracorporeal suturing.

Predictive factors for fever and sepsis following percutaneous nephrolithotomy: A review of 580 patients

AIMS

There has been much speculation and discussion about the infective complications of percutaneous nephrolithotomy (PCNL). While fever is common after PCNL, the incidence of it progressing to urosepsis is fortunately less. Which patient undergoing PCNL is at risk of developing urosepsis and in whom aggressive treatment of fever postoperatively may prevent the progression to severe sepsis becomes a very important question. This study aims to answer these vital questions.

SETTINGS AND DESIGN

This is a single institutional, retrospective study over a period of 3 years.

MATERIALS AND METHODS

Retrospective analysis of medical records of the patients undergoing PCNL from August 2012 to July 2015 was done. A total of 580 patients were included in the study, and the study variables recorded were analyzed statistically.

STATISTICAL ANALYSIS USED

Statistical analysis was performed by Chi-square test.

RESULTS

Three factors significantly correlated with postoperative severe sepsis, namely, stone size >25 mm, prolonged operative time >120 min, and significant bleeding requiring transfusion. Factors associated with fever after PCNL which did not progress to sepsis were the presence of staghorn calculi and multiple access tracts in addition to the factors listed above for sepsis.

CONCLUSIONS

Fever after PCNL is not uncommon but it has a low incidence of progressing to life-threatening severe sepsis and multiorgan dysfunction syndrome. Special precautions and monitoring should be taken in patients with bigger stone (>25 mm) and patients with severe intraoperative hemorrhage requiring blood transfusion. It is better to stage the procedure rather than prolong the operative time (120 min). Identifying these factors and minimizing them may decrease the incidence of this life-threatening complication.

Cyanoacrylate injection in management of recurrent vesicovaginal fistula: Our experience

Treating recurrent vesicovaginal fistula (VVF) is a major clinical problem. We present a technique and special precautions taken during treatment of a small recurrent VVF with the help of combined cystoscopic and/or transvaginal injection of cyanoacrylate in two patients. Except for frequency of micturition in the first patient, postoperative follow-up was uneventful. Endoscopic management with cyanoacrylate is a simple and effective alternative to major reconstructive surgery.

Comparative analysis of genetic diversity among Indian populations of Scirpophaga incertulas by ISSR-PCR and RAPD-PCR

Genetic variation between 28 Indian populations of the rice pest, Scirpophaga incertulas was evaluated using inter-simple sequence repeats (ISSR)-PCR assay. Nine SSR primers gave rise to 79 amplification products of which 67 were polymorphic. A dendrogram constructed from this data indicates that there is no geographical bias to the clustering and that gene flow between populations appears to be relatively unrestricted, substantiating our earlier conclusion based on the RAPD (random amplified polymorphic DNA) data. The dendrograms obtained using each of these marker systems were poorly correlated with each other as determined by Mantel's test for matrix correlation. Estimates of expected heterozygosity and marker index for each of these marker systems suggests that both these marker systems are equally efficient in determining polymorphisms. Matrix correlation analyses suggest that reliable estimates of genetic variation among the S. incertulas pest populations can be obtained by using RAPDs alone or in combination with ISSRs, but ISSRs alone cannot be used for this purpose.

Genetic variation in Indian populations of Scirpophaga incertulas as revealed by RAPD-PCR analysis

Scirpophaga incertulas, commonly referred to as yellow stem borer, is a predominant pest of rice causing serious losses in its yield. Genetic variation among populations of Scirpophaga incertulas collected from 28 hotspot locations in India was examined using the randomly amplified polymorphic DNA-polymerase chain reaction (RAPD-PCR). In all, 32 primers were used and 354 amplification products were observed. No RAPD-PCR bands diagnostic to the pest population from any specific region were identified. Cluster analysis using UPGMA showed that, with the exception of the pest population from Pattambi, all the populations cluster as one group with GD values in the range of 6-22%, suggesting that gene flow between populations is independent of geographic distance and appears to be unrestricted. The relatively high GD value of 48% exhibited by the pest population from Pattambi was the only exception.