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Paediatric urolithiasis is an emerging disease in developing nations especially in India, but a rarer entity compared to its adult counterpart. There is significant geographic variation in the incidence of urolithiasis within India itself. Given the changing dynamics of the disease, this study evaluated paediatric urolithiasis patients in a non-endemic region in South India.
This is a retrospective study of children and adolescents diagnosed with urolithiasis from January 2009 to December 2019 in a single tertiary care centre in South India. The purpose of this study was to investigate and identify the demographic and clinical characteristics, aetiology, management, clearance rates after surgical intervention and disease recurrence of paediatric stone disease
in a non-endemic region in South India.
We evaluated 29 patients which included a total of 97 hospital admissions. Predominantly the study population consisted of males (80.0%), with a mean age of symptom onset of 9.44±5.53-years. All patients were metabolically evaluated, 16 patients (55.2%) had metabolic abnormalities and the most common abnormality was hypocitraturia (37.5%). Spontaneous elimination rate was 6.9% and clearance rates for surgical procedures ranged from 72% to 100%. Recurrent stones were seen in 37.9%. No patient developed chronic kidney disease or mortality due to stone disease within the evaluation period of this study.
Paediatric urolithiasis is an emerging disease in India. There is a high prevalence of metabolic abnormalities in paediatric stone disease which supports the need for metabolic evaluation in all cases. There is more similarity of our study with western literature than the available Indian data which may be due to the lifestyle changes, significant geographic variation within India itself between
endemic and non-endemic regions or changing epidemiology of paediatric stone disease per se.
Paediatrics; Urolithiasis; Urinary tract infection (UTI).
Merkel cell carcinoma (MCC) in an uncommon neuroendocrine neoplasia that originates in the skin in which testicular metastasis is atypical. There are only eight cases reported to date. A 65-year-old patient with a history of MCC in the right thigh who had been treated in 2015 with surgery, chemotherapy and radiation therapy; presented to hospital with pain and right testicular enlargement of one-month duration and with normal testicular tumor markers. An ultrasound study confirmed multiple hypoechoic nodular solid lesions compatible with neoplasia and orchiectomy was subsequently performed. The histological examination reported an immunohistochemical pattern compatible with a diagnosis of MCC. The patient received adjuvant immunotherapy with Avelumab. MCC rarely spreads to the testicle and, due to the shortage of studies, the best treatment of testicular metastasis remains uncertain; however, immunotherapy may be appropriate.
Merkel; Testicular metastasis.
Cystic lymphangioma is a relatively frequent condition. However, the scrotum is one of the least common sites. The diagnosis is made with ultrasonography and the treatment of limited and circumscribed cases, is surgical excision or sclerotherapy where appropriate. We report the case of a 23-year-old boy who presented with asymptomatic scrotal vesicular lesions evolving over 6-years. Clinical and dermoscopic examination supported by ultrasound and histology were in favor of a microcystic lymphangioma.
Cystic Lymphangioma; Circumscriptum; Scrotum; Clinic; Dermoscopy.
A 59-year-old male presented with haematuria and was diagnosed with pleomorphic giant cell carcinoma of the urinary bladder, a very rare variant of urothelial carcinoma. The tumour was staged at pT2N3M1 and the primary tumour was removed by transurethral resection, and nodal metastases were treated with the standard systemic cisplatin and gemcitabine for urothelial cell carcinoma of the bladder. This treatment rendered the tumour clinically undetectable. Despite this treatment the patient developed brain metastases which were not found until the patient presented with neurological symptoms. This is the first recorded case of brain metastases from pleomorphic giant cell carcinoma of the urinary bladder recorded in the literature. CT imaging of the brain should be considered in the follow-up in patients with this tumour.
Urinary bladder; Brain metastases despite; Cisplatin and gemcitabine.
Prostate cancer is generally multifocal, presenting a lesion with a dominant focus (index lesion) that is characterized by being the lesion with the greatest volume and the biological capacity of invasion to adjacent tissues and distant metastases. With the advent of focal therapy and organ preservation in prostate cancer, it is essential to know the real tumour volume and thus, avoid the persistence of disease after treatments with curative intent. The aim of this study is to correlate the results of the dominant tumour volume obtained from the multiparametric magnetic resonance imaging (MRI) of the prostate and the histopathology.
Material and Methods
A retrospective study was performed which included all radical prostatectomies (RP) with previous MRI. A comparative analysis was performed between the tumour volume obtained from the MRI and the histopathology.
A total of 46 patients were included in the study. The sensibility of the MRI in diagnosing the index lesion was 82.6%, highlighting that all tumours with a Gleason score ≥ 4+3 were diagnosed. The mean tumour volume in the MRI was 14.3 mm and in the histological result was 18.82 mm (p<0.05). The estimation tumour volume concordance was greatest in higher risk (International Society of Urological Pathology (ISUP)).
The MRI underestimates the real tumour volume of the prostate cancer index lesion when compared to the histological result of the surgical piece, being significantly lower in high-risk lesions.
Prostate cancer; MRI; Radical prostatectomy; Index lesion; Tumour volume.
Double J (DJ) stenting is a routine procedure in our urological practice to treat ureteral obstruction. We report a rare case where the proximal coil of a DJ stent was found in the second part of duodenum diagnosed on imaging and confirmed by upper gastrointestinal endoscopy, in a patient with chronic right flank pain who underwent emergency right DJ stenting elsewhere. He presented to our institution 3-months later for further management. It is important to be aware of all possible complications before placing DJ stents and be aware that if any such complication arise, they need to be dealt with early. It is important to avoid blind DJ stent insertion especially in acute or inflammatory conditions. One can avoid such situations by stenting under image guidance and preferably with a retrograde pyelogram (RGP) or by deploying a guidewire under direct vision using a ureteroscope. If stent malposition is suspected then early detection and replacement of the malpositioned DJ stent under fluoroscopic guidance is an essential step in management.
Double J stenting; DJ stent malposition; Upper GI endoscopy; DJ stent coil in duodenum; Right contracted kidney; Inflammatory
retroperitoneal mass; Laparoscopic nephrectomy.
Current methods used to assess patient suitability for bladder neck suspension prior to surgery are limited due to their inability to examine patients in physiologic positions. The purpose of this study was to examine the usefulness of upright magnetic resonance imaging (MRI) in the evaluation of patients with genuine stress urinary incontinence (GSUI) prior to undergoing MonarcR bladder neck suspension.
Materials and Methods
Twenty-seven female patients with known GSUI were selected to participate in the study. Each patient was asked to complete an incontinence symptom score and then have 300 ml of sterile water instilled into their bladder. While standing in an upright MRI scanner a T2-weighted image at 0.6 tesla was then obtained while at rest and then undergoing standardized Valsalva maneuver. Special attention was then given to the downward movement of the H-line against the M-line. Measurements were taken to determine excursion of the H-line against the M-line. The procedure was then repeated for each patient three-months after surgery. The change in H-line excursion following surgery was compared to the change in symptom score using Spearman’s rank correlation test.
A positive correlation was found between the pre- and post-operative improvements in international consultation on incontinence questionnaire female lower urinary tract symptoms modules (ICIQ-FLUTS) and the post-operative reduction of excursion of the pelvic floor. These correlations were found to be statistically significant (p<0.001) using Spearman’s rank correlation test.
A greater degree of pelvic floor prolapse visible on magnetic resonance imaging (MRI) with a standardized Valsalva maneuver prior to MonarcR bladder neck suspension surgery predicts for better patient symptom score outcomes as determined by ICIQ-FLUTS.
Magnetic resonance imaging (MRI); Bladder neck suspension; Stress urinary incontinence.
Open nephrectomy is associated with significant post-operative pain. Epidurals have been a core method for provision of analgesia, however, there is increased use of novel analgesic strategies with comparative analgesia but potentially fewer side effects. This pilot study aims to assess the feasibility of a randomised control trial comparing continuous wound infusion (CWI) to epidural analgesia for open renal surgery. Objectives included estimation of recruitment rates, failure rates and complications and refining design of a randomised control trial.
Participants were randomised using randomisation software. Patients received standardised anaesthesia as per the study protocol. Patients randomised to the CWI group had a wound infiltration catheter inserted at the end of surgery. In the epidural group, patients had an epidural sited prior to surgery. Primary outcomes evaluated were visual analogue pain scores. Secondary outcomes included intravenous fluid use, hypotensive episodes, patient mobilisation, evidence of post-operative ileus, respiratory morbidity, demands on medical and nursing care, length of hospital stay and patient acceptability as assessed by the Quality of Recovery (QoR-15) questionnaire.
Pain scores were similar for both groups with marginally higher mean scores in the wound infiltration group on post-operative day 1 and 3. Supplementary analgesia rates were comparable for both groups with tramadol use being higher in the wound infiltration group.
Collecting outcome data for an appropriately powered randomised controlled trial is feasible. Recruitment was challenging due to the increased minimally invasive laparoscopic or robotic nephrectomies and consideration of a multicentre study is warranted. The two analgesic techniques appear broadly comparable in efficacy and time to discharge. CWI potentially presents safety advantages compared to epidural analgesia.
Prostate cancer is the second most common cancer in men. It can be located, present local extension and finally metastasize. Cutaneous metastasis is an infrequent event that is associated with a poor prognosis. We present a clinical case of advanced undifferentiated prostate cancer with cutaneous metastases diagnosed by a punch biopsy and confirmed by immunohistochemistry.
Prostate cancer; Cutaneous metastases; Immunohistochemistry.
We report an atypical clinical case of an infrequent subtype of upper tract urothelial carcinoma (UTUC), with a nested variant. It is an infrequent histological subtype with poor prognosis. Laparoscopic left nephroureterectomy and adjuvant chemotherapy (AC)
with good outcomes were performed.
UTUC; Adjuvant chemotherapy; Nested variant urothelial carcinoma (NVUC).
Miniaturized percutaneous nephrolithotomy (mini-PCNL) is the primary treatment modality in stone management. However, prone and supine positioning remains a matter of concern because of associated complications and morbidity. The present study aimed to compare success and complication rates of supine and prone position in patients undergoing mini-PCNL.
Material and Methods
A prospective observational study was conducted in patients (age >18-years) with renal calculi 1-3 cm in size who performed mini-PCNL between September 2017 and February 2019. The stone size was determined by computed tomography (CT) scan and kidney, ureter, and bladder X-ray. Post-operative parameters and complications were compared in both the groups. Statistical significance was defined as p<0.05.
A total of 116 patients were enrolled (52 in the supine mini-PCNL group and 64 patients in the prone mini PCNL groups). The mean operative time was significantly lower (44.80 mins) in supine mini-PCNL compared to the prone mini-PCNL (53.93 mins) (p<0.0074). The mean hospital stays in supine and prone mini-PCNL group was 2.06 and 2.51-days, respectively (p=0.01). A complete stone clearance was observed in supine mini-PCNL group. The incidence of tubeless and totally tubeless procedure was significantly higher in supine mini-PCNL group (90% and 61%, respectively) (p<0.0001). No difference in terms of complications is reported between the supine and prone mini-PCNL group.
Supine mini-PCNL and prone mini-PCNL found to be comparable in terms of success rate and complications. However, supine mini-PCNL can be preferred due to its shorter operative time in the patients with renal stones.
Percutaneous nephrolithotomy; Prone position; Supine position; Stone free rate.
Department of Urology
Icahn School of Medicine at Mount Sinai
1 Gustave L. Levy Place, Box 1272
New York, NY 10029, USA
Department of Urology
Princess Alexandra Hospital
Ipswich Rd,Woolloongabba 4102