Isolated Xanthogranuloma of Pelvico-Ureteric Junction: is this Beginning of Xanthogranulomatous Pyelonephritis? – A Case Report

Xanthogranulomatous Pyelonephritis (XGP) is a rare condition characterised by chronic granulomatous inflammation of renal tissue [1,2]. This can be due to obstruction, urinary tract infection and renal calculi [1-5]. The exact pathophysiology and progression of this condition is poorly understood, but altered immune response, changes in lipid metabolism, disturbances in leukocyte function, lymphatic obstruction, venous occlusion/haemorrhage, malnutrition, arterial insufficiency and necrosis of pericalyceal fat [2,4]. Its management with surgical intervention in the form of nephrectomy, partial or complete, is the most definitive management option of this condition [1]. We report the case of a woman with isolated xanthogranuloma obstructing the pelviureteric junction. We propose this as the initial pathophysiological process of Xanthogranuloma pyelonephritis

Paediatric urinary tract infections: diagnosis and treatment

BackgroundUrinary tract infections (UTIs) commonly occur in children. An estimated 8% of girls and 2% of boys will have at least one episode by seven years of age. Of these children, 12-30% will experience recurrence within one year. Australian hospital admission records indicate that paediatric UTIs represent 12% of all UTI hospital admissions.ObjectiveThe aim of this article is to review the pathogenesis, clinical assessment and management of UTIs, and prevention strategies in children.DiscussionClinically, paediatric UTI presentations are challenging because symptoms are vague and variable. Young infants may present with sepsis or fever and lack specific symptoms, whereas older children present with classical features such as dysuria, frequency and loin pain. Early diagnosis with appropriate urine specimen collection techniques, investigations and treatment is necessary for prevention of renal damage and recurrence. Effective, evidence-based investigations and treatment options are available, and physicians should feel confident in identifying and managing paediatric UTIs

Vicryl Tack for graft fixation during bulbar urethroplasty

Urethral stricture disease continues to be a prevalent condition with significant morbidity. Oral mucosal graft augmentation urethroplasty for long segment bulbar urethral strictures is an established management option. Here the authors outline the results of their pilot study designed to evaluate the efficacy of using two innovative steps for graft augmentation

A novel method in decision making for the diagnosis of anterior urethral stricture: using methylene blue dye

ObjectiveThe use of methylene blue dye (MB) to highlight anatomical structures in urology has been well-established. Urethral stricture may extend about a centimeter beyond the abnormal area seen on urethrogram. Although the current literature suggests a tension-free and end- to- end anastomosis after excision of the strictured urethral segment with spongiofibrosis and surrounding corpus spongiosum in short bulbar strictures, some centers dealing with urethroplasty prefer anastomosis for short bulbar strictures while others prefer augmentation. With this study, use of MB for delineating stricture line and assessing spongiofibrosis in the diagnosis of urethral stricture was evaluated.Material and methodsFive cc MB including 10 mg/mL is diluted with 10 cc saline. In the first scenario, MB is gently injected into urethra via the meatus before the urethroplasty procedure. Meanwhile, the extent of urethral segment stained by MB is noted. In the second scenario (MB spongiosography) in short bulbar stricture, insulin needles are inserted in spongiosa of the stricture site distally and proximally. MB is gently injected with distal needle. The two remaining needles are then observed. Presence of MB efflux in proximal needle implies deficiency of significant spongiofibrosis, so buccal augmentation is performed. Absence of efflux of MB implies significant spongiofibrosis and anastomotik site excised.ResultsFour hundred and ninety-two consecutive cases prospectively evaluated between 2010 and 2014. Precise staining of stricture was successfully observed in 464 (94%) patients. Grossly normal appearing urothelium remained pink. Histopathology confirmed that the stained urethra had a stricture. Of the 22 short bulbar idiopathic strictures, in 18 (82%) MB was seen across the stricture and urethral transection was avoided. Anastomosis was performed in 4 (18%) cases where no MB went across the primary excision. There were no known allergic complications.ConclusionMB aids in delineating the urethral lumen and exact site of stricture that needs augmentation. MB Spongiography in short bulbar strictures could be used as a beneficial guide in relation to the type of urethral repair to be performed in terms of augmentation versus excision and anastomosis

Management of complex and redo cases of pelvic fracture urethral injuries.

ObjectivesPelvic fracture urethral injuries (PFUI) result from traumatic disruption of the urethra. A significant proportion of cases are complex rendering their management challenging. We described management strategies for eight different complex PFUI scenarios.MethodsOur centre is a tertiary referral centre for complex PFUI cases. We maintain a prospective database (1995-2016), which we retrospectively analysed. All patients with PFUI managed at our institute were included.ResultsOver two decades 1062 cases of PFUI were managed at our institute (521 primary and 541 redo cases). Most redo cases were referred to us from other centres. Redo cases had up to five prior attempts at urethroplasty. We managed complex cases, which included bulbar ischemia, young boys and girls with PFUI, PFUI with double block, concomitant PFUI and iatrogenic anterior urethral strictures. Bulbar ischemia merits substitution urethroplasty, most commonly, using pedicled preputial tube. PFUI in young girls is usually associated with urethrovaginal fistula. Young boys with PFUI commonly have a long gap necessitating trans-abdominal approach. Our success rate with individualised management is 85.60% in primary cases, 79.13% in redo cases and 82.40% in cases of bulbar ischemia.ConclusionThe definition of complex PFUI is ever expanding. The best chance of success is at the first attempt. Anastomotic urethroplasty for PFUI should be performed in experienced hands at high volume centres

Management of complex and redo cases of pelvic fracture urethral injuries

Objectives: Pelvic fracture urethral injuries (PFUI) result from traumatic disruption of the urethra. A significant proportion of cases are complex rendering their management challenging. We described management strategies for eight different complex PFUI scenarios. Methods: Our centre is a tertiary referral centre for complex PFUI cases. We maintain a prospective database (1995–2016), which we retrospectively analysed. All patients with PFUI managed at our institute were included. Results: Over two decades 1062 cases of PFUI were managed at our institute (521 primary and 541 redo cases). Most redo cases were referred to us from other centres. Redo cases had up to five prior attempts at urethroplasty. We managed complex cases, which included bulbar ischemia, young boys and girls with PFUI, PFUI with double block, concomitant PFUI and iatrogenic anterior urethral strictures. Bulbar ischemia merits substitution urethroplasty, most commonly, using pedicled preputial tube. PFUI in young girls is usually associated with urethrovaginal fistula. Young boys with PFUI commonly have a long gap necessitating trans-abdominal approach. Our success rate with individualised management is 85.60% in primary cases, 79.13% in redo cases and 82.40% in cases of bulbar ischemia. Conclusion: The definition of complex PFUI is ever expanding. The best chance of success is at the first attempt. Anastomotic urethroplasty for PFUI should be performed in experienced hands at high volume centres. Keywords: Urethral reconstruction, Pelvic fracture urethral distraction defects, Pelvic fracture urethral injuries, Bulbar necrosis, Long gap, Bladder neck injury, Rectourethral fistul

A novel composite two-stage urethroplasty for complex penile strictures: A multicenter experience

Introduction: Complex penile strictures are usually repaired using a two-stage urethroplasty. Buccal mucosal graft (BMG) placed in the first stage can have a significant contraction rate, which may require a subsequent revision surgery. We describe a composite two-stage penile urethroplasty using BMG for patients of complex penile strictures who have some salvageable urethral plate. Methods: Within a multi-institutional cohort, 82 patients underwent a two-stage urethroplasty for complex stricture of the penile urethra. Of these 42 patients who underwent our composite two-stage penile urethroplasty using BMG implanted at the second-stage were included. Patients with genital lichen sclerosus or incomplete clinical records were excluded from this study. The primary outcome of the study was to evaluate stricture-free success rate. Results: Of total 42, 4 patients were lost to follow-up. 42% of stricture etiology was failed hypospadias repair. Mean stricture length was 4.5 cm (range 3–8 cm). Seventeen (44.7%) patients had undergone the previous urethroplasty. At a median follow-up of 44 months, of 38 patients, 34 (89.5%) were successful, and 4 (10.5%) had a recurrence. No patient required revision surgery before the second-stage and required redo buccal graft harvesting for subsequent urethroplasty. Conclusions: The composite two-stage technique in repairing complex penile urethral strictures is a valid and reproducible surgical treatment for complex penile stricture and it may reduce the rate of contraction of the transplanted BMG