Malakoplakia of the ureter: An unusual case

Malakoplakia of the ureter is a rare pathological entity. We discuss a 15-year-old girl with malakoplakia of the ureter. She presented with obstructive uropathy associated with left flank pain. Radiological investigations showed left lower ureteric stricture without bladder or kidney involvement. She was treated by excision of terminal ureter and ureteroneocystostomy. Histopathologic examination of the excised specimen showed malakoplakia. Postoperative course was uneventful and on follow-up, she has normal serum creatinine and no recurrence of the disease

Predictive factors for lymph node positivity in patients undergoing extended pelvic lymphadenectomy during robot assisted radical prostatectomy

Introduction: Pelvic lymphadenectomy during radical prostatectomy (RP) improves staging and may provide a therapeutic benefit. However, there is no clear consensus on the selection criteria for subjecting patients to this additional procedure. With a growing adoption of robot assisted radical prostatectomy (RARP) in India, it has become imperative to study the incidence and predictive factors for lymph node involvement in our patients. Materials and Methods: From February 2010 to February 2014, 452 RARP procedures were performed at our institution. A total of 100 consecutive patients from July 2011 to August 2012 were additionally subjected to a robotic extended pelvic lymphadenectomy (EPLND). Lymph node positivity rates and lymph node density were analyzed on the basis of preoperative prostate specific antigen (PSA), Gleason score, clinical stage, D′Amico risk category and magnetic resonance imaging (MRI) findings. Multivariate analysis was performed to ascertain factors associated with lymph node positivity in our cohort. Results: The mean age of the patients was 65.5 (47-77) years and the body mass index was 26.3 (16.3-38.7) kg/m 2 . The mean console time for EPLND was 45 (32-68) min. A median of 17 (two to 40) lymph nodes were retrieved. Seventeen patients (17%) had positive lymph nodes (median of 1, range 1-6). Median lymph node density in these patients was 10%. When stratified by PSA, Gleason score, clinical stage, D′Amico risk category and features of locally advanced disease on MRI, a trend towards increasing incidence of lymph node positivity was observed, with an increase in adverse factors. However, on multivariate analysis, clinical stage > T2a was the only significant factor impacting lymph node positivity in our cohort. Conclusions: A significant proportion of men undergoing RARP in India have positive lymph nodes on EPLND. While other variables may also have a potential impact, a higher clinical stage predisposes to an increased incidence of lymph node metastases

Age, gender, and voided volume dependency of peak urinary flow rate and uroflowmetry nomogram in the Indian population

Objectives : The objective of this study was measurement of urine flow parameters by a non invasive urodynamic test. Variation of flow rates based on voided volume, age, and gender are described. Different nomograms are available for different populations and racial differences of urethral physiology are described. Currently, there has been no study from the Indian population on uroflow parameters. So the purpose of this study was to establish normal reference ranges of maximum and average flow rates, to see the influence of age, gender, and voided volume on flow rates, and to chart these values in the form of a nomogram. Methods : We evaluated 1,011 uroflowmetry tests in different age groups in a healthy population (healthy relatives of our patients) 16-50 year old males,> 50 year old males, 5-15 year old children, and> 15 year pre-menopausal and post-menopausal females. The uroflowmetry was done using the gravitimetric method. Flow chart parameters were analyzed and statistical calculations were used for drawing uroflow nomograms. Results : Qmax values in adult males were significantly higher than in the elderly and Qmax values in young females were significantly higher than in young males. Qmax values in males increased with age until 15 years old; followed by a slow decline until reaching 50 years old followed by a rapid decline after 50 years old even after correcting voided volume. Qmax values in females increased with age until they reached age 15 followed by decline in flow rate until a pre-menopausal age followed by no significant decline in post-menopausal females. Qmax values increased with voided volume until 700 cc followed by a plateau and decline. Conclusions : Qmax values more significantly correlated with age and voided volume than Qavg. Nomograms were drawn in centile form to provide normal reference ranges. Qmax values in our population were lower than described in literature. Patients with voided volume up to 50 ml could be evaluated with a nomogram

An unusual complication of silver nitrate therapy for chyluria

Chyluria is a common disorder in the tropics. In our country it is most commonly managed by instillation of silver nitrate. We report a patient who developed severe perinephric hematoma due to pseudoaneurysm of renal artery following silver nitrate instillation. He was managed by angioembolisation followed by drainage of infected perinephric hematoma. We discuss various modalities of treatment of chyluria including complications of silver nitrate therapy

Stepwise case selection using Guy′s stone score reduces complications during percutaneous nephrolithotomy training

Introduction: Traditional percutaneous nephrolithotomy (PCNL) training involved subjective award of cases to the trainee. We restructured this according to the Guy's stone score (GSS) such that each trainee stepwise completed 25 cases of each grade before progressing. This study compares the outcomes of training with traditional versus stepwise approach. Methods: Four hundred consecutive cases equally distributed for two trainees in each group were compared in terms of complications (Clavien-Dindo), stone free rate (SFR), operative and fluoroscopy time. External comparison was also done against a benchmark surgeon. Multivariable regression model was created to compare SFR and complications while adjusting for comorbidity, Amplatz size, access tract location, number of punctures, body mass index, stone complexity, and training approach. Results: The distribution of cases in terms of calculus complexity was similar. Overall, in comparison to traditional training, stepwise training had significantly shorter median operative time (100 vs. 120 min, P < 0.05), fluoroscopy time (136 vs. 150 min, P < 0.05) and fewer overall (29.5% vs. 43.5%, P < 0.005) as well as major complications (3% vs. 8.5%, P - 0.029), though initial SFR was higher but not statistically significant (77% vs. 71.5%). On multivariable analyses, stepwise training was independently associated with lower complications (odds ratio 0.46 [0.20–0.74], P - 0.0013) along with GSS grade, number of punctures, and Amplatz size. Stepwise training had similar fluoroscopy time, major complications and final clearance rate compared to expert surgeon. Conclusions: PCNL has a learning curve specific for each grade of calculus complexity and stepwise training protocol improves outcomes