Normal Urinary Tract Research Articles

MP73-06 EVALUATION OF ACUTE POST-SWL RENAL CHANGES AS DETECTED BY DYNAMIC MRI: A PROSPECTIVE CLINICAL STUDY

You have accessJournal of UrologyStone Disease: Evaluation III1 Apr 2014MP73-06 EVALUATION OF ACUTE POST-SWL RENAL CHANGES AS DETECTED BY DYNAMIC MRI: A PROSPECTIVE CLINICAL STUDY Khaled Sheir, Mohamed Abou El-Ghar, Ahmed El Shal, Mohamed Elsaadany, Diaa-Eldin Taha, and Ahmed EL-Nahas Khaled SheirKhaled Sheir More articles by this author , Mohamed Abou El-GharMohamed Abou El-Ghar More articles by this author , Ahmed El ShalAhmed El Shal More articles by this author , Mohamed ElsaadanyMohamed Elsaadany More articles by this author , Diaa-Eldin TahaDiaa-Eldin Taha More articles by this author , and Ahmed EL-NahasAhmed EL-Nahas More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2359AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To study acute renal anatomical and functional changes after SWL of renal stones using electromagnetic Dornier Lithotripter S (DoLi S) (Dornier Med Tech Germering, Germany). METHODS Between August 2012 and August 2013, 60 adult patients who were eligible for SWL were prospectively included in the study. Inclusion criteria were normotensive non-diabetic patients with single renal stone < 25 mm in a radiologically normal urinary tract with no previous surgical treatment and no other contraindications for SWL. Renal damage was evaluated by estimation of renal perfusion and anatomical changes using dynamic MRI before SWL, 2 hours and one week post-SWL. RESULTS For all cases there was statistically significant decrease of the renal perfusion one week post-SWL (66% of aorta) in comparison to pre-SWL (71%) and 2 hours post-SWL (71%) (p < 0.05). On stratification of cases according to obstruction of renal units at one week follow-up there were 39 non-obstructed and 21obstructed renal units. There was no significant difference in renal perfusion for non obstructed cases at any time while for obstructed cases there was significant decrease of renal perfusion at one week post-SWL (62%) in comparison to pre (76%) and 2 hours post-SWL (75%) (p = 0.003 and 0.005 respectively). Hematoma was observed in 7 cases (12%) 2 hours post-SWL of which 5 were subcapsular and 2 were intrarenal, 3 of the subcapsular hematomas were resolved on one week MRI. Generalized or localized loss of corticomedullary differentiation was observed in 2 patients (3.3%) on 2 hours post-SWL MRI increased to 7 cases (12%) at one week. CONCLUSIONS SWL does not induce any deleterious acute renal anatomical or functional changes. Post-SWL obstruction has a major effect on the renal function on the treated side and must be managed urgently. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e867 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Khaled Sheir More articles by this author Mohamed Abou El-Ghar More articles by this author Ahmed El Shal More articles by this author Mohamed Elsaadany More articles by this author Diaa-Eldin Taha More articles by this author Ahmed EL-Nahas More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP73-08 STONE COMPOSITION INDEPENDENTLY PREDICTS POST- OPERATIVE OUTCOMES AFTER PERCUTANEOUS NEPHROLITHOTOMY (PCNL)

INTRODUCTION AND OBJECTIVES: To study acute renal anatomical and functional changes after SWL of renal stones using electromagnetic Dornier Lithotripter S (DoLi S) (Dornier Med Tech Germering, Germany). METHODS: Between August 2012 and August 2013, 60 adult patients who were eligible for SWL were prospectively included in the study. Inclusion criteria were normotensive non-diabetic patients with single renal stone < 25 mm in a radiologically normal urinary tract with no previous surgical treatment and no other contraindications for SWL. Renal damage was evaluated by estimation of renal perfusion and anatomical changes using dynamic MRI before SWL, 2 hours and one week post-SWL. RESULTS: For all cases there was statistically significant decrease of the renal perfusion one week post-SWL (66% of aorta) in comparison to pre-SWL (71%) and 2 hours post-SWL (71%) (p < 0.05). On stratification of cases according to obstruction of renal units at one week follow-up there were 39 non-obstructed and 21obstructed renal units. There was no significant difference in renal perfusion for non obstructed cases at any time while for obstructed cases there was significant decrease of renal perfusion at one week post-SWL (62%) in comparison to pre (76%) and 2 hours post-SWL (75%) (p 1⁄4 0.003 and 0.005 respectively). Hematoma was observed in 7 cases (12%) 2 hours post-SWL of which 5 were subcapsular and 2 were intrarenal, 3 of the subcapsular hematomas were resolved on one week MRI. Generalized or localized loss of corticomedullary differentiation was observed in 2 patients (3.3%) on 2 hours post-SWL MRI increased to 7 cases (12%) at one week. CONCLUSIONS: SWL does not induce any deleterious acute renal anatomical or functional changes. Post-SWL obstruction has a major effect on the renal function on the treated side and must be managed urgently.

Acute urinary retention in women due to urethral calculi: A rare case

We present a case of a 51-year-old woman with acute urinary retention caused by a urethral calculus. Urethral calculi in women are extremely rare and are usually formed in association with underlying genitourinary pathology. In this case, however, no pathology was detected via thorough urological evaluation. We discuss the pathogenesis, clinical presentation and treatment of urethral calculi. To our knowledge, this is the second reported case of a primary urethral calculus in a female with an anatomically normal urinary tract and the first in a middle-aged Caucasian female.

Renal Relevant Radiology

Ultrasound is commonly used in nephrology for diagnostic studies of the kidneys and lower urinary tract and to guide percutaneous procedures, such as insertion of hemodialysis catheters and kidney biopsy. Nephrologists must, therefore, have a thorough understanding of renal anatomy and the sonographic appearance of normal kidneys and lower urinary tract, and they must be able to recognize common abnormalities. Proper interpretation requires correlation with the clinical scenario. With the advent of affordable, portable scanners, sonography has become a procedure that can be performed by nephrologists, and both training and certification in renal ultrasonography are available.

Morphological aspects and distribution of interstitial cells of Cajal in the human upper urinary tract.

The mechanism by which the ureter propels urine towards the bladder has a myogenic origin, through peristaltic contractions. This pyeloureteral autorhythmicity is generated by specialized, electrically active cells, the interstitial cells of Cajal, located in the proximal regions of the upper urinary tract. The aim of this study was to describe the exact location and the distribution of interstitial Cajal cells in the human upper urinary tract and to analyze their normal number and morphology. This is a preliminary study, which will allow the study of these cells in different urinary tract pathologies. Urinary tract fragments were sampled at different levels, from 13 autopsy cases. Cases with clinical evidence of renal disease, and with histological changes in the kidney or in the urinary tract tissue samples, visible in hematoxylin-eosin staining, were excluded. The interstitial Cajal cells were highlighted with anti-CD117 antibody, immunohistochemically. Cajal cells were indirectly highlighted by the presence of a finely granulated cytoplasm indicating immunoreactivity. These cells were spindle-shaped or stellate, with cytoplasmic extensions at one or both poles of the cell and large oval nucleus. We found that interstitial Cajal cells were located at all upper urinary tract levels, with a higher predominance in the calyces and pyelon. Interstitial Cajal cells were observed mostly between the two layers of the muscularis, but also between the muscle bundles. Most often, these cells were parallel to the muscle fibers. Our study describes the method of detection of interstitial Cajal cells in normal human urinary tract. These results can be used to analyze the number, morphology and the location of these cells in different congenital pathologies, such as vesicoureteral reflux, pyeloureteral junction obstruction or primary obstructive megaureter.

Use of donor bladder tissues for in vitro research

To evaluate deceased non-heart beating (DNHB) donors and deceased heart beating (DHB) brain-stem dead donors, as sources of viable urological tissue for use in biomedical research. To identify sources of viable human bladder tissue as an essential resource for cell biological research aimed at understanding human diseases of the bladder and for developing new tissue engineering and regenerative medicine strategies for bladder reconstruction. Typically, normal human urinary tract tissue is obtained from adult or paediatric surgical patients with benign urological conditions, but few surgical procedures yield useful quantities of healthy bladder tissue for research. Research ethics committee approval was obtained for collection of donor bladder tissue. Consent for DHB donors was undertaken by the Donor Transplant Coordinators. Tissue Donor Coordinators were responsible for consent for DNHB donors and the retrieval of bladders was coordinated through the National Blood Service Tissue Banking Service. All retrievals were performed by practicing urologists and care was taken to maintain sterility and to minimise bacterial contamination. Two bladders were retrieved from DNHB donors and four were retrieved from DHB donors. By histology, DNHB donor bladder tissue exhibited marked urothelial tissue damage and necrosis, with major loss or absence of urothelium. No cell cultures could be established from these specimens, as the urothelial cells were not viable in primary culture. Bladder urothelium from DHB donors was intact, but showed some damage, including loss of superficial cells and variable separation from the basement membrane. All four DHB bladder specimens yielded viable urothelial cells that attached in primary culture, but cell growth was slow to establish and cultures showed a limited capacity to form a functional barrier epithelium and a propensity to senesce early. We have shown that normal human bladder urothelial cell cultures can be established and serially propagated from DHB donor bladders. However, our study suggests that rapid post-mortem changes to the bladder affect the quality and viability of the urothelium, rendering tissue from DNHB donors an inadequate source for urothelial cell culture. Our experience is that whereas patients are willing to donate surgical tissue for research, there is a barrier to obtaining consent from next of kin for retrieved tissues to be used for research purposes.

Reverse autoperitoneal dialysis resulting in pseudo acute renal failure.

A rise in serum creatinine without acute kidney injury (AKI) is possible. In the last 5 years, three patients presented to us for high serum creatinine levels after binge drinking. We already reported on two of these three patients [1, 2]. For the first one, dialysis was instituted as the initial diagnosis was AKI. With the experience gained, the next two patients were examined specifically for a particular cause. They were not dialyzed. The data of the third patient were as follows: a 44-year-old male, admitted after a fall following binge alcohol consumption. He complained of painful abdominal distension and was anuric. Serum creatinine was 6.5 mg/dL (575 µmol/L), blood urea: 66 mg/dL (23.5 mmol/L), serum sodium 134 mmol/L and serum potassium 4.3 mmol/L. An abdominal ultrasound examination showed two normal kidneys, a normal urinary tract and presence of peritoneal fluid. In view of these findings, a bladder rupture was suspected and confirmed by cystoscopy. With bladder drainage, serum creatinine diminished to 3.5 and then 1.4 mg/dL (309–123.7 µmol/L). Laparotomy was done and a 4-cm tear on the dome of urinary bladder was surgically repaired. All three patients had similar histories: (i) an alcoholic binge, (ii) a trauma, (iii) sudden onset of abdominal pain and progressive distension (iv) anuria (v) elevated serum creatinine (vi) cystography revealing a tear in the bladder and (vii) improvement in serum creatinine on continuous bladder drainage. The data of these patients are given in supplementary Table S1. In the majority of bladder ruptures, there is a history of significant abdominal trauma. Following heavy alcohol intake, the distended bladder is very susceptible to injury and can be ruptured by a minor trauma. Alcohol-induced polyuria and impaired sensorium that removes cues for voiding cause overdistension of the bladder and rupture. The intoxicated patient may fail to recall the trauma. In a review of 20 isolated intraperitoneal bladder ruptures, the mean time between presentation and diagnosis was 5.4 days [3]. The diagnosis was based on a compatible history: suprapubic pain, anuria, hematuria and rapidly increasing ascites. The diagnosis was strengthened by rapidly rising serum creatinine without features of hypercatabolism. Continuous bladder drainage normalized laboratory abnormalities. Urinary bladder injuries after blunt or penetrating trauma are rare, owing to the bladder's anatomical position [4]. Bladder ruptures can be extraperitoneal, intraperitoneal or both, depending on the site of the injury. Intraperitoneal bladder ruptures are usually associated with blunt abdominal trauma (excluding iatrogenic causes), and unlike extraperitoneal leaks, they are not usually associated with pelvic fractures. Intraperitoneal ruptures usually occur at the dome of the bladder in contrast to extraperitoneal leaks which are most often lateral [4]. Non-traumatic rupture is even rarer and causes may be essentially divided as increase in intravesical pressure or weakening of the bladder wall. In most cases, spontaneous rupture occurs in the presence of a urothelial neoplasm or after pelvic radiation therapy [2]. In neonates, peritoneal entry of urine is a rare complication. The major causes are congenital obstructive uropathy with urine leakage into the peritoneal cavity and bladder perforation as a complication of umbilical artery catheterization [5]. The expression ‘reverse peritoneal dialysis’ was first used in 1991 [5]. It is characterized by a flux of small molecules such as creatinine and urea from urine collected in the peritoneum along a concentration gradient opposite to conventional peritoneal dialysis where small molecules move from the blood to peritoneal cavity, a phenomenon mentioned as ‘reverse autoperitoneal dialysis’. As a result, the blood values of creatinine and urea are elevated mimicking renal failure despite normally functioning kidneys. This was described as ‘pseudo acute renal failure’ in the literature.

Unenhanced CT in the evaluation of renal/ureteric colic

Unenhanced CT of kidneys, ureters and bladder (CTKUB) is now the recommended imaging modality in the investigation of patients with acute renal or ureteric colic. This review aims to illustrate the normal urinary tract anatomy to assist imaging interpretation, outline the CTKUB imaging technique and image review at the Picture Archiving and Communication System workstation, discuss the pertinent imaging findings such as the direct signs, for example, soft tissue rim sign and comet tail sign, as well as secondary indirect signs such as pale kidney sign, nephromegaly, hydronephrosis, hydroureter and perinephric stranding or edema on the CTKUB for the diagnosis. Imaging pitfalls in the interpretation will be illustrated and discussed, for example in the presence of a ureteral stent and optimal image interpretation with wide windowing on CT. In addition, the discussion will also include the use of scout radiograph, the importance of detecting extraurinary pathology during CTKUB examination and explore Randall...

Further evidence of endogenous hydrogen sulphide as a mediator of relaxation in human and rat bladder

We investigated the expression of hydrogen sulphide (H2S) in human and rat lower urinary tract (including bladder, prostate and urethra) tissues, and we sought to determine whether H2S induces relaxation of human and Sprague-Dawley (SD) rat bladder strips. Human normal lower urinary tract tissue was obtained for the evaluation of endogenous H2S productivity using a sulphide-sensitive electrode and for the analysis of the expression levels of all three synthases of endogenous H2S, cystathionine β-synthase (CBS), cystathionine γ lyase (CSE) and 3-mercaptopyruvate sulphur transferase (MPST, as known as 3-MST) by Western blot assay. CBS, CSE and MPST were located in human sample slides by immunohistochemistry. Human and male adult SD rat bladder strips were tested for H2S function with a transducer and recorded. All experiments were repeated six times. The endogenous H2S productivity and the H2S synthases had various distributions in the human and rat lower urinary tract tissues and were located in both epithelial and stromal sections. L-cysteine (L-Cys, a substrate of CBS, CSE and MPST) elicited relaxation in a dose-dependent manner on human bladder strips pre-contracted by acetylcholine chloride. This effect could be diminished by the ATP-sensitive potassium ion (KATP) channel blocker glibenclamide (GLB), the CSE inhibitor DL-propargylglycine (PPG) and the CBS inhibitor hydroxylamine (HA). H2S and its three synthases were present in the human and rat lower urinary tract tissues and relaxed human and rat bladder strips, which implied that endogenous H2S might play a role in physiological function and pathological disorders of the lower urinary tract symptoms (LUTS) or overactive bladder (OAB).

Outcomes of Targeted Treatment for Vesicoureteral Reflux in Children with Nonneurogenic Lower Urinary Tract Dysfunction

There is a known association between nonneurogenic lower urinary tract conditions and vesicoureteral reflux. Whether reflux is secondary to the lower urinary tract condition or coincidental is controversial. We determined the rate of reflux resolution in patients with lower urinary tract dysfunction using targeted treatment for the underlying condition. Patients diagnosed and treated for a lower urinary tract condition who had concomitant vesicoureteral reflux at or near the time of diagnosis were included. Patients underwent targeted treatment and antibiotic prophylaxis, and reflux was monitored with voiding cystourethrography or videourodynamics. Vesicoureteral reflux was identified in 58 ureters in 36 females and 5 males with a mean age of 6.2 years. After a mean of 3.1 years of treatment reflux resolved with targeted treatment in 26 of 58 ureters (45%). All of these patients had a history of urinary tract infections before starting targeted treatment. Resolution rates of vesicoureteral reflux were similar for all reflux grades. Resolution or significant improvement of reflux was greater in the ureters of patients with dysfunctional voiding (70%) compared to those with idiopathic detrusor overactivity disorder (38%) or detrusor underutilization (40%). Vesicoureteral reflux associated with lower urinary tract conditions resolved with targeted treatment and antibiotic prophylaxis in 45% of ureters. Unlike the resolution rates reported in patients with reflux without a coexisting lower urinary tract condition, we found that there were no differences in resolution rates among grades I to V reflux in patients with lower urinary tract conditions. Patients with dysfunctional voiding had the most improvement and greatest resolution of reflux. Additionally grade V reflux resolved in some patients.

Huge Anterior Sacral Meningocele Simulating Bladder Retention

Anterior sacral meningocele (ASM) is a rare congenital disorder involving herniation of the dural sac through a defect in the anterior surface of the sacrum. We report the case of a young patient with an enormous ASM that simulated bladder retention in terms of symptoms as well as on physical examination and at ultrasonography. After introducing a catheter that excluded urinary retention, computed tomography (CT) scan and magnetic resonance imaging (MRI) showed the ASM. The patient underwent surgical repair of the ASM through a sacral laminectomy and recovered normal lower urinary tract function.

Comparison of Seromuscular Tunnel and Split-cuff Nipple Antireflux Ureteroenteral Anastomosis Techniques in Orthotopic Taenia Myectomy Sigmoid Neobladder: A Prospective, Randomized Study

To compare the functional results and complications of seromuscular tunnel and split-cuff nipple antireflux ureteroenteral implantation techniques in orthotopic taenia myectomy sigmoid neobladder. A randomized prospective study was conducted from January 2004 to January 2009. A total of 62 patients (53 men and 9 women; all of Han ethnicity) with muscle-invasive urothelial carcinoma of the bladder and a normal upper urinary tract were enrolled in the present study. After pelvic lymphadenectomy and radical cystectomy, the ureters were randomized to implantation using seromuscular tunnel anastomosis or a split-cuff nipple technique. Regular follow-up visits included renogram intravenous urography and serum creatinine to evaluate renal function. The mean follow-up period was 52.0 ± 19.2 months (range 12-84). The serum creatinine levels remained normal in all patients throughout the study period. Stenosis occurred in 4 of 118 renoureteral units (4 patients), 2 with a seromuscular tunnel anastomosis and 2 with split-cuff nipple reimplantation. Only 1 stricture required treatment; the patient underwent retrograde balloon dilation after double-J stent insertion. The others received active surveillance, and the hydronephrosis did not worsen. No reflux was observed in any patient. One patient presented with bilateral hydronephrosis due to neovesicourethral stricture, which was treated successfully with transurethral urethrotomy. No difference in stricture formation was seen between the patients treated with the seromuscular tunnel or split-cuff nipple ureteroenteral anastomosis techniques in the orthotopic taenia myectomy sigmoid neobladder. No patients developed reflux. Our results suggest that both the seromuscular tunnel and the split-cuff nipple approach are reliable antireflux ureterointestinal anastomosis techniques, with low morbidity for orthotopic taenia myectomy sigmoid neobladder.

Letter to the Editor Report of surgical correction of a cervicovaginal agenesis case: cervicovaginal reconstruction with pudendal thigh flaps

Letter to the Editor Report of surgical correction of a cervicovaginal agenesis case: cervicovaginal reconstruction with pudendal thigh flaps

Urinary Reflux Screening in Infants with Prenatal Hydronephrosis

Source: Szmanski KM, Al-Said AN, Pippi Salle JL, et al. Do infants with prenatal hydronephrosis benefit from screening for vesicoureteral reflux? J Urol. 2012; 188(2): 576– 581; doi: 10.1016/j. juro.2012.04.017Investigators at Montreal Children’s Hospital sought to determine the necessity of vesicoureteral reflux (VUR) screening in children with prenatally detected hydronephrosis (PHN). They report their experience with consecutive infants seen at their institution with postnatally confirmed PHN from 1998 to 2003. All patients with anatomic abnormalities of the urinary system were excluded from the analysis.At the authors’ institution, some children with low-grade hydronephrosis (grades I and II) underwent screening for VUR with a voiding cystourethrogram (VCUG) while others did not, partly determined by whether they were followed by a urologist or nephrologist. All patients with high-grade hydronephrosis (Grade III or higher) underwent VCUG screening. Medical records of all children with PHN were reviewed for presence of VUR diagnosed by VCUG, circumcision status, gender, exposure to antibiotic prophylaxis, and diagnosis of urinary tract infection (UTI). Children with low-grade PHN were compared to those with high-grade PHN (grades III and IV). The primary outcome measure was development of a symptomatic or febrile UTI, after accounting for gender, circumcision, and VUR.The study included 206 children with PHN, 148 with low-grade hydronephrosis and 58 with high-grade hydronephrosis. Of the 148 infants with low-grade hydronephrosis, 98 (66%) underwent a VCUG. Among the 155 children who underwent VCUG, the overall prevalence of VUR was 11%, and was not statistically different between those in the low-grade PHN group (9%) and those in the high-grade PHN group (14%). No UTIs were noted among patients with grade I hydronephrosis during 53 patient-years of follow-up. The incidence of UTI was 3.6 times higher among the high-grade PHN group (11.1 infections per 100 patient-years) than among the overall low-grade PHN group (3.52 infections per 100 patient-years). In multivariate analysis, UTI was significantly more likely among children with high-grade hydronephrosis than in children with low-grade hydronephrosis after correcting for gender and circumcision status. The association remained strong after also correcting for VUR status but was of borderline statistical significance (P = .053). Gender, circumcision, and VUR on antibiotic prophylaxis were not statistically significant independent risk factors for UTI.The authors conclude that children with low-grade hydronephrosis and anatomically normal upper urinary tracts do not benefit from VCUG screening, since UTI risk appears to be associated with hydronephrosis grade rather than VUR.Dr Shukla has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.PHN is the most common anomaly detected on routine prenatal sonography, seen in 1% to 3% of all pregnancies.1 The standard workup of children with a history of PHN has traditionally included a renal ultrasound and VCUG, but there is lack of consensus as to whether these studies are necessary since controlled trials with appropriately extended postnatal follow-up are lacking. The American Urological Association guidelines, based on a large meta-analysis of available literature, conclude that there is insufficient evidence to accurately assess the risk of UTI in children with a history of PHN, regardless of the presence of VUR.2 The Society of Fetal Urology similarly published a consensus statement recently that does not recommend VCUG as a routine element of the postnatal workup in all children with a history of PHN since the VUR diagnosed in these cases carries a high rate of spontaneous resolution and lower risk of UTI.3It is important to note that the investigators for this study excluded all children with anatomic abnormalities, and, therefore, children with the potential diagnosis of posterior urethral valve, ureterocele, ectopic ureter, or neurogenic bladder, for example, must be carefully investigated and the approach discussed here is not applicable. Many children with these anatomic abnormalities have low-grade or no hydronephrosis.Rigorously differentiating low-grade from high-grade hydronephrosis is a subjective dilemma. As confirmed in this study, children with high-grade hydronephrosis warrant a full evaluation with a postnatal renal ultrasound, VCUG, and perhaps a diuretic nuclear renogram. These children have a much higher risk of developing a UTI, and may also have concurrently high risk for anatomical anomalies.Overall, however, this study confirms a broad trend in pediatric medicine to utilize the VCUG judiciously.

A unusual case of 356 vesical calculii

Multiple vesical calculi are rarely seen in urological practice. Males are affected more than the females. Vesical calculi are usually secondary to bladder outlet obstruction. These patients present with recurrent urinary tract infection, haematuria or with retention of urine. We report a 43 years male patient who presented with acute urinary retention. He had history of trauma over perineal region three years back following which he had recurrent urinary tract infection and thinning of stream. USG abdomen revealed normal upper urinary tract with echogenic debris in partially filled urinary bladder. Renal function test was with in normal limit. Per urethral catheterization failed and over antibiotic cover, patient was posted for cystourethroscopy followed by suprapubic cystostomy under spinal anaesthesia. Membranous urethral stricture found during urethroscopy could be managed by optical internal urethrotomy. On cystoscopy whole of bladder was filled with thick pus like material with multiple large urinary bladder calculi. Open cystolithotomy was done and we were surprised to see 356 stones of various size and shape after removal. Patient made uneventful recovery and discharged after 12 days of hospital stay. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-1, 44-47 DOI: http://dx.doi.org/10.3126/jcmsn.v8i1.6825

Infective endocarditis complicated by aortic graft infection and osteomyelitis: case report and review of literature

Primary aortic graft infection early after aortic graft insertion is well described in the literature. Here, we present a unique case of late aortic graft infection 5 years after insertion secondary to mitral valve endocarditis, resulting from cellulitis in a patient with severe venous varicosities. A 63-year-old male presented for severe low back pain, constipation, and low-grade fever. An abdominal computed tomography scan with oral and intravenous contrast showed a normal spine and urinary tract. Blood and urine cultures, done at the same time, grew Staphylococcus aureus. A transesophageal echocardiogram confirmed the diagnosis of endocarditis. Subsequently, a gallium scan showed increased uptake in the vertebral bodies, aortic graft, left patella, and left ankle. After 3 months of antibiotic therapy, the patient’s low back pain resolved with normalization of his laboratory values. He remained free of infection at a 2-year follow-up. We reviewed the literature concerning the atypical presentation of infective endocarditis, with a focus on distant metastases at initial presentation, such as osteomyelitis and aortic graft infection, as well as the different treatment modalities. This report describes successful medical treatment with intravenous followed by oral antibiotics for an infected endovascular graft without any surgical intervention.

O uso de vacinas na profilaxia das infecções do trato urinário

The urinary tract is the most common site of bacterial infections. Urinary tract infections (UTIs) in women without urinary tract anatomic abnormalities require frequent and repeated use of antibiotics, increasing the prevalence of antimicrobial-resistant microorganisms. The possibility of an alternative approach, with the use of vaccines produced from inactivated bacteria or structural components of these microorganisms, is a reality. Confirming the results observed experimentally, controlled clinical studies of oral or vaginal immunotherapy have shown reductions in the number of episodes of recurrence, without significant side-effects. We reviewed the mechanisms of aggression and defense involved in the pathogenesis of UTIs in women with anatomically normal urinary tracts, the evolution of knowledge about the immunotherapy of UTIs, and the vaccines already available or under development for the treatment of this important clinical condition.

Laparoscopically Assisted Vaginal Pull-through for High Urogenital Sinus: A New Surgical Technique

To evaluate feasibility and outcome of a laparoscopically assisted vaginal pull through procedure for suprasphincteric high urogenital sinus malformation with hydrometrocolpos and normal external genitalia. A tension-free anastomosis of the vagina to the perineum was realized after laparoscopic mobilization of the vagina, separation from the bladder neck at the confluence and pull-through via an externally introduced expandable trocar, thereby avoiding perineal or perirectal dissection. The approach resulted in good cosmetic and unimpaired functional outcome. Voiding cystourethrography showed normal lower urinary tract anatomy. No disturbances of bladder function could be detected 2 years after surgery. Laparoscopic assisted vaginal pull-through is a new approach for high UGS that significantly improved exposure of the uretro-vaginal junction, allowed extensive mobilization of the vagina and showed excellent cosmetic and functional result.

Penoscrotal Transposition: A Case Report

Penoscrotal transposition (PST) is an extremely rare congenital malformation, usually associated with a wide variety of other anomalies. We describe an exceptional case of a newborn with PST, but normal upper urinary tract and no other associated malformations. An unbooked newborn male delivered at term with no reported antenatal complications. There was no evidence of mother being exposed to teratogens during pregnancy. On physical examination, an abnormal appearance of the external genitalia could be seen. There was a complete rotation of the external genitalia with cryptorchidism. Penis with chordee was noted (Fig. 1). Urinalysis, renal and vesical sonography, and voiding cystourethrography showed no other urological abnormalities. There were no associated cardiological or gastrointestinal anomalies. Fig. 1 Complete penoscrotal transposition PST is a very uncommon heterogeneous condition in which the scrotum is positioned superior and anterior to the penis. Less than 20 cases of extreme degree of PST with normal scrotum have been reported in the literature [1]. PST results from abnormal genital tubercle development around the 6th week of gestation. It is associated with delay in the midline fusion of the urethral folds. Although the occurrence of most reported cases of PST has been sporadic, other congenital anomalies such as hypospadias, chordee, and renal agenesis or dysplasia could be found in approximately 90% of patients [2]. Gastrointestinal abnormalities, predominantly imperforate anus, were found in 30% of cases [3]. PST may present with a broad spectrum of abnormalities ranging from simple shawl scrotum (doughnut scrotum) to very complex extreme transposition with cardiac, gastrointestinal, craniofacial, central nervous system, genital, and urological malformations [4]. Growth deficiency and mental retardation have also been noticed in 60% of patients [5]. Differential diagnosis must include pseudohermaphroditism, penoscrotal hypospadias, micropenis, intrauterine penile amputation, and especially penile agenesis with a midline skin tag anterior to the anus. Complete penoscrotal transpositions have been rarely reported in the Indian literature [6]. Surgery in more complex cases of PST is technically challenging. It is usually performed between 12–18 months. The size of the phallus and its potential to develop at puberty into a sexually satisfactory penis are of paramount relevance when surgery is planned. In order to assess this situation, a surgeon must carefully palpate the corporal bodies to determine their bulk and sometimes perform a testosterone test to demonstrate erections. Extreme penoscrotal transposition with severe hypospadias and chordee is difficult to differentiate from penile agenesis with a midline skin tag anterior to the anus (with penile atrophic body buried in the perineum). In both cases the penile reconstruction and repositioning are often unsatisfactory, and female gender reassignment, while ethically controversial, may be a prudent therapeutic in selected cases.

3‐dimensional morphometric analysis of murine bladder development and dysmorphogenesis

Disorders of the urinary tract represent a major cause of morbidity and impaired quality of life. To better understand the morphological events responsible for normal urinary tract development, we performed 3-D reconstructive analysis of developing mouse bladders in control, mgb-/-, and Fgfr2(Mes-/-) mice. Detrusor smooth muscle differentiation initiated in the bladder dome and progressed caudally with the leading edge extending down the right posterior surface of the bladder. Gender-specific differences in detrusor smooth muscle development were observed during early embryonic development. Bladder trigone morphology transitioned from an isosceles to equilateral triangle during development due to the preferential lengthening of the urethra to ureter distance. The primary defect observed in mgb-/- bladders was a significant reduction in detrusor smooth muscle differentiation throughout development. Deviations from normal trigone morphology correlated best with VUR development in Fgfr2(Mes-/-) mice, while alterations in intravesicular tunnel length did not. Multivariate morphometric analysis provides a powerful tool to quantify and assess urinary tract development.