Purpose: We aim to present our experience for the repair of vesicovaginal fistula (VVF) with special reference to surgical approach. Materials and Methods: From January 1999 to June 2005, 52 VVF patients with mean age of 32 years underwent operative treatment. Fistulas were divided into two groups, simple and complex, depending on site, size, etiology and associated anomalies. Simple VVFs were approached through the vaginal route and complex VVFs via the transabdominal route. Patients were evaluated at two to three weeks initially, three-monthly twice and later depending on symptoms. Results: Thirty-two (61.5%) had simple fistulas and 20 (38.5%) complex fistulas. The most common etiology was obstetric trauma in 31 (59.6%) patients, while the second most common cause was post hysterectomy VVF. Thirty-two (61.5%) patients were managed by transvaginal route, of which 17 had supratrigonal and 15 trigonal fistulas. Twenty (38.5%) patients with complex fistulas were managed by abdominal route. The mean blood loss, postoperative pain and mean hospital stay were shorter in transvaginal repair. Eleven (21.2%) patients required ancillary procedures for various other associated anomalies at the time of fistula repair. Three patients failed repair giving a success rate of 94.2%. At a mean follow-up of three years 48 women were sexually active, of these 10 (19.2%) complained of mild to moderate dyspareunia. Conclusion: Most of the simple fistulas irrespective their locations are easily accessible transvaginally while in complex fistulas we recommend the transabdominal approach. Depending on the clinical context both the approaches achieved comparable success rates.

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Objectives: To describe an evaluation protocol for pediatric stone formers for risk assessment and management strategies. Materials and Methods: Between 2002-2006, 2618 children of age three months to 15 years were evaluated for stone disease. Evaluation included demographics, history, anthropometry, diet, ultrasound, X-ray KUB, IVU, blood and 24h urine chemistry and cultures. Stones were analyzed by IR spectroscopy. Results: The median age was seven years with a M:F ratio of 2.2:1. Of the 2618 patients, 2216 presented with normal renal function and 402 with renal failure. Main symptoms were abdominal pain (33%), flank pain (38%) and fever (38%). Renal failure patients also had shortness of breath (38%) and oligo-anuria (26%). Children were malnourished with height and weight deficits in 65% and 76% respectively. Diet was low in protein (74%), calcium (55%) and fluids in (55%), high in oxalate (55%), sodium (39%), purines (42%) and refined sugar (41%). Overall urine cultures were positive in 1208 (46%) with E. coli (38%) and Klebsiella (8%). Stone distribution was renal in 64%, ureter in 8%, bladder in 18%, bilateral in 40% and multiple sites in 18%. Median stone size was >1.5-2.0 cm. The frequency of compounds in stones was ammonium urate (58%), calcium oxalate (63%), uric acid (6%), calcium phosphate (12%) and struvite (8%). Metabolic abnormalities included hypovolumia (31%), hypocitraturia (87%), hyperoxaluria (43%) and hyperuricosuria (26%). Dietary and medical treatment corrected risk factors in two-thirds of patients with a recurrence rate of about 1.15%. Conclusion: An evaluation based on history, imaging, diet, metabolic analysis and stone type can help to tailor management strategies.

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Bladder augmentation is an important tool in the management of children requiring reconstructions for urinary incontinence or preserving of the upper urinary tract in congenital malformations. We reviewed the literature and evaluated the long-term results of enterocystoplasty in the pediatric age group and summarized techniques, experimental options and future perspectives for the treatment of these patients. For this purpose, a directed Medline literature review for the assessment of enterocystoplasty was performed. Information gained from these data was reviewed and new perspectives were summarized. The ideal gastrointestinal (GI) segment for enterocystoplasty remains controversial. The use of GI segments for enterocystoplasty is associated with different short and long-term complications. The results of different centers reported in the literature concerning urological complications after enterocystoplasty are difficult to compare because of the non-comparable aspects and different items included by different authors. On the other hand, there are more and more case reports about cancer arising from bowel segments used for bladder augmentation in recent publications. Although bladder reconstruction with GI segments can be associated with multiple complications, such as metabolic disorders, calculus formation, mucus production, enteric fistulas and potential for malignancy, enterocystoplasty is unfortunately still the gold standard. However, there is an urgent need for the development of alternative tissues for bladder augmentation.

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Acute urinary retention (AUR) is one of the most significant, uncomfortable and inconvenient event in the natural history of benign prostatic hyperplasia (BPH). The immediate treatment is bladder decompression using urethral or suprapubic catheterization. Several factors have been identified that are associated with or precipitate AUR. It is useful to classify AUR as BPH-related or not, than spontaneous or precipitated when the initial management is considered. Use of prophylactic 5 a-reductase inhibitors can prevent AUR in men with BPH having moderate to severe lower urinary tract symptoms and large prostate size. Alpha blockers can prevent AUR in symptomatic BPH patients and also facilitate catheter removal following episodes of spontaneous AUR. Anticholinergics can be safely combined with alpha blockers in symptomatic BPH patients without increasing the risk of AUR. Surgical treatment carries a higher rate of morbidity and mortality in men presenting with AUR compared to those presenting with symptoms alone. Urgent prostatic surgery after AUR is associated with greater morbidity and mortality than delayed prostatectomy. Alpha blockers mainly help to delay the surgery and may avoid surgery altogether in a subgroup of patients. TURP remains the "gold standard" if a trial without catheter fails. Alternative minimally invasive procedures can be considered in poor-risk patients, but its value is yet to be established.

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Pediatric urolithiasis poses a technical challenge to the urologist. A review of the recent literature on the subject was performed to highlight the various treatment modalities in the management of pediatric stones. A Medline search was used to identify manuscripts dealing with management options such as percutaneous nephrolithotomy, shock wave lithotripsy, ureteroscopy and cystolithotripsy in pediatric stone diseases. We also share our experience on the subject. Shock wave lithotripsy should be the treatment modality for renal stone less than 1cm or < 150 mm ² and proximal non-impacted ureteric stone less than 1 cm with normal renal function, no infection and favorable anatomy. Indications for PCNL in children are large burden stone more than 2cm or more than 150mm ² with or without hydronephrosis, urosepsis and renal insufficiency, more than 1cm impacted upper ureteric stone, failure of SWL and significant volume of residual stones after open surgery. Shock wave lithotripsy can be offered for more soft (<900 HU on CT scan) renal stones between 1-2cm. Primary vesical stone more than 1cm can be tackled with percutaneous cystolithomy or open cystolithotomy. Open renal stone surgery can be done for renal stones with associated structural abnormalities, large burden infective and staghorn stones, large impacted proximal ureteric stone. The role of laparoscopic surgery for stone disease in children still needs to be explored.

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Vesicoureteral reflux is a common clinical entity and is one of the keystones of the establishment of pediatric urology as a urological subspeciality. There has been continued evolution in the management of vesicoureteral reflux as new insights are gained on its role in renal damage. The optimal treatment algorithm remains controversial. This review aims to highlight the current literature on VUR and its association with urinary tract infections and renal damage. The protocol of management of a child with VUR followed at The Hospital for Sick Children, Toronto is described.

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Aims and Objectives: The aim of the study was to establish the prevalence of enuresis in school children and to determine contributing factors along with treatment methods used in these children. Materials and Methods: The parents of 1473 children aged between 6-10 years completed a self-administered semi-structured questionnaire. Socio-demographic profiles, enuresis data, medical and psychiatric disorders and family stressors were collected. The data was analyzed and the results presented. Results: The response rate was 89.22%. The overall prevalence of enuresis was 7.61%. Enuresis was more common in boys. A positive family history of enuresis was seen in 28.57% children; 14.29% of the children had daytime wetting as well. Only 24.11% of the parents had taken their child to a doctor for the problem. Family stressors, significant birth history and lower socioeconomic status was present to a larger extent in the enuretic group. Scholastic backwardness was also an important factor in this group. Conclusions: This study reports on the prevalence of enuresis in school-going children and stresses on the need for parental education and awareness about this problem.

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Urinary tract infections are common following renal transplant. The spectrum varies from asymptomatic bacteriuria to septicemia. Gas-producing infections of the urinary tract are rare but tend to have a grave prognosis when they do occur. We report a 57-year-old gentleman who underwent a renal transplant 20 months earlier. He presented to us with fever and dysuria. Clinical examination revealed a febrile and ill-looking patient with severe graft tenderness. An emergency pelvic CT scan revealed presence of emphysematous prostatitis, cystitis and pyelitis. Urine and blood cultures grew E. coli . Endoscopic abscess drainage was done and antibiotics given but he succumbed to his illness due to multiorgan failure within 48h. This is the first reported case of emphysematous prostatitis in a renal allograft recipient.

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Introduction : Researches show that chronic illnesses may affect marital adjustment and sexual function. Therefore, the purpose of this research was to recognize marital satisfaction, sexual dysfunction and demographic factors among Chemically Injured Veterans (CIV). Materials and Methods: In this descriptive research, we selected and studied 185 cases of CIVs referred to Tehran's hospitals. Data gathering tools were Enrich Marital Satisfaction Scale and structured interview. The items of interview included 28 questions about sexual dysfunction according to DSM-IV-r. The statistical methods were T-test, ANOVA and Correlation. Results: The results show that 45.5%, i.e. nearly half of the CIV subjects were dissatisfied with their marriage and marital relationship and the dissatisfaction level in 11% was very high. Other results show that 65/4% of veterans with chemical injuries suffered from a kind of sexual dysfunction. The most common dysfunctions were: erectile problem and libido reduction by 49.2% and 48.6% respectively. Also, results show that there was a relation between demographic factors and sexual dysfunction in CIVs. Discussion: As far as the results show, sexual libido reduction rate in CIVs is like that in chronic obstructive pulmonary disease patients. Therefore, sex therapy, psychotherapy and couple therapy must be a component of the treatment of CIVs.

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Schwannoma is a rare primary tumor originating in the neural sheath with a good prognosis. The management is surgical. We present a case in which a retroperitoneal mass arising from the adrenal gland was excised and histopathology revealed a schwannoma with coexisting tuberculosis. This case report highlights the need to be aware of the potential coexistence of tuberculosis in any case of incidentaloma, especially due to resurgence of tuberculosis as a global epidemic with the increasing incidence of HIV and AIDS. To the best of our knowledge, this is the first reported case of a schwannoma and tuberculosis coexisting in the adrenal gland.

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The prevalence of vesicoureteral reflux (VUR) has been estimated as. 4 to 1.8% among the pediatric population. In children with urinary tract infection the prevalence is typically from 30-50% with higher incidence occurring in infancy. When correction of VUR is determined to be necessary, traditionally open ureteral reimplantation by a variety of techniques has been the mainstay of treatment. This approach is justified because surgical correction affords a very high success rate of 99% in experienced hands and a low complication rate. In that context the purpose of this review article is to highlight the use of laparoscopy and robot-assisted techniques to perform ureteric reimplantation for the management of pediatric VUR. A detailed review of recent literature on the subject is performed to find out various aspects of minimally invasive surgery in the treatment of VUR, highlighting evolution of management approaches, operative steps, complications, results and the current status in clinical practice. We also share our experience on the subject.

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Posterior urethral valves are the commonest cause of lower urinary tract outflow obstruction in male infants with an estimated incidence of 1:5000 male infants and 1:25,000 live births. Despite treatment with fulguration of the obstructing valves, bladder function is abnormal in up to 70% of older children and adolescents. Bladder dysfunction causes morbidity e.g. urinary incontinence and has been implicated in the late deterioration of renal function in this population. A poor understanding and inappropriate management of bladder dysfunction can result in unnecessary morbidity, which can handicap a child for life. Any method that measures function or dysfunction of the lower urinary tract constitutes a urodynamics investigation. Broadly, the investigations can be classified into simple or noninvasive urodynamics and invasive urodynamics. The objective of urodynamics assessments in children is to reproduce the patient's complaints or symptoms. Video urodynamics can provide additional information that may contribute to a further understanding of the problem under investigation. Urodynamics provides a useful tool to test the efficacy of treatment as well as determine any refinements necessary to improve the outcome of such treatment.

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Complete eversion and transurethral prolapse of the urinary bladder is rare. We report a case of complete eversion and prolapse of bladder that occurred due to self pulling out of an indwelling Foley catheter in a 72-year-old woman. She presented with retention of urine concurrent with complete uterine procidentia. An indwelling Foley catheter was given to relieve the retention. The senile lady pulled out the catheter resulting in complete transurethral prolapse with bladder eversion. Under injection Midazolam sedation and with application of xylocain jelly the prolapsed bladder could be reduced manually back through the urethra. Definite corrective surgery was done later for the uterine prolapse.

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The number of pediatric patients with end stage renal disease (ESRD) has been steadily growing during the last 10 years all over the world, because of the improvement of medical and surgical treatment of severe urologic malformations and congenital and acquired nephrological disorders. Kidney transplantation (Tx) with a live related donor continues to be the gold standard therapy to treat ESRD in children because of the best final results, the chronic lack of cadaveric donors and the frequent possibility of young patients to have parents or relatives as a source of a potential graft donor. Nowadays almost every pediatric patient can be dialyzed and transplanted, even early in life, if he or she has the possibility of a live related donor. Improvements in pediatric anesthesiology and intensive care have also been very important, in reducing the morbidity and mortality related to Tx procedures. Here we report our experience with Tx for the last 25 years, specially our long experience of live related donor transplantation in children and adolescents with emphasis on technical issues in small children and pediatric patients with severe urologic malformations and bladder dysfunction. We'll make special considerations on the improvement in short and long follow-up with the actual prevention and treatment of graft rejection, due to the new immunosuppressive agents and protocols.

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Wilms' tumor (WT) is the commonest pediatric renal tumor, predominantly seen in children less than five years of age. The majority of patients present with an abdominal lump and CT scan is the usual imaging modality for determining the extent of disease. With multimodality management, the results of treatment of WT have improved dramatically over the last 50 years. The treatment protocols have been devised and modified repeatedly depending on evidence from randomized trials by several cooperative groups - mainly National Wilms' Tumor Study Group (NWTSG) and the International Society of Pediatric Oncology (SIOP). The NWTSG recommends primary surgery followed by chemotherapy while SIOP advocates four weeks of chemotherapy prior to surgery. The regimen, dose and duration of chemotherapy have been repeatedly modified to reduce toxicity while maintaining efficacy. The role of radiation therapy has also been customized. Most centers have reported excellent survival rates with the modern day treatment protocols, except in patients with an unfavorable histology. The results of treatment of relapsed WT have also improved with newer drugs and combinations being used for the same.

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Objective: To present the outcome of dorsal onlay urethroplasty in 73 patients for stricture urethra over a period of eight years. Materials and Methods: Seventy-three patients of stricture urethra have undergone dorsal onlay urethroplasty from July 1998 to February 2006. Age distribution: 14-58 years. Etiology: Trauma 20/73 (27.39%), Balanitis Xerotica Obliterans 2/73 (2.73%), Iatrogenic 26/73(35.61%), Infection 3/73 (4.10%), Idiopathic 22/73 (30.13%). Site: Penobulbar-25/73, bulbar-38/73, membranous-8/73 and long length-2/73. Suprapubic catheter was inserted preoperatively: 21/73 patients. Preputial / distal penile skin was used in all patients. Buccal mucosa was not used in any patient. Hospitalization was for four to five days. Catheter was removed after 21 days. All patients had their first endoscopic checkup after three months. Subsequently they were followed up by uroflometry. Routine imaging of urethra for follow-up was not carried out. Results: 63/73 (86.30%) patients had satisfactory outcome not requiring any further treatment, 8/73 (10.95%) developed anastomotic stricture (3/8-optical internal urethrotomy, 5/8 dilatation alone). 2/73 (2.75%) developed external meatal stenosis. None had urinary fistula and required repeat urethroplasty. Follow-up ranged from three months to eight years. Conclusion: Dorsal onlay urethroplasty using preputial/distal penile skin is a satisfactory procedure. Preputial/distal penile skin is devoid of hair and fat and hence an ideal graft material. Even in circumscribed patients distal penile skin can be harvested. Long-term follow-up is required in judging results of patients with stricture urethra.

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The million-dollar question that we wish to address in this article is who should be the specialist for urological problems in children in India. What are the special attributes of a pediatric urologist? The answer to this question is far from simple and straightforward. Dogmatic rules do not provide a functional solution. While one has to admit that in India pediatric urological problems will be dealt with by urologists, as well as by pediatric and general surgeons, one has to also accept that lacunae do exist in the current curriculum and the methodology of training. A pediatric urologist by the virtue of definition would be a specially trained surgeon who would deal with urological diseases of children from newborn to adolescence (0-14 years). (In some instances e.g. exstrophy, renal transplant and continent procedures the age of treatment may even exceed up to 16 and above). He has the experience and the expertise to treat a child. Children are not miniaturized adults and newborns are not miniaturized children. Their physiology is different, they cannot always express their problems, answer questions and may not be cooperative during clinical examination.

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We present a case of an eight-year-old female presenting with four months history of progressive weight gain, short stature, obesity, mild acanthosis, moon facies and buffalo hump. Biochemically, low-dose and high-dose Dexamethasone tests were not suppressible, ACTH was raised and 24h urinary metanephrines were normal. The CECT scan showed a 3cm paraganglioma. Tumor was excised via 11 ^th rib transcostal approach and the mass was found arising from the sympathetic chain. Histopathology was suggestive of ganglioneuroma positive for ACTH immunostaining.

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Background: Advanced and inoperable solid tumors in children are great killer despite aggressive multimodality treatment. Intravenous chemotherapy, due to high dose of drug given systemically, at times leads to abandonment of therapy due to systemic toxicities. To overcome this problem lots of studies are going on to explore alternative modes of giving anticancer drugs so as to decrease the systemic toxicities of the drugs and increase their therapeutic index at the same time. Aim: The study was conducted to know the results of anterior intratumoral chemotherapy and its comparison to anterior intravenous chemotherapy. Materials and Methods: Forty patients of advanced inoperable solid tumors in children (Wilms' tumor and neuroblastoma) between 2000-2004 were randomly allocated to two groups. Group A (20 patients) was given intratumoral chemotherapy while Group B (20 patients) was given intravenous chemotherapy. Both the groups were compared in terms of reduction in size and volume, resectability of tumor, histopathological changes and side-effects of chemotherapeutic drugs. The Institute's ethics committee approved this study. Results: Males were predominant in both type of cases (Wilms' tumor and neuroblastoma) in both the groups (Group A and Group B). Mean age in the study was 3.27 years. All cases in Group A had Stage III disease except three cases which had Stage IV disease (one case of Wilms' tumor and two cases of neuroblastoma) while in Group B only two cases had Stage IV disease (one case of Wilms' tumor and one case of neuroblastoma). Intratumoral chemotherapy was found to be superior over intravenous chemotherapy in terms of reduction of size and volume (63% in Group A vs. 22% in Group B). The resectability was 70% in the intratumoral group in comparison to 40% in the intravenous group. The overall good histopathological response was 71% in Group A as opposed to 0% in Group B. Moreover, the incidence and severity of side-effects of chemotherapy and morbidity was less in intratumoral chemotherapy. Mortality was also low in Group A (5%) in comparison to Group B (20%). Conclusion: In this study intratumoral chemotherapy was found to be superior over intravenous chemotherapy in terms of better and early tumor regression, minimal side-effects, better tumor resectability and well response on histopathological criteria. This study is still going on at our center where different drug combinations, different drug doses, their toxicities, their mechanisms of action, their serum levels and long-term results of intratumoral mode of chemotherapy are to be evaluated thoroughly in future.

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The medical care of adolescents has become a growth area in many disciplines. There are two major aspects. Firstly, adolescents have specific medical and emotional needs which are not fulfilled either by paediatric or by adult specialists. Secondly, some childhood problems, particularly the congenital deformities, have no equivalent in adult life and so lifelong care is mandatory. Renal damage, especially dysplasia and scarring, leads to a substantial risk of early onset hypertension and, occasionally, to renal failure. Bladder outlet obstruction in utero, such as from a posterior urethral valve, causes irreversible changes to the wall that will act adversely on the kidneys in adolescence or early adulthood. The incidence of renal failure in early adulthood is about 36%. Bladder reconstruction with bowel has been very beneficial in preventing renal failure and improving continence. Life long follow-up is needed because of the high incidence of complications. These include stones, hyperchloraemic acidosis, perforation, anastomotic stenosis and, possibly, cancer. Patients have a normal expectation of sexuality and fertility. Their desires cannot always be achieved but they require considerable emotional and surgical support.

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Pediatric Urology is a surgical subspecialty that is very dependent upon radiographic imaging as the majority of the genitourinary (GU) tract is internally located. Technological advances in various imaging modalities (e.g. ultrasonography, nuclear medicine, CT and MRI) have aided in our ability to visualize and evaluate the functionality of the GU tract, enabling the diagnosis of various disease processes that affect the genitourinary system. Collectively the advances in uro-radiology have improved our understanding of the natural history of many conditions that involve the GU tract. As a result of these newer imaging modalities, some of the more traditional techniques have assumed a limited role in the diagnostic evaluation of the pediatric GU patient (e.g. intravenous urography). The purpose of this article is to review the advances in radiographic imaging, in particular the cross-sectional imaging modalities and discuss their utility (appropriate indications and application) in Pediatric Urology, so that the reader can maximize the diagnostic yield of these studies. For a thorough review of any of the imaging modalities discussed in this article and their utility in the practice of pediatric urology, I would direct the readers to articles in the radiological literature that are specific to that technology. Besides the obvious technological advances in imaging modalities, this review also discusses the attention to radiation safety for the pediatric patient that every physician who orders a diagnostic imaging study in a child should be aware of.

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Seizures can lead to different types of injuries which can be as simple as minor lacerations and at times as serious as fractures and head injuries. We are reporting a case wherein a female patient presented with a history of abdominal pain and not passing urine for 24h following an attack of seizure. After catheterization the urine drained was blood-stained. On clinical suspicion a cystogram was done which showed intraperitoneal rupture of the bladder. At laparotomy an isolated rent in the dome of the bladder was found which was repaired in three layers. Postoperative period was uneventful. To our knowledge this is the second case of its kind reported in the literature. Our case illustrates that a thorough abdominal examination is desirable while examining a patient following an episode of generalized seizure.

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Aim: To determine the surgical complications of open retropubic radical prostatectomy. Materials and Methods: Fifty-nine cases of localized prostate cancer underwent retropubic radical prostatectomy in our department in the last seven years. Standard technique of open retropubic radical prostatectomy as described by Walsh was used. During follow-up cancer control and quality of life indices (potency and urinary continence) were noted. Result: Postoperative recovery of all patients except one was excellent. This patient required cardio-respiratory support and nine units of blood transfusion. Forty-nine out of 52 patients were continent, two had stress incontinence and one was totally incontinent at one year. Bladder neck contracture was present in eight out of 52 patients at one year. Forty-five patients were impotent at one year with or without oral tablet sildenafil. Cancer control was present in 45 out of 52 cases. Seven cases had biochemical failure at one year. Conclusion: Though retropubic radical prostatectomy is the standard treatment for early prostate cancer it is not without complications. It has a steep learning curve. More number of cases and refinement in technique is required to achieve world-class results.

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For the reconstruction of urethra-vesical anastamosis after radical prostatectomy and for neobladder reconstruction, taking adequate sutures to include the urethral mucosa is vital. Due to the retraction of the urethra and unfriendly pelvis, the process of taking satisfactory urethral sutures may be laborious. Here, we describe a simple method by which we could overcome similar technical problems during surgery using Foley catheter as the guide for the suture.

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