Infections continue to be a significant cause of morbidity and mortality in renal transplant recipients, as they are susceptible to opportunistic infections. During the first post- transplant year, two thirds of transplant recipients experience at least one infection. Infectious agents commonly implicated are BK polyoma virus, Cytomegalo virus and Ebstein Barr virus. Filamentous fungal infections are rare in the kidney. 5% of infections in transplant recipients are due to fungi.We report a rare case of isolated renal graft mucormycosis.

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An unmarried 35 years old male, who took 25mg sildenafil daily for 8 days followed by 12.5 mg daily for 4 days, with consultation with a local chemist for nocturnal emission developed priapism. He presented to an urologist after 72 hours where a corporal wash and distal shunt was tried but it did not give any relief to the patient. He had no other identified contributing factors for priapism. A proximal caverno-spongiosal shunting (Quackels cavernoso-spongiosal shunts) was done which subsequently relieved his symptoms. To our knowledge this is the first reported case of priapism resulting from supposedly safe doses of sildenafil in a healthy individual. Distal shunts are associated with high failure rates which may warrant a more proximal shunt. Even when seen after a considerable time a shunt may be useful. After the delayed surgery, relief of pain without complete detumesence suggests a role for watch-full waiting. This case also highlights the existence of unfortunate myths surrounding the omnipotence of sildenafil in all sorts of sex related problems. It points toward an urgent need for steps to prevent unauthorized prescription and misuse of this drug..

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OBJECTIVE: To assess the safety of shock wave lithotripsy (SWL) in treatment of urinary calculi, in patients with bleeding diathesis. MATERIALS AND METHODS: From 1996 to 2004, seven patients with bleeding diathesis were treated by SWL for urolithiasis. Change of oral anticoagulants to heparin (low molecular heparin) and substitution of deficient coagulation factors was done on the day of treatment. RESULTS: Two out of seven patients had mild hematuria, which settled within 48 hours. None of them required transfusion. Six out of seven were stone-free at one month. None of them required any secondary procedure. CONCLUSION: SWL is a safe method for the treatment of urolithiasis in patients with bleeding diathesis, provided deficient coagulation factors are corrected.

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Laparoscopic radical nephrectomy is a safe and oncologically appropriate treatment modality for patients with renal cell carcinoma.[1] Till date, there are only 3 cases of port site metastasis reported after laparoscopic radical nephrectomy for renal cell carcinoma. We herein report another case of port site recurrence after transperitoneal radical nephrectomy for a 5 cm renal tumor.

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OBJECTIVE : To evaluate the ability of transrectal power doppler sonography (TRPDS) in combination with conventional grey scale transrectal ultrasonography (TRUS), uroflowmetry and clinical parameters, to predict bladder outlet obstruction (BOO) in benign prostatic hyperplasia (BPH). MATERIALS AND METHODS : Sixty-nine male patients with more than 50 years of age, presenting with lower urinary tract symptoms were evaluated prospectively for BOO secondary to BPH. TRUS was done to estimate prostate volume (PV), transition zone volume (TZV), median lobe projection in the bladder (ML) and bladder wall thickness (BWT). TRPDS was done to measure resistive index (RI) of transition zone vessels. All patients also underwent PFS and depending upon its results, the patients were divided into Group 1 [Abram-Griffiths (AG) number < 40] and Group 2 (AG number >40). Mean values of TRUS and TRPDS parameters and uroflowmetry in the two groups were compared to identify predictive factors for BOO. RESULTS : Demographic profile of Group 1 (n= 42) was similar to that of Group 2 (n= 27). Significant independent factors for prediction of BOO were maximum flow rate, resistive index of transition zone, median lobe projection into the bladder and post void residue. BOO scoring system was developed based on these 4 factors, which showed a specificity of 77.8% and a sensitivity of 85.7%, with an overall predictive value of 82.6%. CONCLUSIONS : Transrectal power doppler ultrasonography (resistive index) in combination with uroflowmetry, median lobe projection in bladder and post void residue measurement can predict BOO with a high specificity and sensitivity.

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Buccal mucosa onlay graft urethroplasty represents one of the most widespread methods for the repair of strictures in the bulbar urethra, because of its thick and highly vascular spongiosum tissue. Recently the location of the patch has become a contentious issue, since we described our original techniques of dorsal onlay graft urethroplasty. The design rationale for this approach was based on the concept that the corporeal body remains a healthy host for receiving a free transplanted tissues. Moreover, graft fixation onto a defined surface may decrease graft shrinkage and sacculation. The success rate using buccal mucosa grafts for the repair of bulbar urethral strictures has generally been high with dorsal or ventral onlay grafts or using an augmented roof-strip anastomotic urethroplasty. We describe here the fundamental concepts of the bulbar urethra reconstruction using buccal mucosal grafts, presenting a new surgical technique of dorsal onlay buccal mucosa graft urethroplasty using fibrin glue.

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OBJECTIVES: We prospectively analyzed the efficacy and safety of apical block, bilateral (B/L) basolateral prostatic plexus block and unilateral (U/L) basolateral prostatic plexus block in patients undergoing transrectal ultrasound (TRUS)- guided prostatic biopsies. MATERIALS AND METHODS: From July 2003 to July 2004, 60 patients of median age 63 yrs and median PSA of15.8 ng/ml, underwent TRUS- guided prostatic biopsies. These biopsies were performed in the left lateral position, after cleansing enema and single dose of antibiotic. Patients were randomized into 3 groups. Under TRUS guidance, group1 (n=20) received 10 ml of 1% lignocaine at the apical area of the prostate, group 2 (n=20) received 5 ml of 1% lignocaine in the basolateral prostatic plexus bilaterally and group 3 (n=20) received 10 ml of 1% lignocaine at basolateral prostatic plexus unilaterally, using an 18 F needle. Five minutes after the injection, a series of 10 prostatic biopsies were performed. Pain during biopsy was assessed using visual analogue pain score. RESULTS: Patients with apical prostatic block had significantly lower pain scores (1.5 ± 0.9) than those with B/L (2.6 ±1.2) and U/L basolateral prostatic plexus block (2.8 ± 1.4). The three groups were similar in regard to age, prostatic volume and number of cores. CONCLUSIONS: Apical prostatic plexus block was the most effective technique and could be a useful alternative to basolateral prostatic plexus block.

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OBJECTIVES: To determine the outcome of expectant therapy in steinstrasse according to its type. MATERIALS AND METHODS: A chart review was performed on patients who underwent extracorporeal shock wave lithotripsy (SWL) between 1995 and June 2004. Demographic profile, stone size, site, characteristics of steinstrasse (type 1; multiple small fragments, type 2; lead fragment of 5 mm or more with small fragments proximal to it and type 3; multiple fragments of 5 mm or more) and mode of treatment used, were noted. Patients of steinstrasse, diagnosed on X-Ray KUB were kept on expectant treatment for 4 weeks. Patients with high grade fever and infected hydronephrosis were treated with percutaneous nephrostomy (PCN) insertion. Non responders at 4 weeks, were treated with SWL and/or ureterorenoscopy (URS). RESULTS: 1000 patients of mean age 37.85 years, with urinary stones, received SWL (827 renal stones and 173 ureteric stones). Sixty patients (6%) developed steinstrasse. Mean stone size was 2.03 cm (0.6-4 cm). Type 1, 2 and 3 steinstrasse was present in 32 (53%), 20 (33%) and 8 (13%) patients, respectively. Conservative management was successful in 30 (50%) patients at 4 weeks. 3 patients who presented with infected hydronephrosis, required PCN. The remaining (27 patients) were subjected to repeat SWL. 24 of these 27 patients could be successfully treated with SWL, whereas the remaining 3 required URS. Of non- responders to conservative treatment i.e., 30 patients, 17 (56%) and 8 (26%) patients had type 2 and 3 steinstrasse respectively, whereas only 3 out of 30 (10%) responders had type 2 and none of the responders had type 3 steinstrasse, P value < 0.01. CONCLUSION: Type 2 and 3 steinstrasse have 90% (25 out of 28 failed) chance of not responding to the conservative treatment at 4 weeks. To avoid the risk of infected hydronephrosis (5%), active intervention should be done in patients with lead fragment of 5 mm or more (type 2 and 3 steinstrasse), as early as possible. SWL is successful in most of these patients and should be the primary modality of treatment.

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Flexible retrograde ureteroscope is now being widely used in endoscopic management of the urinary calculi. We report technique of supine ante grade flexible ureteroscopy in treating impacted upper and mid ureteric calculi in a pediatric patient. A six year-old boy with a history of acute right ureteric colic was investigated and found to have right upper and middle impacted ureteric calculi. He was planned for ureteroscopy, but the intramural part of the ureter could not be dilated. Hence, a decision was taken to do an antegrade flexible ureteroscopy in the supine position. An antegrade renal access was established in the supine position using ultrasound- guided puncture, a 22 Fr Amplatz was placed after serial dilatation of the tract and the stones were accessed using a flexible ureteroscope. The stones were then disintegrated using holmium laser. The ureter was stented at the end of the procedure. IVU done after six months revealed normal right kidney.

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OBJECTIVE: The aim of this study was to compare the efficacy, safety and tolerability of Dutasteride vs Finasteride in a fixed dose combination, with a uro-selective a-blocker Tamsulosin, in the management of symptomatic BPH associated with LUTS. MATERIALS AND METHODS: 105 males between 40-80 years, clinically diagnosed as Benign prostatic hyperplasia (BPH) having a baseline evaluation of their IPSS, UFR, PSA, LFT, KFT, sex health, ultrasound of prostate and PVUV, were randomized to receive a fixed dose combination therapy of Tamsulosin (0.4 mg) with Finasteride (5 mg), vs Tamsulosin (0.4 mg) with Dutasteride (0.5 mg), daily for six consecutive months. Follow- up at the end of the 2nd, 4th, 8th, 12th and 24th week was done with IPSS, UFR, PSA, ultrasound of Prostate, PVUV and sex health. RESULTS: There were five dropouts, three from the Finasteride arm and two from Dutasteride arm, leaving a total of 100 patients for the final evaluation. Patients in both the groups showed improvement in their symptoms score and urine flow rate from the baseline, but those with the Dutasteride combination not only showed much better improvement in their symptoms score and urine flow, but were also relieved of their obstructive symptoms earlier (10-14 days) than seen in the Finasteride group (24-35 days). None of the patients had acute retention of urine (AUR) during the trial. The post void urine volume was decreased more in the Dutasteride group, than in patients with Finasteride. Sexual dysfunction incidence was same in both the groups. Approximately 50% reduction in the PSA level was seen in both the groups, while LFT did not show significant difference from the baseline, in either group. Both the drugs were well tolerated, with the patient's good compliance and with no drop-out due to adverse effects. CONCLUSION : A combination of a-adrenergic blocker and 5-ARI is the best therapeutic option for medical management of BPH as it is safe, effective and well tolerated. A combination of Tamsulosin with Dutasteride results in early symptomatic relief and low PVUV, than seen with the Tamsulosin with Finasteride combination.

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Infections arising from the urinary tract may either elicit a Systemic Inflammatory Response Syndrome or result in Sepsis. This may progress to severe sepsis with associated multi-organ dysfunction and perfusion abnormalities, including hypotension. The mortality associated with sepsis is high, reaching up to 46% in patients with septic shock. Infections arising from the urinary tract may arise either following a primary pathology in the urinary tract or may be acquired as a nosocomial infection. Most of these infections are caused by gram negative organisms, though occasionally gram positive organisms and fungi can infect the urinary tract under certain circumstances. Evaluation of a patient with sepsis should include establishing the diagnosis based on standard criteria, a search for the source and appropriate microbial cultures. Management of these patients requires aggressive fluid resuscitation to achieve well defined goals. This may need to be accompanied by the use of vasopressors and mechanical ventilation. Antimicrobial therapy based on the likely causative organism should be initiated, pending the culture results. Appropriate source control measures should also be taken. Prompt recognition, aggressive resuscitation and appropriate source control measures along with appropriate antimicrobial therapy will help to reduce the mortality in patients with urosepsis.

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Varicoceles are variably considered the commonest 'correctable' cause of male infertility or the commonest 'over-reported' cause of infertility, depending on the individual viewpoint. This dichotomy has resulted from a lack of clear understanding of the effect of varicoceles on spermatogenesis and an absence of well-designed trials to evaluate the outcomes. This is coupled with surgery in unclear indications and sometimes by surgeons with limited surgical skills who assume that the surgery can cause no harm. A recent debate on 'Are we overdoing varicocelectomies' that was initiated by the Urological Society of India at its annual meeting in 2006 prompted us to review the recent developments in the fields of pathogenesis and surgical technique and the issue of 'overdoing' varicocelectomies. A review of recent literature on the subject was performed. There is an increasing body of evidence pointing towards the role of reactive oxygen species (ROS) and oxidative stress in the pathogenesis of varicocele related subfertility. This has been found in studies evaluating both direct and indirect markers of oxidative stress. Apoptosis and DNA fragmentation may be the end effectors of ROS induced damage. Other proposed etiologic factors are tissue hypoxia and hormonal imbalances. Among the various therapeutic options for varicoceles, microsurgical ligation has the best results with minimal complications. Loupe magnification may be an acceptable alternative in case of non availability of expertise with microsurgery or the microscope itself. The anatomical reasons for this and the studies on which this conclusion is based are reviewed. Finally, we discuss the problem of too many varicocele surgeries and its possible demerits. We also review the current guidelines and the need for proper case selection before surgery.

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We report the second case of prolapsing anterior urethral polyp, which was diagnosed on urethral ultrasonography and was confirmed on cystourethroscopy, successfully treated by transurethral resection.

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Urethral diverticulum in males can be congenital or acquired (secondry to stricture, stenosis). Congenital urethral diverticulae of male urethra are rare. Most of them occur ventral to the native urethra, arising from the cystic dilatation of the Cowper's gland ducts. Ours is the report of urethral diverticulum, which was present on the dorsal side of the urethra, with splaying of the two corpora cavernosa and thinning of the corpus spongiosum. The diverticulum was excised and urethroplasty was done. Postoperatively there was a marked improvement in the symptoms, with good cosmesis

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Local recurrence after radical nephrectomy for renal cell carcinoma (RCC) occurs in about 2% cases within the first 5 years.[1] However, isolated local recurrence in RCC after 10 years is very rare. We report a case of local recurrence, twenty-five years after radical nephrectomy.

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Pheochromocytoma classically presents with paroxysms of hypertension and adrenergic symptoms including headaches, palpitation, tremor and anxiety. However, these tumors can be clinically silent and occasionally manifest only when catecholamine release is upregulated by exogenous stimuli. In addition, the clinical presentation of pheochromocytoma can mimic a number of other medical conditions including migraine, cardiac arrhythmias, myocardial infarction and stroke, thus, making the diagnosis of pheochromocytoma difficult. We present a case of a 43-year old male patient who presented for evaluation of adrenal mass in the department of endocrine surgery. This patient had a previous history of right side hemiperasis and lateral wall ischemia, with no residual clinical deficit.

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A rare case of ventral diverticulum of fossa navicularis was encountered in an adult. This has not been reported earlier in the urological literature.

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