PurposeUrosepsis implies clinically evident severe infection of urinary tract with features of systemic inflammatory response syndrome (SIRS). We validate the role of a single Acute Physiology and Chronic Health Evaluation II (APACHE II) score at 24 hours after admission in predicting mortality in urosepsis.Materials and MethodsA prospective observational study was done in 178 patients admitted with urosepsis in the Department of Urology, in a tertiary care institute from January 2015 to August 2016. Patients >18 years diagnosed as urosepsis using SIRS criteria with positive urine or blood culture for bacteria were included. At 24 hours after admission to intensive care unit, APACHE II score was calculated using 12 physiological variables, age and chronic health.ResultsMean±standard deviation (SD) APACHE II score was 26.03±7.03. It was 24.31±6.48 in survivors and 32.39±5.09 in those expired (p<0.001). Among patients undergoing surgery, mean±SD score was higher (30.74±4.85) than among survivors (24.30±6.54) (p<0.001). Receiver operating characteristic (ROC) analysis revealed area under curve (AUC) of 0.825 with cutoff 25.5 being 94.7% sensitive and 56.4% specific to predict mortality. Mean±SD score in those undergoing surgery was 25.22±6.70 and was lesser than those who did not undergo surgery (28.44±7.49) (p=0.007). ROC analysis revealed AUC of 0.760 with cutoff 25.5 being 94.7% sensitive and 45.6% specific to predict mortality even after surgery.ConclusionsA single APACHE II score assessed at 24 hours after admission was able to predict morbidity, mortality, need for surgical intervention, length of hospitalization, treatment success and outcome in urosepsis patients.

Wunderlich Syndrome (WS) is an uncommon condition where acute onset of spontaneous bleeding occurs into the subcapsular and perirenal spaces. It can prove fatal if not recognized and treated aggressively at the appropriate time. A 32-year-old male diagnosed elsewhere as acute renal failure presented with tender left loin mass, fever and hypovolemic shock with serum creatinine 8.4 mg/dl. He was started on higher antibiotics and initiated on haemodialysis. Ultrasonogram (USG), Non-Contrast Computed Tomography (NCCT) and Magnetic Resonance Imaging (MRI) showed bilateral perirenal subcapsular haematomas - right 3.6 x 3.1 cm and left 10.3 x 10.3 cm compressing and displacing left kidney, fed by capsular branch of left renal artery on CT angiogram. Initial aspirate was bloody but he persisted to have febrile spikes, renal failure and urosepsis and he was managed conservatively. Repeat NCCT 10 days later revealed left perinephric abscess and Percutaneous Drainage (PCD) was done. Patient improved, serum creatinine stabilized at 2 mg/dl without haemodialysis and PCD was removed after two weeks. To conclude, bilateral idiopathic spontaneous retroperitoneal haemorrhage with renal failure is a rare presentation. This case highlights the need for high index of suspicion, the role of repeated imaging and successful minimally invasive management with timely PCD and supportive care.

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A 65-year-old male presented with the symptoms of lower urinary tract obstruction for 8 months. He was circumcised in infancy. He developed acute urinary retention and suprapubic cystostomy was done. Local examination revealed post circumcision status with stenosis of external urethral meatus. There was no evidence of lichen sclerosus et atrophicus. He was a chronic smoker and tobacco chewer, hypertensive on treatment. Oral cavity showed grade II trismus and submucosal fibrosis with tobacco staining. His blood urea was 31 mg/dl, serum creatinine 0.9 mg/dl and hemoglobin was 12 g/dl. His urine culture was sterile, ultrasound (US) showed no hydroureteronephrosis or prostatomegaly and uroflowmetry showed a flat pattern with Qmax of 3 ml/sec. Retrograde urethrogram (RGU) showed distal penile urethral stricture [Table /Fig-1a,b]. Patient was taken up for penile circular fasciocutaneous flap urethroplasty as his donor site for buccal mucosa was not available due to trismus and submucous fibrosis. Patient was placed in dorsal lithotomy under central neuraxial blockade. Circular penile skin flap was marked and a 1.4cm wide circumferential dartos based fasciocutaneous flap was harvested. The flap was 12cm in length after splitting dorsally. A ventral urethrotomy was made over the distal tip of the catheter and extended proximally until the normal caliber urethra is encountered. The most proximal and distal portions of the flap are secured to the normal urethra using interrupted 4-0 vicryl and flap suturing was completed [Table/ Fig-2a-e]. Pericatheter RGU was done after 3 weeks and uroflowmetry showed a good flow [Table/ Fig-3].