Grand Journal of Urology
E-ISSN : 2757-7163

Current Issue
Dear colleagues, I am honored to share with you the third issue of 2023 (volume 3, issue 3) of the Grand Journal of Urology (Grand J Urol) with the contributions of many respected researchers and authors. Grand Journal of Urology (GJU) aims to carry written and visual scientific urology studies to academic platforms and to make significant contributions to the science of urology. Our journal has been abstracted/indexed in Tubitak Ulakbim TR Index, DOAJ, EBSCOhost, J-Gate, Index Copernicus International, EuroPub, SciLit, ResearchGate, ScienceGate and Google Scholar international databases. As of these achievements, the Grand Journal of Urology (GJU) has taken its place among the journals indexed by national and international databases. In this issue of our journal, there are many valuable articles under the subheadings of Andrology, rological Oncology, Endourology, Urolithiasis, Pediatric Urology, Functional Urology and General Urology. I hope that these carefully prepared articles will make important contributions to valuable readers, researchers and the urology literature. On this occasion, I would like to express my heartfelt gratitude to our authors who have contributed to our journal with their articles, to our reviewers who have meticulously evaluate the articles. Respectfully yours September 2023 Assoc. Prof. Ekrem GUNER, MD Editor-in-Chief
Original Article
Objective: As a urological emergency, testicular torsion is one of the causes of acute scrotum in all age groups. This study aimed to evaluate the effectiveness of manual detorsion performed before surgical intervention. Materials and Methods: Retrospective data analysis of the patients with acute scrotum who applied to the emergency department of a 3rd level hospital between the years January 2010 and January 2023 with the complaint acute unbearable pain within the first 12 hours of its onset was performed. Patients were grouped according to whether or not manual detorsion was performed in the emergency department. Successful manual detorsion was defined as postprocedural normal color Doppler ultrasound findings and complete resolution of pain. All patients had undergone surgical exploration. Age, laterality of the torsional testis, manual testicular detorsion attempt (if any), and surgical conditions resulting in testis preservation or orchiectomy were the patient data analyzed. Results: Sixty patients were included in the study. Manual detorsion was performed in 29 (48.3%) patients in the emergency department (Group 1). Scrotal exploration was performed in 31 (51.7%) patients without applying manual detorsion (Group 2). In Group 1, testicular preservation was achieved in 26 (89.7%) patients. In Group 1, in 3 patients (10.3%) testicular necrosis occurred due to failure to achieve adequate blood supply, while orchiectomy was performed in 11 (35.5%) patients in Group 2. Lower rates of orchiectomy were observed in Group 1 compared to Group 2 (p=0.021). We also observed that manual detorsion decreased the rate of orchiectomy (rho- 0.297, p=0.021), and the probability of undergoing orchiectomy increased with increasing age (rho 0.512, p
Pediatric Urology, Online First: 10 July 2023
Grand J Urol 2023;3(3):075-079, DOI: 10.5505/GJU.2023.72691
Objective: Our goal was to determine whether or not a double-J (DJ) stent insertion is required in cases of ureteral stones based on the absolute white blood cell (WBC) counts, neutrophillymphocyte ratio (NLR), absolute monocyte counts, and other laboratory markers. Materials and Methods: The patients were divided into two groups as those who did (Group 1), and did not (Group 2) need DJ stent insertion. The age, symptoms, diagnosis, hemogram parameters, and treatment results of the patients were evaluated. Results: Forty-nine percent (n=44) of the patients were female and 51% (n=46) were male. The groups did not differ in terms of age and gender (p>0.05). A higher incidence of hematuria was observed in Group 1 (p
General Urology, Online First: 13 July 2023
Grand J Urol 2023;3(3):080-084, DOI: 10.5505/GJU.2023.80774
Objective: This study aims to discuss the techniques for safely, quickly, and successfully removing transurethral (TU) foley catheter balloons in patients who present to the emergency and urology clinics due to the inability to remove the catheter through normal means, and to contribute options and insights to the literature. Materials and Methods: This retrospective study included patients who presented to the emergency department for the inability to remove the TU foley catheter, patients referred to the urology clinic, or patients consulted from other clinics, between January 2017 and September 2022. The treatment methods applied by the urologist in this patient group, hospitalization durations, voiding status, and any developed complications were recorded based on patient files. Results: A total of 22 patients who had a transurethral (TU) catheter inserted for various reasons and were unable to remove it were included in our study. It was found that 7 of the patients had permanent TU catheters due to comorbidities, while the remaining 15 had TU catheters inserted after acute urinary retention. Among them, 2 cases had the catheter removed by cutting the inflation channel, 1 case with the assistance of a guidewire, 2 cases by puncturing the balloon with a needle under transrectal ultrasound guidance, 10 cases by puncturing the catheter balloon with a needle under suprapubic ultrasound guidance, and 7 cases had their catheters removed by laser under anesthesia. Only 1 patient who had the balloon punctured by a needle under transrectal ultrasound guidance developed fever after the procedure and had a total of 5 days of hospitalization, while the others were discharged either immediately after the procedure or 1 day later. Conclusion: Patients with indwelling foley catheters that cannot be removed rarely present to us; however, these patients often come to us in an agitated state after multiple unsuccessful attempts to remove the catheter. Therefore, it is important to know which technique should be applied to this patient group in a faster, appropriate, and reliable manner as soon as possible.
Endourology, Online First: 24 July 2023
Grand J Urol 2023;3(3):085-089, DOI: 10.5505/GJU.2023.85047
Objective: In this study, we aimed to investigate whether there is a difference in the reliability and efficacy of the method according to age in patients divided into 3 different age groups who underwent RIRS due to kidney stones. Materials and Methods: Patients who underwent Retrograde Intra Renal Surgery (RIRS) for kidney or ureteral stone disease at the Urology Clinic of Health Sciences University Umraniye Health Application and Research Hospital between May 2017 and January 2021 were retrospectively screened, and those aged 20-80 years were included in the study. The demographic and clinical data of the patients and stone-related data were recorded. Patients aged 20-40 years were classified as Group 1, those aged 41- 60 years as Group 2, and those aged 61-80 years as Group 3. Results: After the inclusion and exclusion criteria were applied, the sample consisted of a total of 320 patients, of whom 121 (37.8%) were in Group 1, 133 (41.5%) were in Group 2, and 66 (20.6%) were in Group 3. The mean operative times and stone-free rates were similar between the groups. However, the mean hospital stay was significantly longer in Groups 3 compared to Groups 1 and 2. The minor complication rates were 2.4% in Group 1, 3% in Group 2, and 13.6% in Group 3, indicating a statistically significantly higher value in Group 3 compared to the remaining two groups (p=0.03). The major complication rates of Groups 1, 2, and 3 were 0.8%, 0.7%, and 7.5%, respectively. Accordingly, Group 3 had a significantly higher rate than Groups 1 and 2 (p=0.04). Conclusion: RIRS can be performed on the elderly with success rates comparable to other age groups. However, the elderly, who represent a higher-risk patient population with more comorbidities, have increased rates of minor and major complications both in the perioperative and postoperative periods.
Pediatric Urology, Online First: 26 July 2023
Grand J Urol 2023;3(3):090-096, DOI: 10.5505/GJU.2023.40427
Objective: Circumcision is one of the most common surgical procedures in the world which is performed for various reasons. The aim is to investigate whether people's satisfaction with circumcision, their perspectives on circumcision, and whether there is a connection between circumcision and psychological/urological problems. Materials and Methods: Between 21 March 2023- 10 April 2023, 1009 men aged between 18- 50 who volunteered to participate in the survey were included in the study. Demographic structures of the people (age, education, income status), age of circumcision, by whom, where and with what type of anesthesia; problems during circumcision, satisfaction with circumcision, any sexual and psychological problems and the relationship of this problem with circumcision were investigated. Results: Mean age of 1009 participants was 32.02±9.15 and mean age of circumcision was 6.18±3.10. 269 (26.7%) men stated that they experienced circumcision complications and 145 (14.4%) stated that they were not satisfied with circumcision. 267 men (26.5%) had sexual or urological problems, and 274 (27.2%) had psychological problems, but the relationship of both problems with circumcision was not significant. Both sexual/urological problems and psychological problems were found to be significantly higher in the group satisfied with circumcision (both p:0.000, p
Functional Urology, Online First: 01 September 2023
Grand J Urol 2023;3(3):097-101, DOI: 10.5505/GJU.2023.27147
Objective: To reveal the effect of preoperative Kegel exercises on early period continence rates after open radical prostatectomy. Materials and Methods: Data of patients with open radical prostatectomy between January 2019 and July 2022, in a tertiary academic health center were retrospectively reviewed. Patient" characteristics, perioperative parameters and postoperative follow-up results were recorded. Patients were divided into two groups as those who did Kegel exercises in the preoperative period and those who did not, and groups were compared. Results: There were 38 patients in the Kegel exercise group and 40 patients in the other group. Postoperative 1st month and postoperative 3rd month incontinence rates were similar between the groups (p=0.406, and p=0.387). At 6th months postoperatively, the rate of incontinence in the Kegel group was 7.9%, while it was 25.0% in the other group (p=0.043). Similarly, the rate of incontinence at 1st year postoperatively was significantly lower in the Kegel group (5.3% vs 20.0%, p=0.001). At 6 months postoperatively, the QoL score in the Kegel positive group was 86, while it was 65 in the other group (p=0.001). In the postoperative 1st year controls, the quality of life (QoL) score was statistically significantly higher in patients with preoperative Kegel exercise (p=0.001). Conclusion: Our study demonstrated that preoperative Kegel exercises had a significant positive effect on continence rate after radical prostatectomy in the postoperative 6th month and in the first year follow-up, and preparative Kegel exercises were significantly associated with higher quality of life scores at 6th months and 1st year follow-up.
Andrology (Male Sexual Disfunction, Infertility), Online First: 03 September 2023
Grand J Urol 2023;3(3):102-108, DOI: 10.5505/GJU.2023.62207
Objective: No effective medical approach for the treatment of Peyronie's disease (PD) has to date been described. This study was intended to evaluate the antifibrotic, antioxidant, and antiinflammatory effects of curcumin on fibrotic tissue in the tunica albuginea (TA) in a rat model of PD. Materials and Methods: Twenty-four male Sprague Dawley rats aged 10 months were randomized into three groups (n = 8 in each). No PD model was induced in the control group. The PD+saline (PD+Ps) group received fibrin injection, followed two weeks later by saline administration by oral gavage for 14 days. The PD+Curcumin (PD+Cur) group received fibrin injection into the TA followed two weeks later by curcumin administration by oral gavage for 14 days. At the end of the experiment, fibrotic activity was evaluated using stereological and histopathological methods. Transforming growth factor-β1 (TGF-β1), one of the most fibrogenic cytokines, was evaluated using immunohistochemistry with an anti-TGF-β1 rabbit monoclonal antibody. Results: Stereological analysis revealed significantly greater Peyronie-like plaque areas in the TA in the PD+Ps group than in the control and PD+Cur groups (p
Urological Oncology, Online First: 06 September 2023
Grand J Urol 2023;3(3):109-112, DOI: 10.5505/GJU.2023.35229
Objective: To examine the relationship between prostate weight and oncological and functional outcomes of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP). Materials and Methods: Data of the patients who underwent RS-RARP in our clinic between December 2018 and December 2020 were evaluated retrospectively. A total of 106 patients with 12-month postoperative follow-up data were included in the study. The patients were separated into 2 groups according to the weights of the pathology specimens as Group 1 (n=53, prostate weight less than 50 g), and Group 2 (n=53, prostate weight more than 50 g). Postoperative oncological and functional data were analyzed. At the end of the 12th month, continence was regarded as requirement of no pad or 1 pad per day. Potency was considered as the ability to have sexual intercourse. Prostate-specific antigen (PSA) above 0.2 ng/ml in the follow-up period was considered as biochemical recurrence. Results: Preoperative PSA levels were comparable between groups (9.78+7.84 ng/ml vs. 11.87+8.38 ng/ml). There was no difference in clinical cancer stages and The International Society of Urological Pathology (ISUP) scores between the groups. Median vesicourethral anastomosis time (30 minvs.33 min) and median operative time (240 min vs. 240 min) were comparable in both groups (p>0.05). There was no difference in localized disease and locally advanced disease rates between the groups (pT2: 58.5% vs. 67.9%, pT3: 41.5% vs. 32.0%). Respective surgical margin positivity (SMP) ([16.9% (n=9) vs 9.4% (n=5]), and 12th month biochemical recurrence rates (11.32% vs 3.77%) for Groups 1 and Group 2, were as indicated (p>0.05). Postoperative urinary continence rates at 12 months were 89% and 90% in Groups 1 and 2, respectively (p>0.05). Continence status was not different between the groups. Potency rates at 12 months were comparable between the groups. Conclusion: RS-RARP can be applied in patients with any size of prostates with comparable functional and oncological outcomes.
Urolithiasis, Online First: 20 September 2023
Grand J Urol 2023;3(3):113-120, DOI: 10.5505/GJU.2023.63325
Objective: To compare extracorporeal shock wave lithotripsy (ESWL) induced renal injury in patients undergoing different ESWL treatment protocols by measuring urinary tissue metalloproteinase-2 inhibitor (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7) excretion. Materials and Methods: This prospective, randomized study was conducted between April 2016 and June 2016 in group 1 patients undergoing fixed voltage ESWL and group 2 patients undergoing ramping voltage ESWL. Urinary TIMP-2 and IGFBP7 levels were analyzed before ESWL and 2 hours after ESWL, and urinary beta- 2-microglobulin (β2-MG) and albumin were analyzed before ESWL and 1 week after ESWL to assess renal injury. The primary outcome was to compare the effect of ESWL on early renal injury with biochemical markers in the different treatment protocols, and the secondary outcome was to compare the two treatment protocols in terms of stone free rate and complications. Results: There was no statistically significant difference between groups in terms of demographic and stone characteristics. There were statistically significant differences in serum creatinine and e-GFR at baseline and one week after treatment (p
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Andrology (Male Sexual Disfunction, Infertility), Online First: 17 July 2023
Grand J Urol 2023;3(3):121-123, DOI: 10.5505/GJU.2023.22932
A 50-year-old male patient was admitted to our emergency department with the complaint of prolonged erection lasting for about three hours without sexual stimulation. As understood from the patient's anamnesis and medical file, he applied to the emergency department with the complaints of fever, lassitude, and fatigability in 2015. His hemogram parameters on admission were: WBC:18.2 x109/L, Hgb: 12.9 g/dl, Htc: 39%, PLT: 379 x103 K/μL. Besides, his lactate dehydrogenase (LDH) and uric acid values were elevated were found to be high, and he was referred to the hematology clinic with a preliminary diagnosis of leukemia. In the physical examination, any remarkable finding other than splenomegaly was not detected. Microscopic examination of his peripheral blood smear revealed the presence of platelet deformities, megakaryocyte fragments, normocytic normochromic erythrocytes, all cells of myeloid series, markedly increased number of basophils and eosinophils, myelocytes, metamyelocytes, rods and fragmented neutrophils. It was learned from his medical documents that the patient received the diagnosis of "CML in chronic phase" based on the histopathologic examination reports of the bone marrow aspiration and biopsy specimens obtained for definitive diagnosis, Karyotype analysis revealed the presence of Philadelphia (Ph*) chromosome, and BCR/ABL chimeric gene was detected using PCR and FISH techniques. The patient diagnosed with CML received initial treatment with single daily oral doses of a firstgeneration tyrosine kinase inhibitor (imatinib 400 mg cap.) and allopurinol (300 mg tb) and he was called for outpatient control. The patient, who claimed that severe muscle and bone pain developed during the imatinib treatment stopped taking the drug by his own decision, so hematology physician started to give him second generation tyrosine kinase inhibitors in turn (nilotinib and dasatinib). However, it was observed that these drugs also caused severe pancytopenia, and treatment with single daily oral doses of 400 mg imatinib was started again. Still, it was noted that the patient used the drug irregularly, stopped using the drug from time to time and did not routinely attend the hematology outpatient clinics for control. The patient stated that he had been prescribed trazodone HCl (50 mg/d PO) in another center due to the anxiety he had experienced and had taken the first dose the previous evening. The patient said that he had never experienced a spontaneously prolonged erection before and thought that the cause of the problem developed was related to trazodone tablet he had used for the first time the previous evening. From the anamnesis of the patient, it was learned that he did not use any drugs containing phosphodiesterase-5 (PDE-5) inhibitors. The results of the hemogram test performed when the patient applied to our emergency department were as follows; WBC: 22.2 x109/L, Hgb: 10.9 g/dl, Htc: 30%, and PLT: 579 x103 K/μL. The patient was admitted to the urology clinic for examination and treatment because of the sustained rigid erection. As the first intervention performed in the urology clinic, an 18G butterfly needle was inserted laterally into both penile corpora cavernosa of the patient to aspirate cavernosal blood. When the erection persisted despite aspiration, intracavernosal irrigation with 0.90% w/v saline was performed, but when detumescence could not be achieved, intracavernosal injection of 2 ml 1/100,000 adrenaline was performed. After the procedure, detumescence was ensured, a CobanTM self-adherent bandage was wrapped around the penis to prevent development of hematoma. The patient was monitorized for 4 hours, and then discharged. Priapism did not occur again during the follow-up period. Chronic Myeloid Leukemia (CML) is a stem cell disease manifested by abnormal clonal proliferation of myeloid precursor cells and accounts for 15% of adult leukemias. Its incidence is 1-2/100,000. It is more common in men (male/ female: 1.3/1) and its incidence increases between the ages of 40-60. CML was the first disease in humans to be associated with a specific chromosomal abnormality. In more than 90% of CML cases, the Philadelphia (Ph*) chromosome is detected by cytogenetic analysis [,]. Symptoms associated with anemia (such as weakness, fatigue, effort intolerance, decreased functional capacity), splenomegaly (abdominal swelling and pain, rapid satiety due to pressure of enlarged spleen on the stomach) hypermetabolic state (fever, anorexia, weight loss, gout), platelet dysfunction (hemorrhage, ecchymosis, hematoma, thromboembolic events, retinal hemorrhage), hyperleukocytosis and hyperviscosity-related findings (tinnitus, stupor, visual impairment, dyspnea, priapism and cerebrovacular events), thrombocytosis, hypereosinophilia, increase in basophil counts, anemia, elevated LDH and uric acid levels can be seen in CML. Physical examination reveals the presence of splenomegaly in 50-90%, and hepatomegaly in 10- 20% of CML patients [,]. Priapism is an uncontrolled, prolonged, and sustained erection developing without sexual stimulation and cannot be terminated by ejaculation, (Figure 1). This is a true urological emergency and early intervention is crucial for functional recovery. It has ischemic, non-ischemic and intermittent subtypes. Although often idiopathic priapism is seen, many etiologic factors of priapism are known including hematological diseases (ie. sickle cell anemia, thalassemia, leukemia, multiple myeloma), toxins (ie. scorpion, spider, malaria), metabolic diseases (ie. Fabry disease, amyloidosis), neurogenic diseases (ie. brain tumors, cerebrovascular diseases, spinal cord injury), metastatic or local invasion of tumors (ie. prostate, urethra, testis, lung) and drugs (PDE-5 inhibitors, vasoactive erectile agents such as papaverine, alpha adrenergic receptor agonists, heparin, warfarin, antidepressants, antipsychotics, antihypertensives, testosterone, alcohol, and cocaine) []. Figure 1. Top: Flask penis, Bottom: Erect penis Corporeal relaxation exerts external pressure on the emissary veins emerging from the tunica albuginea, causing blood to remain in the penis resulting in an erection. Imatinib mesylate is the first selective tyrosine kinase inhibitor (TKI) to target the BCR-ABL protein. While nilotinib and dasatinib are second generation tyrosine kinase inhibitors used in the treatment of imatinib-resistant CML. Muscle cramps, joint, muscle or bone pain, which are common imatinib-related side effects, may also occur during imatinib treatment or after its discontinuation []. Trazodone HCl is an antidepressant used in the treatment of symptoms caused by anxiety and depression such as anxiety, appetite disorder, insomnia, and attention deficit. Serotonin reuptake inhibitors (SSRIs) belong to the drug group and its most basic feature is that their effects start to improve symptoms within a short period of about a week. In addition to common side effects such as blurred vision, headache, dizziness, and severe fatigue, long-term painful erection (not associated with sexual activity) may also occur in men when using trazodone HCl []. Although the relevant mechanism is not fully understood, its high affinity for the α1 and α2 receptors that trazodone antagonizes is blamed in the pathophysiology []. This antagonism causes an increase in blood flow due to arteriolar dilation followed by a decrease in venous flow and obstruction of the emissary veins. In addition, α1 blockade may trigger nitric oxide release in nerves innervating arterioles and corpora cavernosa []. This whole process results in an erection. CML is one of the etiologies of priapism and there are multiple relevant case reports in the literature [,]. Herein, it has been accepted that priapism develops due to stasis associated with leukocyte aggregation in the corpora cavernosa and penile dorsal vein due to hyperleukocytosis. Another contributing factor to venous occlusion is the mechanical effect of pressure from the abdominal veins draining the spleen. In addition, infiltration into the sacral nerves or central nervous system by leukemia cells is thought to contribute to the process []. In our case, remission of the disease could not be achieved because the patient did not regularly use tyrosine kinase inhibitor (TKI) drugs that regulate the leukocyte level of the patient. Despite hyperleukocytosis and hyperviscosity in the bloodstream, which are considered to be the causes of priapism in CML, the patient did not develop priapism. However, priapism, which cannot develop on the basis of CML alone, has been predicted to develop due to the synergistic effect of antidepressant agent trazodone HCL in the pathogenesis. Ethics Committee Approval: N / A. Informed Consent: An informed consent was obtained from the patient. Publication: The results of the study were not published in full or in part in form of abstracts. Peer-review: Externally and internally peer-reviewed. Authorship Contributions: Any contribution was not made by any individual not listed as an author. Concept – S.I.G.; Design – S.I.G.; Supervision – S.I.G., E.G.; Resources – D.N.O.; Materials – D.N.O.; Data Collection and/or Processing – S.I.G., D.N.O.; Analysis and/or Interpretation – S.I.G., D.N.O.; Literature Search – D.N.O.; Writing – S.I.G.; Critical Review – S.I.G., E.G. Conflict of Interest: The authors declare that they have no conflict of interest. Financial Disclosure: The authors declare that this study received no financial support.
General Urology, Online First: 21 August 2023
Grand J Urol 2023;3(3):124-125, DOI: 10.5505/GJU.2023.80775
Pediatric kidneys are more susceptible to trauma due to poor protective mechanisms due to immature and more pliable thoracic cage, weak abdominal wall musculature and inadequate perirenal fat. Ureteropelvic junction obstruction (UPJO) is one of the most frequently found renal anomaly, and pelvicalyceal (PCS) rupture is a rare presentation whose diagnosis may be delayed due to lack of hematuria and unnoticed trauma. We present a case of child with PCS rupture in solitary functioning right kidney following trivial trauma. A 6 -year- old male child was referred with complaint of abdominal pain with anuria for 2 days after a small fight with a close friend. Physical examination findings were as follows: abdominal distension with fullness in the right renal fossa, stable vitals, and lack of any urine output on catherization, while he had lower hemoglobin (11.6 mg/dl), and higher serum creatinine (1.8 mg/dl) levels. Whole abdominal ultrasound demonstrated grossly hydronephrotic right kidney with large perinephric fluid collection, absence of left kidney, and empty bladder. Contrast Enhanced Computed Tomography (CECT) of the whole abdomen demonstrated right PCS rupture: grossly dilated right PCS with large perinephric fluid collection extending to the pelvis, absence of the left kidney (Figure 1). Right side USG- guided percutaneous nephrostomy (PCN) was performed under general anesthesia and immediately after 500 ml clear urine was drained. While 24 hrurine output reached up to 1000ml, and serum creatinine levels normalized 3 days later. After 6 weeks, repeat CT urography revealed the diagnosis of right UPJO. Then the patient underwent open Anderson- Hynes dismembered pyeloplasty (Figure 2). Figure 1. A-B: Abdominal CECT during initial presentation just after trauma Figure 2. C-D: Follow- up CT urography 6 weeks after trauma E: Intraoperative picture of ureteropelvic junction Most children with grade IV/V renal injury following blunt trauma can be managed nonoperatively []. Kidneys are affected in 8-10% of the cases exposed to blunt abdominal trauma which is seen twice more commonly in children. Trivial trauma leading to PCS rupture is a rare presentation. This is more common in children with hydronephrotic kidney mostly due to UPJO. High level of suspicion is required as occasionally it manifests minimal symptoms so its diagnosis is delayed. Our patient presented as a case of emergency within 2 days after the traumatic incident due to solitary functioning kidney with anuria. DJ stenting and PCN insertion are appropriate options for these patients in emergency situation. Sometimes these patients may present with hemodynamic instability requiring immediate exploration. Judicious and early use of minimally invasive interventions, instead of persisting with nonoperative management improve functional outcomes [].