 The next form of injuries are the urethral injuries where the sign, the first symptom what they show is neatal bleeding and we try to put a catheter that catheter does not cook. So what do we do at that time? It can be a small contusion in the urethra, it can be a partial rupture or it can be a complete disruption. So the first thing is to never put the catheter blindly, yes gentle one attempt of catheter can be done in the emergency OR if the clinician is experienced in that otherwise call for help. The first thing what we do generally in emergency setting where the patient is not ready, we will do a gentle attempt and see at what level the catheter is not passing. We might pass a small guideware and see if the guideware is coiling in the bladder and over the guideware will pass a catheter number 2. Suppose if the patient is ready we can take him for a scistoscopy and pass a catheter and of all these 3 things fail, then we will just decompress the bladder by putting a supra vivid catheter, wait for about 2 weeks just to see that how much of the urethra is healed and then take the patient for a retrograde urethrogram, see where the problem is. If it is a stricture then manage accordingly. Suppose if it was just a false passage then we can again reinsert catheter per urethrile and maybe we can remove the catheter at about 2-3 weeks. Suppose if it was just a hematoma at about 2-4 weeks even if we clamp the supra vivid catheter and ask the patient to void sometimes most of the patients will void. So the key thing is never do a blind insertion of catheter or never do a multiple attempt. It is like do no harm for the patient when it comes to urethra injuries because these injuries will not take his life but yes definitely that person will remember you for life. That is it from my topic and last topic is a penile fracture. These are included in this is in the emergency because they come, they do come in the late night or early morning when they realize. This happens when the Rangoch penis is bent suddenly forcefully. This results in rupture of the both corpora caerosa and the treatment for this type of injury is really exploration and repair unless it is a very mild injury. The diagnosis for this type of injury is by two things, one with the color duplex ultrasound. Suppose if that is not possible an MRI of the penis will confirm its diagnosis. That is by exploration removal of the hematoma and closure of the tunica which is very important because if you do not read it now they will end up with Peronese disease or erectile dysfunction later on. Thank you. Regarding investigation modality for renal laboratory calculate you said CT is the reference. Yes sir. We know ultrasound is poor man CT should we refer all the cases for CT or ultrasound. No if you are one depends on what center you are so with a ureteric colleague you do a ultrasound sometimes you do not find a stone. So in that situation we have two options stone might still be there but it is not in seen in ultrasound or stone might be in the lower ureter which is missed. So if there is any hydronephrosis many times we see an ultrasound which shows only hydronephrosis but no stone. And those patients definitely has to go and undergo CT scan. So regarding the persistent pyrophysm by using paparverine while doing the penent oplot and using of this sildenaphyl is there any for what to do for long lasting pyrophysm? You see generally pyrophysm does not happen on its own. Suppose if patient has had his first dose of sildenaphyl. Generally that type of erection stop comes down by about 4 hours. Never they go beyond 4 hours sildenaphyl is not that a drug which will cause praepism. But yes whenever we send patients for a penent oplot some radiologists use intra cavernosal injection. So that might trigger a praepism and if that is a cause then yes if it is more than 4 hours we will have to relieve that praepism with evacuation, give multiple washes till the drug is washed out and then wait. Generally with one bout of wash this will settle down. Strictural repairs, urethral strictural repairs sometimes they use bakal mikoza is it ok sir? Yes, yes. Made to plastic, correct? Yes it is called urethroplasty. Urethroplasty. Where we use the bakal mikoza. Why we use bakal mikoza is because the quality and texture of that mikoza resembles more with the urethral mikoza. How long it will last? That depends on the patient but generally as a with lot of studies the success rate of urethroplasty compared to a endoscopic VIU in reasonably long segment structures is about 80 to 90 percent. So definitely that gives a more durable solution compared to a VIU which has a more recurrence rate. It gives a recurrence rate of about 35 percent. You do VIU in 100 patients only 35 will not come back, 65 will come back to you for a permanent solution. Distribute them from CA. CA, yes endoscopically what we do for all protruding regions in the bladder we excise like how we excise a polyp from the stomach. We do a stoscopy and excise by doing something called as TORBT, trans urethral resection of the tumor and send it for biopsy that comes from the diagnosis. Papillomas are treated conservatively. Papillomas and low grade TCCs, transitional carcinomas are treated conservatively. There is no role for any extensive surgeries. Only muscle invasive diseases of the bladder requires a major surgery. Superficial lesions are treated conservatively. Generally the consensus is if the tumor has caused a hydronephrosis there are two situations. One it is blocking the orifice of the vesicleurated junction one or it is invading the wall of the urethral. If it is invading the wall then it is a high grade tumor, it is a muscle invasive. So, it requires a next modality of treatment in the form of stectomy. If it is only invading then only the resection of the tumor is enough. So, only by doing that we will get to know. Thank you Dr. Shahid. I would like to call upon Dr. Harish Kumar to hand over a moment to as a token of appreciation and gratitude to Dr. Shahid. Thank you all for coming out in big numbers and helping us in making this a grand success. A big shout to all our speakers. Thank you all so much. I am on behalf of the management of Manipal Hospital, Millars Road. I am extending the season's greetings. I know it is 8 days in advance and Christmas is on 25th. So, please accept our seasonal greetings too. So, the dinner is being served on the right side of the conference hall. Thank you Dr. Divya. I request Dr. Kiran Kana Prasad to thank you for hosting our program.