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   Table of Contents - Current issue
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July-September 2022
Volume 38 | Issue 3
Page Nos. 165-246

Online since Friday, July 1, 2022

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EDITORIALS  

Tailoring the dose of Moscow strain of intravesical bacillus Calmette-Guérin for Indian patients: A plea for urgent action p. 165
Amandeep Arora, Ganesh Bakshi, Mahendra Pal, Sanjai Addla, Santosh Waigankar, Gagan Prakash
DOI:10.4103/iju.iju_69_22  
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Roundup p. 170
Swarnendu Mandal
DOI:10.4103/iju.iju_205_22  
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REVIEW ARTICLES Top

Robot-assisted partial nephrectomy for moderate to highly complex renal masses. A systematic review and meta-analysis p. 174
Gopal Sharma, Aditya Prakash Sharma, Shantanu Tyagi, Girdhar Singh Bora, Ravimohan Suryanarayan Mavuduru, Sudheer Kumar Devana, Shrawan Kumar Singh
DOI:10.4103/iju.iju_393_21  
Introduction: Multiple studies have been published recently assessing feasibility of robot-assisted partial nephrectomy (RAPN) for moderate to highly complex renal masses. Some studies have even compared partial nephrectomy (PN) performed through various modalities such as open PN (OPN) versus RAPN and laparoscopic PN (LPN) versus OPN. The primary aim of this review was to analyze perioperative outcomes such as warm ischemia time (WIT), duration of surgery, estimated blood loss (EBL), complications, blood transfusion, length of stay, and margin status following RAPN for complex renal masses. Another objective was to compare perioperative outcomes following various surgical modalities, i.e., OPN, LPN, or RAPN. Methods: Literature search was conducted to identify studies reporting perioperative outcomes following RAPN for moderate (Radius, Endophytic/Exophytic, Nearness, Anterior/posterior location [RENAL] score 7–9 or Preoperative Aspects of Dimension used for anatomic classification [PADUA] score 8–9) to high complexity renal masses (RENAL or PADUA score ≥ 10). Meta-analysis of robotic versus OPN and robotic versus LPN was also performed. Study protocol was registered with PROPSERO (CRD42019121259). Results: In this review, 22 studies including 2,659 patients were included. Mean duration of surgery, WIT, and EBL was 132.5–250.8 min, 15.5–30 min, and 100–321 ml, respectively. From pooled analysis, positive surgical margin, need for blood transfusion, minor and major complications were seen in 3.9%, 5.2%, 19.3%, and 6.3% of the patients. No significant difference was noted between RAPN and LPN for any of the perioperative outcomes. Compared to OPN, RAPN had significantly lower EBL, complications rate, and need for transfusion. Conclusions: RAPN for moderate to high complexity renal masses is associated with acceptable perioperative outcomes. LPN and RAPN were equal in terms of perioperative outcomes for complex masses whereas, OPN had significantly higher blood loss, complications rate, and need for transfusion as compared to RAPN.
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What should urologists know about Pseudojournals and open access publishing? A narrative review of the literature Highly accessed article p. 184
Rahul Jena, Aditya Prakash Sharma, Kumar Madhavan, Ashwin Narasimha Sridhar, Kalpesh Parmar, Nikita Shrivastava
DOI:10.4103/iju.iju_403_21  
Introduction: The majority of the open access publishing allows the researchers to publish their articles for a fee and at the same time enables the readers to access the research without paying the expensive journal subscription charges. Under the garb of open access publishing, predatory journals run a scam to dupe the researchers of money. This study was conducted to highlight the characteristics of pseudojournals and increase the awareness about their modus operandi. Methods: The email inboxes of 3 academic urologists (APS, AS, and KP) were searched for emails soliciting articles for open access journals. A list of all such journals was compiled. These journals were checked for metrics from the Journal Citation Reports and the Scimago Journal Rankings. All these journals were then cross-checked with the available whitelists and blacklists. Features pointing toward a pseudo journal were identified as red flag signs for these journals and were noted. A literature search was performed on open access publishing and predatory journals, and the salient points were noted. A checklist of red flag signs was compiled. Results: A total of 71 emails soliciting article submissions from 68 journals were received by the three urologists (APS, AS, KP). Of these, 54 were highly suggestive of being a pseudojournal, 5 journals were operating in the gray zone between genuine open access journals and outright predatory journals, and 9 were genuine open access journals. A total of 33 articles on predatory journals were reviewed after the literature search as per the PRISMA guidelines. The red flag signs identified along with the literature review were used to create the SAFEiMAP checklist, which can be used to identify predatory journals. Conclusion: Predatory journals have infiltrated the whitelists, and the indexing databases like PubMed and no blacklist is all-inclusive. Understanding the concept and the types of open access publishing gives the researchers a better idea on how to differentiate fake journals from the genuine ones. Using a checklist will help to identify the red flag signs of such journals and identify those journals that operate in the gray zone.
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ORIGINAL ARTICLES Top

The clinical efficiency and safety of 60W superpulse thulium fiber laser in retrograde intrarenal surgery p. 191
Chandra Mohan Vaddi, Paidakula Ramakrishna, Soundarya Ganeshan, Siddalinga Swamy, Hemnath Anandan, Manas Babu, Rakesh Panda
DOI:10.4103/iju.iju_60_22  
Introduction: Our aim is to evaluate the clinical efficiency and safety of 60W Thulium fiber laser (TFL) during retrograde intrarenal surgery (RIRS). The performance of the TFL across different ranges of stone volumes and stone densities is assessed. Materials and Methods: Between October 2019 and August 2020, a prospective study was done on 135 patients with < 20 mm renal stones, who underwent RIRS using TFL. Stone parameters, total laser time, total energy delivered (kJ), and fiber burn-back were recorded. Laser efficacy (J/mm3) and ablation speed (mm3/s) were calculated. Results: Data of 126 of 135 patients included in the study were analyzed. The mean patient age was 45.04 ± 12.30 years. Mean stone size was 15.19 ± 4.52 mm, and mean stone volume was 1061.85 ± 806.81 mm3. Mean laser time was 19.78 ± 12.32 min. At higher stone volume (>1000 mm3), J/mm3 decreased significantly from 16.18 ± 5.90 to 10.92 ± 3.21 (P < 0.001) and the ablation speed increased significantly (0.77 ± 0.28–1.04 ± 0.28 mm3/s [P < 0.001]). Stone density did not have a significant influence on the laser efficacy [B = -0.31 (-2.45 to 1.82, p=0.771)] or on the ablation speed [B = -0.06 (-0.17 to 0.05, p=0.278)]. Overall SFR was 93.6%. The complication rate was 16.6% (21/126). Out of the 21, 12 patients had hematuria and 9 had fever, which were of Clavien grades 1–2. Conclusion: Superpulse TFL is efficient and safe. The work efficiency increases for larger volume stones. The work efficiency remains the same across different stone densities. No complication more than Clavien grade 2 was encountered.
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Development and internal validation of preoperative and postoperative nomograms predicting quadrifecta outcomes following robotic radical prostatectomy p. 197
Gopal Sharma, Danny Darlington, Puneet Ahluwalia, Gagan Gautam
DOI:10.4103/iju.iju_381_21  
Introduction: Literature on the factors predicting functional and oncological outcomes following robot-assisted radical prostatectomy (RARP) is sparse for the Indian population. Hence, the primary objective of this study was to develop preoperative and postoperative nomograms predicting these outcomes in patients with prostate cancer undergoing RARP. Methods: This retrospective analysis identified the predictors of quadrifecta outcomes, i.e., the patients who did not have complications, were continent, had negative surgical margins, and were biochemical recurrence free with at least 1 year of follow-up following RARP. We excluded the return of sexual potency as the majority of the patients in our series were sexually inactive preoperatively. We used the backward stepwise logistic regression analysis method to identify the predictors of quadrifecta. Preoperative and postoperative nomograms using these predictors were developed and validated with bootstrapping, goodness of fit, calibration plot, decision curve analysis (DCA), and theits receiver operating characteristic (ROC) analysis. Results: Of the 688 patients who underwent RARP, 399 were included in this study, and 123 (30.8%) of these achieved the quadrifecta outcomes. Preoperative nomogram was developed using four variables, i.e., prostate-specific antigen (PSA), Charlson Comorbidity Index (CCI), biopsy Gleason score, and clinical stage. Postoperative nomogram included PSA, CCI, pathological tumor stage, tumor grade, and positive lymph node. Both the models were internally valid on bootstrapping, calibration plots, and goodness of fit. On the ROC analysis, preoperative and postoperative nomograms had an area under the curve of 0.71 and 0.79, respectively. On the DCA, at a threshold probability of 5%, both the models showed a net benefit. Conclusions: We developed and validated accurate nomograms for predicting quadrifecta outcomes following RARP for the Indian population.
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The value of webinars during COVID-19 pandemic: A questionnaire-based survey p. 204
Preetham Dev, B Yuvaraja Thyavihally, Santosh Subhash Waigankar, Varun Agarwal, Abhinav P Pednekar, Akash Shah
DOI:10.4103/iju.iju_349_21  
Introduction: An opportunity for e-learning has been created by the ongoing pandemic and lockdown, along with the availability of efficient technology. Webinars have filled in the lacunae of the learning process. We conducted an online survey to evaluate the interest and opinion regarding webinars, which enables for standardization of future webinars and reap the maximum benefits. Methods: An online survey was conducted among practicing urologists and urology residents. The survey was formulated and edited by a group of urologists and uro-oncologists who had experience conducting several regional and international conferences and webinars. The survey comprised 39 questions divided into six parts. Results: A total of 328 urologists throughout the country participated in the survey, and 303 complete responses were obtained for the analysis. 67.3% subjects felt that live webinars are the preferred method of knowledge exchange during the coronavirus disease pandemic, and 58.1% felt that this concept of webinars had to be extended even after the pandemic was over. Few shortcomings in the webinars included lack of networking (41.3%), lack of personal connection (73.3%), and lack of practical skills (35%). About 85.5% felt that the duration should be <90 min, and 83.2% thought that speakers should be restricted to <5. They were comfortable attending the webinars on weekends (48.8%) or weekdays but after hospital hours (43.9%). Most of them felt (92.4%) that webinars should be focused, covering a single theme and including international and national speakers (84.2%). Conclusions: Webinars can be streamlined for the better and continued after the pandemic. A few issues in this novel learning process have to be adequately addressed to strengthen this modality of academic urology.
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Association of human papillomavirus in penile cancer: A single-center analysis p. 210
Prashant Kumar Sharma, Sridhar Panaiyadiyan, Santosh Kurra, Raman Kumar, Brusabhanu Nayak, Seema Kaushal, Alpana Sharma, Rajeev Kumar, Amlesh Seth, Prabhjot Singh
DOI:10.4103/iju.iju_41_22  
Introduction: Human papillomavirus (HPV) is a known risk factor of penile cancer (PeCa). However, studies evaluating its true association are limited. In this study, we aimed to estimate HPV prevalence and its true association with PeCa in terms of molecular biological activities. Materials and Methods: This single-institutional prospective observational study was conducted between June 2016 and August 2019. We included 40 men with PeCa as a study group and 20 age-matched uncircumcised men who underwent circumcision for phimosis as a control group. Both the groups underwent deoxyribonucleic acid isolation for HPV subtyping followed by evaluation of relative E6/E7 messenger ribonucleic acid (mRNA) expression profile and relative telomerase activity in tissue samples. HPV-16 and -18 were categorized as high-risk, whereas HPV-6 and -11 were categorized as low-risk subtypes. Results: The mean (±standard deviation) age of PeCa was 51 ± 15.9 years. The majority of patients had stage II disease, and the most common procedure done was partial penectomy. The overall prevalence of HPV in PeCa was 42.5% (n = 17) as compared to 20% (n = 4) in controls. Among the subtypes, the most common subtype was HPV-16 noted in 33.3% (8/24) of cases, followed by HPV-18 in 29.2% (7/24) of cases. PeCa tissues had a significantly higher relative E7 mRNA expression for HPV-18 than the control group (P = 0.016). The mean relative telomerase activity was significantly higher in the PeCa tissues than the control group (138.66 vs. 14.46, P < 0.001). A significantly higher relative telomerase activity was noted in the PeCa tissues positive for high-risk HPV subtypes than controls (141.90 vs. 14.46, P = 0.0008), but not between high-risk HPV-positive and HPV-negative PeCa cases (141.90 vs. 137.03, P = 0.79). High-risk subtypes were not associated with tumor stage (P = 0.76) or lymph node metastasis (P = 0.816). Conclusions: HPV was associated in 42.5% of PeCa cases based on our experience from a single institution. PeCa tissues had a higher relative E7 mRNA expression for HPV-18 and relative telomerase activity as compared to controls suggesting their potential role as surrogate markers of virus-induced tumorigenesis.
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Comparison of two drainage parameters on diuretic renogram in predicting the fate of prenatally detected pelvi-ureteric junction-like obstruction p. 216
Gyanendra Ravindra Sharma, Anshu Gyanendra Sharma, Neha Gyanendra Sharma
DOI:10.4103/iju.iju_34_22  
Introduction: In infants with suspected pelviureteric junction (PUJ) like obstruction, we compared the drainage patterns suggested by t 1/2 and normalized residual activity (NORA) to determine which parameter can differentiate obstructive from nonobstructive dilatation and thus predict the need for surgery. Materials and Methods: Infants presenting with prenatally detected PUJ-like obstruction from January 2014 to March 2020 were evaluated with ultrasonography. Diuretic renogram was performed using Tc99m ethylene dicysteine using the F0 protocol. Subjects with a differential renal function >40% were included in the study. The t ½ values were noted. NORA was calculated by dividing the tracer values at 60 min with the values at 2 min. The infants were followed using ultrasonography. Renogram was repeated if there was increase in hydronephrosis or after 6 months if hydronephrosis did not regress. The follow-up was continued till a decision for pyeloplasty was made or the hydronephrosis regressed. Pyeloplasty was advised if differential function dropped to below 40%. Results: 34 patients met the inclusion criteria. NORA and t ½ had very poor concordance in defining the drainage pattern. t ½ values did not correlate with the need for surgery or conservative management (P ≥ 0.05). Good drainage pattern by NORA was associated with regression of hydronephrosis (P ≤ 0.001). NORA predicted obstruction more accurately. Conclusion: NORA can define good drainage in a much larger subset of patients with PUJ-like obstruction who eventually do not need surgery. However, further multicenter studies are needed to confirm this.
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Combination therapy in metastatic castration sensitive prostate cancer: A Systematic review and network meta-analysis p. 220
Jatinder Kumar, Muhammad Umar Alam, Seyed Behzad Jazayeri, Karthik Tanneru, Soroush Bazargani, Charu Shastri, Shiva Gautam, Shahriar Koochekpour, Sanjeev Shukla, Mark Bandyk, Joseph Costa, KC Balaji
DOI:10.4103/iju.iju_402_21  
Introduction: Studies directly comparing the different combination therapies offered to men with metastatic castration sensitive prostate cancer (mCSPC), are not available yet. This study was designed using the network meta-analysis (NMA) framework to provide a comparison of the different available options for the treatment of men with mCSPC. Methods: A systematic search was performed and the prospective randomized controlled trials reporting the overall survival (OS) or failure-free survival (FFS) were selected for review. A total of 14 studies were included in the NMA. Results: The addition of abiraterone, apalutamide, docetaxel, and docetaxel with zoledronic acid to the androgen deprivation therapy (ADT) demonstrated a significant improvement in the OS. In indirect comparison, abiraterone had a higher impact on the OS as compared to docetaxel (hazard ratio [HR]: 1.21, 95% confidence interval [CI]: 1.0–1.46) and docetaxel with zoledronic acid (HR: 1.31, 95% CI: 1.05–1.63) but not apalutamide. Furthermore, apalutamide was not different than docetaxel or docetaxel with zoledronic acid. There was a significant improvement in the FFS with the combination of abiraterone, apalutamide, docetaxel (HR: 0.61, 95% CI: 0.46–0.81), docetaxel with zoledronic acid (HR: 0.62, 95% CI: 0.43–0.9), and enzalutamide (HR: 0.39, 95% CI: 0.25–0.61) as compared to the ADT alone. Similar to the indirect comparison of OS, abiraterone outperformed docetaxel (HR: 1.66, 95% CI: 1.12–2.47), docetaxel with zoledronic acid (HR: 1.69, 95% CI: 1.06–2.68), and enzalutamide (HR: 1.06, 95% CI: 0.63–1.80), but not apalutamide in terms of impact on the FFS. Conclusion: Overall, abiraterone demonstrated better OS and FFS outcomes as compared to all the other combination strategies in this NMA.
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CASE REPORTS Top

Endovascular control during partial nephrectomy in a renal allograft p. 227
Shivashankar Damodaran, Ayman Ahmed, Obi Ekwenna
DOI:10.4103/iju.iju_38_22  
Partial nephrectomy of renal allografts is technically challenging. We report a case of robotic-assisted laparoscopic partial nephrectomy performed with selective cannulation and endovascular balloon occlusion of vascular inflow to transplanted kidney. Endovascular control during partial nephrectomy in a renal allograft and review of literature.
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Metastatic epithelioid trophoblastic tumor in retroperitoneal nodes in a case of regressed germ cell tumor of testis: An extremely rare occurrence p. 230
Uma Sakhadeo, Santosh Menon, Gagan Prakash, Sangeeta B Desai
DOI:10.4103/iju.iju_58_22  
Epithelioid trophoblastic tumor is an extremely rare tumor which occurs in women of the reproductive age group following a previous gestation. Its occurrence in male patients is remarkably rare, with only six cases reported in the English literature. Herein, we discuss the unusual occurrence of this tumor in a 31-years-old male patient as a component of non-seminomatous germ cell tumor. It presented as retroperitoneal metastasis with associated testicular microlithiasis (regressed germ cell tumor).
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UROLOGICAL IMAGES Top

Right renal artery arising from the celiac artery – A rare anatomical variation p. 234
Sunil Kumar, Priya Singh, Manish Kumar
DOI:10.4103/iju.iju_63_22  
Variations in origin and number of renal artery are common. We present a very rare anatomical variation where superior right renal artery was arising from celiac artery. This variation has important surgical implication.
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A giant vesical calculus p. 236
Gopalakrishnan Chandrasekaran, Chelian Mathirajan, Rajasabai Pandiarajan
DOI:10.4103/iju.iju_103_22  
Vesical calculi are common in urological practice. However, encountering a giant vesical calculus weighing more than 100 g is rather rare. We report a patient who presented with mild symptoms and was found to have a single giant vesical calculus weighing about 1334 g. Lack of access to basic medical facilities and milder symptoms may be the predisposing factors in this patient for a calculus to enlarge into such abnormal weight.
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UROSCAN Top

ARASENS Trial: Should darolutamide now be added to androgen-deprivation therapy and docetaxel in patients with metastatic, hormone-sensitive prostate cancer? p. 238
Naveen Kumar
DOI:10.4103/iju.iju_81_22  
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LETTERS TO EDITOR Top

Re: Kandasamy SG, Chandran KR, Pooleri GK. Minimal invasive approaches in lymph node management of carcinoma of penis: A review. Indian J Urol 2022;38:15-21 p. 240
Anand Raja, Arun Ramdas Menon, Kanuj Malik
DOI:10.4103/iju.iju_88_22  
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Author reply Re: Kandasamy SG, Chandran KR, Pooleri GK. Minimal invasive approaches in lymph node management of carcinoma of penis: A review. Indian J Urol. 2022;38:15-21 p. 241
Shreedhar Gurunathan Kandasamy, Chandran Kosur Ravi, Ginil Kumar Pooleri
DOI:10.4103/iju.iju_133_22  
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Re: Sivaraman A, Ramasamy V, Aarthy P, Sankar V, Sivaraman PB. Safety and feasibility of freehand transperineal prostate biopsy under local anesthesia: Our initial experience. Indian J Urol 2022;38:34-41 p. 242
Akif Erbin, Fevzi Sinan Erdal
DOI:10.4103/iju.iju_92_22  
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Extreme self-mutilation due to 'Dhat' syndrome p. 243
Pankaj N Maheshwari, Neerja Deepak Tillu, Utsav Shailesh Shah
DOI:10.4103/iju.iju_94_22  
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Re: Mannem SR, Mallikarjuna C, Bhavatej E, Taif NB, Ravichander O, Syed MG. Incidence of urethral stricture following bipolar transurethral resection of prostate: A single-center study. Indian J Urol 2022;38:146-50 p. 244
Abhay Singh Gaur, Vivek Tarigopula, Swarnendu Mandal, Manoj K Das, Prasant Nayak
DOI:10.4103/iju.iju_107_22  
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Author reply Re: Mannem SR, Mallikarjuna C, Bhavatej E, Taif NB, Ravichander O, Syed MG. Incidence of urethral stricture following bipolar transurethral resection of prostate: A single-center study. Indian J Urol 2022;38:146-50 p. 245
Srinath Reddy Mannem, Chiruvella Mallikarjuna, Enganti Bhavatej, N Bendigeri Mohammed Taif, Oleti Ravichander, M Ghouse Syed
DOI:10.4103/iju.iju_203_22  
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