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   Table of Contents - Current issue
Coverpage
October-December 2022
Volume 38 | Issue 4
Page Nos. 247-332

Online since Saturday, October 1, 2022

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EDITORIALS  

The paradox of why and how in urology! p. 247
Anil Mandhani
DOI:10.4103/iju.iju_315_22  
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Round up p. 249
Swarnendu Mandal
DOI:10.4103/iju.iju_319_22  
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The Urological Society of India guidelines for the evaluation and management of prostate cancer (executive summary) Highly accessed article p. 252
Anup Kumar, Siddharth Yadav, Raghunath S Krishnappa, Gagan Gautam, Narasimhan Raghavan, Ganesh Bakshi, Gagan Prakash, Puneet Ahluwalia, Ashwin Tamankar, Sanjoy Surekha, Niraj Kumar, Sandeep Kumar, Ashwin Mallya, Gagan Saini, Manish Singhal, Ravimohan Mavuduru, Brusabhanu Nayak, Prabhjot Singh, Jiten Jaipuria, Vijoy Kumar, Sudhir K Rawal, Narmada Prasad Gupta
DOI:10.4103/iju.iju_232_22  
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REVIEW ARTICLES Top

The role of tranexamic acid in reducing bleeding during transurethral resection of the prostate: An updated systematic review and meta-analysis of randomized controlled trials Highly accessed article p. 258
Firmantya Hadi Pranata, Yudhistira Pradnyan Kloping, Furqan Hidayatullah, Zakaria Aulia Rahman, Niwanda Yogiswara, Ilham Akbar Rahman, Nafis Audrey Febriansyah, Doddy Moesbadianto Soebadi
DOI:10.4103/iju.iju_98_22  
Introduction: Transurethral resection of the prostate (TURP) is regarded as the current gold standard surgical intervention for benign prostatic hyperplasia (BPH). However, this procedure is associated with significant chances of intraoperative and postoperative bleeding. Several studies have reported the role of tranexamic acid in prostatic surgeries, but, its role in TURP is still unclear. This review aims to evaluate the role of tranexamic acid in reducing the blood loss during TURP. Materials and Methods: A systematic search was performed on Medline, Scopus, Embase, and Cochrane, up to December 2021. Relevant randomized controlled trials (RCTs) evaluating the role of tranexamic acid in TURP were screened using our predefined eligibility criteria. Data were expressed as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CIs). All analyses were performed using RevMan 5.4 (Cochrane Collaboration, UK). Results: Six trials were included in this meta-analysis, comprising of 582 patients with BPH who underwent TURP. The meta-analysis revealed an insignificant difference in the rate of blood transfusion (OR 0.68, 95% CI 0.34, 1.34, P = 0.27) but, a significantly lower amount of blood loss and a lower reduction in the hemoglobin (Hb) levels in the patients receiving tranexamic acid as compared to the control group (MD − 127.03, 95% CI − 233.11, −20.95, P = 0.02; MD − 0.53, 95% CI − 0.84, −0.22, P < 0.01; respectively). Also, the operative time (P = 0.12) and the length of hospitalization (P = 0.59) were similar between the two groups. Conclusion: The administration of tranexamic acid was not found to be effective in reducing the need for blood transfusion, the operative time, and the length of hospitalization during the TURP. However, it could reduce the amount of blood loss and the fall in the Hb levels.
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Urgency and urgency incontinence following stress urinary incontinence surgery: A review of evaluation and management p. 268
Alex Gomelsky, Heather Steckenrider, Roger R Dmochowski
DOI:10.4103/iju.iju_147_22  
The presence of urgency urinary incontinence (U/UUI) after sling surgery is a common reason for dissatisfaction and imposition on quality of life. We aimed to evaluate and analyze the pathophysiology, evaluation, and treatment of U/UUI after sling surgery. A MEDLINE review was performed for relevant, English-language articles relating to storage and emptying symptoms after sling surgery. U/UUI may persist, be improved, or worsen in women with preoperative mixed urinary incontinence and may appear de novo in those women originally presenting with pure stress urinary incontinence (SUI). While the exact mechanism is not clear, partial bladder outlet obstruction (BOO) should always be suspected, especially in those women with worsened or de novo symptoms soon after sling surgery. Initial workup should elucidate the temporality, quality, and bother associated with symptoms and to evaluate the woman for urinary tract infection (UTI), pelvic organ prolapse (POP), or perforation of the lower urinary tract. The utility of urodynamics in attaining a definitive diagnosis of BOO is inconclusive. Treatment options include reevaluation of the patient after sling incision or after addressing UTI, POP, and perforation of the bladder or urethra. Women also typically undergo a multitiered approach to storage lower urinary tract symptoms outlined in the American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Overactive Bladder Guidelines. While improvement is typically seen with multimodality treatment, all women should be counseled regarding need for additional treatment for U/UUI, BOO, and SUI in the future.
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ORIGINAL ARTICLES Top

Impact of multimodal therapy on margin status on overall survival for patients undergoing adrenalectomy for localized adrenocortical carcinoma p. 276
Kyle Hickey, Afzal Shakir, Caitlin Shepherd, Robin Djang, Sanjay Patel
DOI:10.4103/iju.iju_77_22  
Introduction: Adrenocortical carcinoma is a rare malignancy that typically presents with advanced features and carries a poor prognosis. Complete surgical resection offers patients the best survival outcomes, but this is not always achievable and many require additional therapy for advanced features. Some literature has explored the role of chemotherapy and radiation, but little has been conducted to explore the effects of multimodal therapy. Methods: We retrospectively reviewed the National Cancer Database for adults with primary nonmetastatic adrenocortical carcinoma (ACC) who underwent either partial or radical adrenalectomy. Excluded patients included those with metastatic disease and those with primary tumor >30 cm. Patients were categorized based on adjuvant treatment; chemotherapy, radiation therapy (RT), RT + chemotherapy, or no adjuvant therapy. Overall survival (OS) was compared using survival curves, log rank tests, and multivariate survival analysis. Results: We identified 1644 patients with localized ACC treated with adrenalectomy. The median tumor size was 10.6 cm. A total of 278 patients had positive margin status (R1), and 416 patients had nodal (pN+) disease. Out of all patients, a minority (39.4%) received adjuvant therapy, which was most commonly given as chemotherapy only. Statistically significant increase in OS was noted with the use of RT + chemotherapy in the node-negative, margins-positive (pN0/pNx; R1) subgroup versus patients who did not receive adjuvant therapy (5-year OS 60.5% and 28.2%, respectively [P = 0.002]). This held true on multivariate analysis with significant improvement in OS in the pN0/pNx; R1 population with RT + chemotherapy compared to those who received no treatment (hazard ratio: 0.40 [95% confidence interval: 0.2–0.9], P = 0.02). Conclusions: Our findings support the use of adjuvant chemotherapy plus RT in patients with positive surgical margins and no nodal disease. Additional studies are required to confirm these findings, clarify the objective benefit of multimodal therapy, and to determine the optimal chemotherapy/RT combination.
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Challenges and gender-based differences for women in the Indian urological workforce: Results of a survey p. 282
Shruti Rahul Pandit, P Venugopal, Ramaiah Keshavamurthy, Arun Chawla
DOI:10.4103/iju.iju_143_22  
Introduction: Entry of women into urology has not kept pace with that in other surgical branches with only 1% of Urological Society of India (USI) members being female. The objective of this study was to explore the personal and professional challenges, practice barriers, and level of satisfaction among female urologists/urology trainees in India. Methods: A strictly confidential and anonymous 26-item questionnaire with respect to professional and personal challenges, workplace discrimination, and family satisfaction was circulated as a Google form through email and WhatsApp to all the female members of the USI (full and associate) and trainees (n = 48) based on identification from the USI directory. Results: Thirty-three out of 48 female urologists responded (68%). Among the respondents (n = 33), majority had <5 years of experience (60.6%), of which 30.3% were residents, which reflected a recent surge in women joining urology. Majority (57.7%) chose to subspecialize, commonly in “female urology”. Many (72.7%) were encouraged to take this subspecialty. Gender discrimination at workplace was reported by 54.5%, commonly by patients and consultants. 68% of respondents had conceived either before or during residency, leading to additional domestic responsibilities. 9.1% suffered a pregnancy-related complication, which they believed was a direct consequence of their work environment. These obstacles led to 30.3% of women reporting that their personal life had compromised their careers. Professional dissatisfaction was reported by 60.1% of women, with common causes being less operative time than male counterparts and lack of mentorship. Despite these challenges given a chance, 78.7% would choose urology again, and 66.7% would encourage their daughter to pursue a career in urology. Conclusion: Professional and personal challenges as perceived by women responding to our survey include gender discrimination in training and work, lack of mentorship, pregnancy-related compilations, and compromised career due to family responsibilities. Despite these, most would choose this specialty again.
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Editorial Comment p. 287
Sanjay Sinha
DOI:10.4103/iju.iju_322_22  
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Perioperative outcomes following robot-assisted partial nephrectomy for complex renal masses: A Vattikuti Collective Quality Initiative database study p. 288
Gopal Sharma, Milap Shah, Puneet Ahluwalia, Prokar Dasgupta, Benjamin J Challacombe, Mahendra Bhandari, Rajesh Ahlawat, Sudhir Rawal, Nicolo M Buffi, Ananthakrishnan Sivaraman, James R Porter, Craig Rogers, Alexandre Mottrie, Ronney Abaza, Khoon Ho Rha, Daniel Moon, Yuvaraja B Thyavihally, Dipen J Parekh, Umberto Capitanio, Kris K Maes, Francesco Porpiglia, Levent Turkeri, Gagan Gautam
DOI:10.4103/iju.iju_154_22  
Introduction: Outcomes of robot-assisted partial nephrectomy (RAPN) depend on tumor complexity, surgeon experience and patient profile among other variables. We aimed to study the perioperative outcomes of RAPN for patients with complex renal masses using the Vattikuti Collective Quality Initiative (VCQI) database that allowed evaluation of multinational data. Methods: From the VCQI, we extracted data for all the patients who underwent RAPN with preoperative aspects and dimensions used for an anatomical (PADUA) score of ≥10. Multivariate logistic regression was conducted to ascertain predictors of trifecta (absence of complications, negative surgical margins, and warm ischemia times [WIT] <25 min or zero ischemia) outcomes. Results: Of 3,801 patients, 514 with PADUA scores ≥10 were included. The median operative time, WIT, and blood loss were 173 (range 45–546) min, 21 (range 0–55) min, and 150 (range 50–3500) ml, respectively. Intraoperative complications and blood transfusions were reported in 2.1% and 6%, respectively. In 8.8% of the patients, postoperative complications were noted, and surgical margins were positive in 10.3% of the patients. Trifecta could be achieved in 60.7% of patients. Clinical tumor size, duration of surgery, WIT, and complication rates were significantly higher in the group with a high (12 or 13) PADUA score while the trifecta was significantly lower in this group (48.4%). On multivariate analysis, surgical approach (retroperitoneal vs. transperitoneal) and high PADUA score (12/13) were identified as predictors of the trifecta outcomes. Conclusion: RAPN may be a reasonable surgical option for patients with complex renal masses with acceptable perioperative outcomes.
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Percutaneous embolization of renal pseudoaneurysms: A retrospective study p. 296
Seyed Morteza Bagheri, Mostafa Ghadamzadeh, Mohammadreza Chavoshi
DOI:10.4103/iju.iju_109_22  
Introduction: We evaluated the efficacy of the mixture of autologous blood and a hemostatic agent, oxidized regenerative cellulose (ORC), as an alternative material for ultrasound (US)-guided percutaneous embolization of renal pseudoaneurysm (PA). Methods: In this retrospective study, consecutive patients diagnosed with renal PA were included. The exclusion criteria were: PA of the main renal artery, tiny PA not visualized on the colour doppler ultrasonography, PA more than 3 cm in max diameter or extracapsular PA with the possibility of massive bleeding, and patients with a history of coagulation disorders. After localizing the PA, a mixture of autologous blood and ORC was injected under US guidance with a 15G coaxial needle. Patients were followed up for at least 6 months. Results: Twenty-nine patients with PA were included, of which 26 had a history of percutaneous nephrolithotomy, and three patients had a history of renal biopsy (24 men and five women with an average age of 44.3 years). Gross hematuria was the most common mode of presentation. The mean size of the PA was 16.6 mm and the mean duration of follow-up was 9 months. The clinical and the technical success rate was 100%. The PA could be thrombosed in all the patients with a single-session of injection. No acute (hematoma, infection, and bleeding) or chronic (thromboembolic events, renal cortical atrophy, and recurrence) complications were seen. Conclusion: Percutaneous embolization of renal PA under US guidance with a mixture of autologous blood and ORC is an efficient and easily available first-line method to treat this potentially life-threatening condition when endovascular embolization or other expensive thrombotic agents are not available.
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A prospective, observational study to assess the feasibility and safety of supine percutaneous nephrolithotomy under regional anesthesia for obese patients with a body mass index ≥30 p. 302
Samer Mahmoud Morsy, Islam Nasser Abdelaziz, Ahmed Mohamed Rammah, Mahmoud Abdelaziz Labana, Hussein Aly Hussein
DOI:10.4103/iju.iju_186_22  
Introduction: Besides being a risk factor for urolithiasis, obesity is a challenge in the treatment of urolithiasis from the perspective of both the surgeon and the anesthetist. In this study, we tried to assess the feasibility and safety of supine percutaneous nephrolithotomy (PCNL) under regional anesthesia in obese patients with a body mass index (BMI) ≥30. Methods: This was a prospective observational study and included 51 obese patients (BMI ≥30 kg/m2) with renal stones planned for PCNL. All patients underwent supine PCNL under regional anesthesia with the standard technique. A decision for totally tubeless or a tubeless PCNL was made at the end of the procedure and the intraoperative and postoperative data were recorded. All patients underwent computed tomography (CT) imaging at 1 month after surgery to assess the stone-free status and the need for additional treatment. Results: The mean age of the patients was 53.2 ± 8.09 years, and the mean BMI was 34.4 ± 2.369 kg/m2. The mean operative time was 73.3 ± 26.2 min, the mean hospital stay was 58.3 ± 22.1 h, and the mean postoperative Visual Analog Score (VAS) for pain was 3.8 ± 1.4. The stone-free rate was 68.6% on the follow-up CT performed after 1 month, and 31.4% of the patients had significant residual fragments which required re-treatment either by retrograde intrarenal surgery (RIRS) in 19.6% (either as primary RIRS for the residual calculi in one patient [1.9%] or as RIRS for post shock wave lithotripsy (SWL) or alkalinization failure in 9 patients), SWL in 21.6%, or urine alkalinization in 7.8%. Conclusion: Supine PCNL under regional anesthesia, in this subgroup of obese patients, was found to be feasible and safe with satisfactory stone-free rates and minimal postoperative pain.
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CASE REPORTS Top

Development of phimosis as an adverse drug reaction to capecitabine with irinotecan p. 307
Priyeshkumar Patel, Nagendra Nath Mishra, Taral Patel
DOI:10.4103/iju.iju_169_22  
We present a case of a 32-year-old male who developed capecitabine-induced phimosis which resolved spontaneously without the need for circumcision within a few days of discontinuation of chemotherapy. The patient was on capecitabine with irinotecan chemotherapy for peritoneal metastasis from adenocarcinoma of the lower esophagus. A detailed literature review showed a few case reports with penile and scrotal erythema, ulceration, and swelling along with hand-foot syndrome, but none reported the occurrence of phimosis with spontaneous resolution.
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Renal vein injury during percutaneous nephrolithotomy: A surgical catastrophe – Management and lessons learned p. 309
Amit Aggarwal, Priyank Bhargava, Deepak Prakash Bhirud
DOI:10.4103/iju.iju_241_22  
Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large and complex renal calculi. We encountered a patient who was planned for PCNL in a peripheral hospital, without a preoperative computed tomography scan but was abandoned during tract dilatation due to intractable bleeding and was referred to our institute with nephrostomy in situ in a clamped state. After evaluation, the tip of the nephrostomy tube was found to be in the left renal vein causing secondary thrombosis. Due to the nonfunctional status of the kidney in the dynamic scan, the patient underwent laparoscopic left simple nephrectomy with thrombectomy without any major intraoperative complication and was discharged in stable condition.
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Iatrogenic partial glanular amputation: A rare complication of circumcision p. 312
Aditya Prakash Sharma, Thummala Yashaswi, Jerry R John, Shrawan Kumar Singh
DOI:10.4103/iju.iju_166_22  
Circumcision is a customary ritual across many cultures. However, the safety of such procedures remains a concern. A boy underwent circumcision in 2014 by a religious worker at the age of 7 years. Post circumcision, the patient had gradual narrowing of the penis, between the glans and the shaft, with an iatrogenic partial glanular amputation and presented to us at the age of 14 years. The patient underwent end-to-end urethroplasty and glansplasty. Postoperatively, the patient did well and the wound remained healthy. Circumcision has complications even in expert hands. Religious circumcision can result in dreadful complications in children and adolescents.
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UROLOGICAL IMAGE Top

A rare neurological presentation of emphysematous pyelonephritis p. 315
S Lal Darsan, Biju S Pillai, H Krishnamoorthy
DOI:10.4103/iju.iju_145_22  
Emphysematous pyelonephritis (EPN) is an acute necrotizing infection of the kidney with features of air formation in the pelvicalyceal system, renal parenchyma, and surrounding structures. Although septic embolization has been reported to occur in distant organs, air pockets occurring intracranially leading to neurological manifestations in EPN have not been reported in the literature. We present a case report of a patient with EPN showing air pockets in renal parenchyma, pelvicalyceal system, renal vein, inferior vena cava, and multiple intracranial venous sinuses, presenting predominantly with neurological symptoms. This patient was aggressively managed with antibiotics, ureteral stenting, and drainage of the right kidney.
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UROSCANS Top

Long-term follow-up results of nivolumab plus cabozantinib versus sunitinib for advanced renal cell cancer: Checkmate 9ER trial p. 317
Vivek Tarigopula
DOI:10.4103/iju.iju_219_22  
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PROpel trial: Are PARP inhibitors ready to become the first-line treatment for mCRPC? p. 319
Abhay Singh Gaur
DOI:10.4103/iju.iju_229_22  
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Comparison of multiparametric ultrasound versus multiparametric magnetic resonance imaging for diagnosis of carcinoma prostate: The CADMUS trial p. 321
Vivek Tarigopula
DOI:10.4103/iju.iju_221_22  
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Triple therapy for metastatic castration sensitive prostate cancer: PEACE-1 trial p. 323
Kirti Singh
DOI:10.4103/iju.iju_200_22  
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Fluorodeoxyglucose-positron emission tomography/computed tomography-based chemotherapy dosage adjustment in seminoma: The GETUG SEMITEP trial p. 325
Dheeraj Kumar Dheeroo
DOI:10.4103/iju.iju_226_22  
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LETTERS TO EDITOR Top

Re: Sharma GR, Sharma AG, Sharma NG. Comparison of two drainage parameters on diuretic renogram in predicting the fate of prenatally detected pelvi-ureteric junction-like obstruction. Indian J Urol 2022;38:216-9 p. 327
Ritesh Goel, Pankush Gupta
DOI:10.4103/iju.iju_245_22  
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Author Reply Re: Sharma GR, Sharma AG, Sharma NG. Comparison of two drainage parameters on diuretic renogram in predicting the fate of prenatally detected pelvi-ureteric junction-like obstruction. Indian J Urol 2022;38:216-9 p. 328
Gyanendra Ravindra Sharma, Anshu Gyanendra Sharma, Neha Gyanendra Sharma
DOI:10.4103/iju.iju_261_22  
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Re: Sharma PK, Panaiyadiyan S, Kurra S, Kumar R, Nayak B, Singh P, et al. Association of human papillomavirus in penile cancer: A single-center analysis. Indian J Urol 2022;38(3): 210-15. p. 328
Prasanna Ram, Santosh Kumaraswamy, Swarnendu Mandal, Manoj K Das, Sambit Tripathy, Prasant Nayak
DOI:10.4103/iju.iju_234_22  
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Author Reply Re: Sharma PK, Panaiyadiyan S, Kurra S, Kumar R, Nayak B, Kaushal S, et al. Association of human papillomavirus in penile cancer: A single-center analysis. Indian J Urol 2022;38:210 p. 330
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_273_22  
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Re: Vaddi CM, Ramakrishna P, Ganeshan S, Swamy S, Anandan H, Babu M, et al. The clinical efficiency and safety of 60W superpulse thulium fiber laser in retrograde intrarenal surgery. Indian J Urol 2022; 38:191-6 p. 330
Dheeraj Kumar Dheeroo, Swarnendu Mandal, Manoj K Das, Sambit Tripathy, Prasant Nayak
DOI:10.4103/iju.iju_230_22  
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Author Reply Re: Vaddi CM, Ramakrishna P, Ganeshan S, Swamy S, Anandan H, Babu M, et al. The clinical efficiency and safety of 60W superpulse thulium fiber laser in retrograde intrarenal surgery. Indian J Urol 2022;38:191-6 p. 332
Vaddi Chandra Mohan, Paidakula Ramakrishna, Soundarya Ganesan, Siddalinga Swamy, Hemnath Anandan, Manas Babu, Rakesh Panda
DOI:10.4103/iju.iju_318_22  
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