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   Table of Contents - Current issue
January-March 2022
Volume 38 | Issue 1
Page Nos. 1-81

Online since Saturday, January 1, 2022

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Surveys in urology p. 1
Rajeev Kumar
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Round up p. 3
Swarnendu Mandal
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Focal therapy for localized prostate cancer – Current status p. 7
Shrikanth Atluri, Ali Mouzannar, Vivek Venkatramani, Dipen J Parekh, Bruno Nahar
Focal therapy (FT) has recently gained popularity for the treatment of localized prostate cancer (PCa). FT achieves cancer control by targeting the lesions or the regions of the cancer and avoids damage to the surrounding tissues thus minimizing side effects which are common to the radical treatment, such as urinary continence and sexual function, and bowel-related side effects. Various ablative methods are used to deliver energy to the cancerous tissue. We review the different modalities of treatment and the current state of FT for PCa.
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Minimal invasive approaches in lymph node management of carcinoma of penis: A review p. 15
Shreedhar Gurunathan Kandasamy, Kosur Ravi Chandran, Ginil Kumar Pooleri
Introduction: Inguinal lymph node dissection (ILND) is an integral part in the management of carcinoma penis. The concerns about the postoperative morbidity associated with open ILND led to modification in the template of dissection and adoption of minimally invasive techniques such as video endoscopic inguinal lymphadenectomy (VEIL) and robotic-assisted VEIL (R-VEIL). In this review, we aim to describe the techniques, case selection, perioperative outcomes, and oncological outcomes of VEIL and R-VEIL and to compare it with open ILND. Methods: Databases of PubMed, Embase, and Google Scholar were searched to identify the articles for VEIL and R-VEIL. Using PRISMA guidelines, literature search yielded 3783 articles, of which 32 full-text articles relevant to the topic were selected and reviewed, after consensus from authors. Results: After the first description of VEIL, various modifications in port placements and approaches were described. Several studies have shown, VEIL and R VEIL are safe and feasible in both node-negative and node-positive Ca penis patients. Compared to open ILND, VEIL had fewer wound infections and skin necrosis, minimal blood loss, shorter mean hospital stays, and reduced duration of drain kept. There is no difference in mean lymph node yield and recurrence rates between open ILND, VEIL, R-VEIL. Conclusion: VEIL and R-VEIL are safe and have comparable oncological outcomes with open ILND.
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Raised prostate-specific antigen alone may not be a true predictor in high-risk prostate cancer: A retrospective cohort analysis p. 22
Harshit Garg, Amlesh Seth, Rajeev Kumar
Introduction: Prostate-specific antigen (PSA) >20 ng/mL in isolation is a criterion for classification as “high-risk” prostate cancer (PCa). However, among Indian men, PSA elevation is often seen even in the absence of PCa and patients with PSA as the sole criterion for the high-risk disease may have different outcomes from those categorized as high risk due to adverse pathological features. We compared the operative, oncological, and functional outcomes after robot-assisted radical prostatectomy (RARP) in men with high-risk PCa categorized using PSA alone versus clinical and histopathological findings. Materials and Methods: In an Institute Review Board-approved study, men undergoing RARP with high-risk PCa with at least 2-year follow-up were categorized into those with PSA >20 ng/ml being the sole criteria for being high risk (Group A) versus those with Gleason score ≥8 or ≥T2c disease but any PSA level (Group B). The two groups were compared for perioperative, oncological, and functional outcomes. Results: Fifty-three patients with high-risk disease were included. Twenty-six patients (48.9%) were classified into Group A while 27 patients (50.9%) were classified into Group B. The median PSA was significantly higher in Group A (31 [26–35] ng/ml in Group A vs. 21 [12–34] ng/ml in Group B, P = 0.006) and on histopathology of radical prostatectomy specimen, 24 (92.3%) patients had GG ≤3 disease in Group A versus 10 (37%) patients in Group B (P < 0.001). Patients in both the groups had similar perioperative and continence outcomes. However, Group A had significantly lower biochemical recurrence rate (3/26 [11.5%]) as compared to Group B (11/27 [40.7%]) (P = 0.012). Conclusions: PSA >20 ng/ml is the single most common criterion for stratification as high-risk PCa. However, men with PSA >20 ng/ml in isolation, without another adverse criterion, have better outcomes than men with adverse clinical or pathological criteria for high-risk disease.
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Utility of WhatsApp in emergency urological practice: An interrater reliability study p. 29
Aditya Prakash Sharma, Saket Singh, Sudheer Kumar Devana, Kapil Chaudhary, Tarun Pareek, Shrawan K Singh
Introduction: The messaging application 'WhatsApp' is used in clinical practice, often for communication between a medical trainee and a consultant. We designed this study to find the interrater reliability of the data transmitted through this application and validating its use in urological practice. Materials and Methods: Clinical details and computerized tomographic (CT) images of 30 patients visiting the urology emergency were posted in a closed WhatsApp group involving three consultants (SKD, APS, and KC). The CT images were posted in the WhatsApp group as Whole Image (WI) and Image of Interest (IOI) format and rated on a scale of 1–5. The consultants formulated a provisional diagnosis and initial management strategy. The interrater reliability of these responses was analyzed in the study. Results: Mean WI rating ranged from 3.03 ± 0.61 to 3.73 ± 0.64 (Cronbach alfa [α]-0.494, P = 0.006). Mean IOI rating ranged from 3.4 ± 0.56 to 4.13 ± 0.73 (α-0.824, P < 0.0001). For diagnosis, the proportion of observed agreement (P0) was 83.3% for SKD and APS, 76.6% for SKD and KC, and 73.3% for APS and KC. For management, P0 was 86.6% for APS and KC, 86.6% for SKD and APS, and 80% for SKD and KC. Conclusions: WhatsApp Messenger serves to transmit good quality pictures of CT scan images. A reasonable diagnosis and management strategy can be formulated using this app with fair inter-rater reliability.
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Safety and feasibility of freehand transperineal prostate biopsy under local anesthesia: Our initial experience p. 34
Ananthakrishnan Sivaraman, Vasantharaja Ramasamy, P Aarthy, Vinoth Sankar, PB Sivaraman
Introduction: With the emergence of multidrug-resistant organisms causing urosepsis after transrectal biopsy of prostate, the need for an alternative approach has increased. We assessed the safety and feasibility of transrectal ultrasound (TRUS) guided free-hand transperineal prostate biopsy under local anesthesia (LA) for suspected prostate cancer. Materials and Methods: This prospective study was conducted from July 2019 to December 2020 in which patients with elevated prostate-specific antigen (PSA) and/or abnormal digital rectal examination underwent magnetic resonance imaging-TRUS cognitive fusion transperineal prostate biopsy (target and systematic) using coaxial needle. Demographic, perioperative, and outcome data of 50 consecutive patients were analyzed. Results: The mean age of the patients was 69.6 ± 7.61 years, median PSA 13.55 ng/mL (4.17–672) and prostate size 45cc (16–520). Prostate Imaging–Reporting and Data System (PIRADS) 2, 3, 4, and 5 lesions were found in 2, 12, 12, and 24 patients, respectively. Average procedure duration was 20 min (15-40 min) and number of cores ranged from 12 to 38 (median 20). Forty out of fifty (40/50) patients experienced only mild pain with visual analog scale ≤2. Histopathological examination showed adenocarcinoma, benign prostatic hyperplasia, and chronic prostatitis in 41, 5, and 4 patients respectively with 82% cancer detection rate (CDR). Over 95% of cases showed clinically significant cancer (International Society of Urological Pathology class ≥ 2) and 91.7% of patients with PIRADS score 4/5 and 66.7% with PIRADS score 3 had malignancy. Three patients developed complications (two hematuria, one urinary retention), both were managed conservatively and none had urosepsis. Conclusions: Free-hand transperineal prostate biopsy by coaxial needle technique under LA is safe and feasible with good tolerability, high CDR, and minimal complications particularly reduced urosepsis.
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Thulium fiber laser versus holmium:yttrium aluminum garnet laser for stone lithotripsy during mini-percutaneous nephrolithotomy: A prospective randomized trial p. 42
Abhay Dinkar Mahajan, Sumeeta Abhay Mahajan
Introduction: We aimed to evaluate the effectiveness and safety of the newly launched thulium fiber laser (TFL) with holmium laser lithotripsy in the miniaturized percutaneous nephrolithotomy (Miniperc) procedure for renal stones. Methods: The prospective study included patients with renal stones of size >1 cm to ≤3 cm. The patients who opted for extracorporeal shock wave lithotripsy, retrograde intrarenal surgeries, and stones >3 cm were excluded from the study. Demographics such as patient's age, sex, stone volume, and hardness were evaluated. The patients were randomized into holmium and TFL group for stone lithotripsy. Both the procedures were evaluated for stone disintegration time, operative time, hospital stay, intra- and postoperative complications, and stone-free rate. Results: A total of 125 patients with renal stones who underwent Miniperc were included in this study. The average size of the stone was comparable in both the groups (P = 0.053). The median stone disintegration time with holmium laser was 20 min 45 s and with TFL, it was 11 min 19 s (P < 0.001). The most common complications were Clavien grade I and II complications (P = 0.128). Prolonged postoperative hematuria was observed in the Thulium fiber laser group, which was conservatively managed. The stone-free rate with TFL (94.9%) was better than Holmium lithotripsy (90.9%). Conclusions: The TFL has significant less stone disintegration time which effectively reduced the operative time of Miniperc procedure. The stone-free rate is better, but the incidence of self-limiting hematuria is higher with TFL as compared to Holmium laser.
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Abdominal wall closure in adult patients with untreated exstrophy of bladder p. 48
Ashish Kumar Gupta, Amish Jayantilal Gohil, Shashank Lamba
Introduction: Bladder exstrophy is an anomaly, which if not treated early in the age, poses a surgical challenge in providing an adequate abdominal wall closure. We report our experience in patients with untreated exstrophy of the bladder, who underwent cystectomy, ileal conduit, and abdominal reconstruction using the anterior rectus sheath turndown flap and paired inguinal skin flaps. Materials and Methods: Ten previously unoperated adult patients with exstrophy with epispadias, who underwent surgery at our institute from January 2010 till January 2021, were included in this study to evaluate the adequacy of abdominal wall closure with our technique of retrograde turndown anterior rectus sheath flap with paired inguinal flap, and to document immediate and delayed complications, especially incisional hernia. Results: The mean follow-up period of the study was 16.5 months. We found that our technique provided adequate local tissue for a sturdy two-layered closure of the lower abdominal wall defect. Out of the ten patients, only one required an additional flap for abdominal wound closure. There were no stoma-related complications or incisional hernia. Conclusion: Abdominal wall reconstruction, for skin and fascial defects, in such complex cases can be performed by local skin and fascia using a relatively simple, safe, easy, and affordable technique as we have described. Our technique avoids the use of synthetic mesh, thereby reducing the chances of infection in such chronic open wounds.
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Timing of intraoperative crystalloid infusion may decrease total volume of infusate without affecting early graft function in live related renal transplant surgery: A randomized, surgeon-blinded clinical study p. 53
Abhishek Singh, Rashmi Ramachandran, C Chandralekha, Anjan Trikha, Bikash Ranjan Ray, Virinder Kumar Bansal, Sandeep Mahajan, Krishna Asuri, Vimi Rewari
Introduction: Early graft function is crucial for successful kidney transplantation. Intravascular volume maintenance is paramount in ensuring reperfusion of transplanted kidney. This study was planned to compare whether the timing of fluid infusion can help to decrease amount of fluid given without altering early graft function during renal transplantation. Materials and Methods: The present study included forty recipients, randomized into standard (Group-S) or targeted fluid therapy (Group-T). Group S received fluid according to conventional fasting deficit while Group T received at 1 ml/kg/h from the start of surgery till start of vascular anastomosis after which fluid infusion rate in both group was increased to maintain a central venous pressure of 13–15 mm of Hg till reperfusion. Primary outcome measured was serum creatinine level on first postoperative day while secondary outcomes were IV fluid given, perioperative hemodynamics, onset of diuresis, graft turgidity, urine output, and renal function during first 6 postoperative days. Results: The study showed Group T postoperatively had early fall in serum creatinine (day 3) than S (day 6) although this difference was not statistically significant. Group T had received significantly less fluid per kg of dry weight (T-42.7 ± 9.7 ml/kg, S-61.1 ± 11.1 ml/kg, P < 0.001), had early diuresis, better graft turgidity and urine output than Group S. Conclusion: Targeted hydration significantly decreases the total amount of fluid infused during the intraoperative period without altering early graft function. Targeted hydration during vascular anastomosis produced stable hemodynamics and early diuresis without any side-effects pertaining to hypo or hyper-volemia. Clinical trial identifier number-CTRI/2016/07/007111.
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Superselective angioembolization in posttraumatic pseudoaneurysm of corpora cavernosa presenting as acute urinary retention p. 62
Pavan Surwase, Suhas Lele, Ravindra Sabnis, Arvind Ganpule
Pseudoaneurysm of corpora cavernosa is rare and its presentation as acute urinary retention has not been reported in the literature so far. We report a 47-year-old gentleman who presented with acute urinary retention. Doppler ultrasound revealed pseudoaneurysm of corpora cavernosa at bulbar urethra region with 2 feeder vessels with turbulent flow inside. Selective internal pudendal artery angiogram was done and two feeder arteries from bilateral pudendal arteries were confirmed. Trans perineal thrombin & fibrinogen instillation and selective coil embolization of left internal pudendal artery were done, leading to complete obliteration of pseudoaneurysm and alleviation of patient's symptoms.
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Urethral caruncle in penile urethra in a young male p. 65
Rishikesh Arun Kore, Rajiv Nilkanth Kore
Urethral caruncles are seen almost exclusively in women. When these lesions are diagnosed in a male patient, he is likely to undergo unnecessary radical treatment mistaking a urethral caruncle for a malignant urethral neoplasm. Hence, a proper histopathological diagnosis is mandatory before deciding the final treatment. We report a case of fleshy masses in the penile urethra of a young male patient. Simple excision was performed and the histopathology revealed a urethral caruncle of the angiomatous variety.
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Ultrasound-guided supine mini-percutaneous nephrolithotomy in ectopic pelvic kidney p. 68
Laxmi Kant Sharma, Vigneswara Srinivasan Sockkalingam Venkatachalapathy, Dilip Kumar Mishra, Madhu Sudan Agrawal
Management of urolithiasis in an ectopic pelvic kidney is challenging and laparoscopic pyelolithotomy and laparoscopy-guided percutaneous nephrolithotomy (PCNL) are commonly favored options. We report a case of ultrasound-guided supine mini-PCNL in ectopic pelvic kidney in an adolescent female. Complete stone clearance was achieved with an uneventful postoperative period. Ultrasound-guided supine mini-PCNL is safe and effective treatment option for the management of calculus in the ectopic pelvic kidney. The risk of injury to surrounding structures associated with ultrasound modality of access can be avoided with proper case selection and careful technique.
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STHLM3-MRI study: Role of magnetic resonance imaging-targeted biopsy in prostate cancer screening p. 71
Abhay S Gaur
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PROFOUND trial –a new era in targeted therapeutics for prostate carcinoma Highly accessed article p. 73
Jyoti Mohan Tosh
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KEYNOTE-564: Adjuvant immunotherapy for renal cell carcinoma Highly accessed article p. 75
Abhishek Pandey
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Re: Nerli RB, Ghagane SC, Rangrez S, Chandra S, Thakur ML, Gomella L. Detection of bladder cancer using voided urine sample and by targeting genomic VPAC receptors. Indian J Urol 2021;37:345-9 p. 77
Soumya Shivasis Pattnaik
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Author Reply Re: Nerli RB, Ghagane SC, Rangrez S, Chandra S, Thakur ML, Gomella L. Detection of bladder cancer using voided urine sample and by targeting genomic VPAC receptors. Indian J Urol 2021;37:345-9 p. 78
Rajendra B Nerli, Shridhar C Ghagane, Shadab Sadiq Rangrez, Shreya Chandra, Madhukar L Thakur, Leonard Gomella
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IJU Awards 2021 p. 80

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