This review of the literature on the principles and prac­tice of clean intermittent self-catheterisation includes the role of antiseptics/antibiotics, and outcome. It covers ac­ceptance of the technique, urinary tract infection, conti­nence, and preservation of upper urinary tract.

Objectives: The prognostic significance and the fre­quency of occurrence of serum alkaline-phosphatase fare in patients with advanced prostate cancer commenced on hormonal treatment is controversial. Present study was carried out to clarify its prognostic value and the frequency of occurrence in relation to progression and survival in these patients. Methods: Case notes of 168 (101 metastatic and 67 lo­cally advanced) patients with advanced carcinoma of the prostate diagnosed between July 1984 through December 1995 were analysed retrospectively. All cases were fol­lowed until death or until March 1997 when the cases were censored. Serum alkaline-phosphatase values ob­tained immediately prior to and within 6 weeks of initia­ting the hormonal therapy were analysed in relation to progression free and overall survival. Results: Of the total of 168 evaluable cases, 101(60.1 %) had metastatic and 67 (39.9%) locally advanced tumours. Mean pre-treatment serum alkaline-phosphatase levels were higher (350IU/1) in the group which exhibited fare phenomenon post-treatment than the other which didn't (180 IU/1). Overall, flare activity in SAP levels was ob­served in 59 (35.1 %) of the total cases. Also, a greater proportion of the cases with metastatic disease had SAP flare than the other who had locally advanced disease (52.4% verses 8.9%). Flare in SAP levels were associated with decreased progression free and overall survival (p=0.001; p=0.002); greater the rise in SAP levels post­treatment, worse the prognosis. Conclusions: A significant proportion of patients with advanced carcinoma of the prostate have flare in SAP le­vels soon after initiating the treatment. We confirm that the flare activity in SAP levels is a negative prognostic indicator and it is possible to identify early treatment fail­ures by frequent measurements of SAP levels during first 6 weeks of commencing the therapy. The significance of SAP fare and androgen resistance is discussed.

Aim: A study to evaluate the safety and efficacy of laparoscopy using conventional laparoscopy equipment in children presenting with impalpable testis. Patients and Methods: Prospective study to include all boys referred with impalpable testis between 2 yrs-12 yrs. Examination under sedation (Chloral hydrate 50-75 mg/ kg oral) by a consultant pediatric surgeon. Period of study included all consecutive boys referred between October 97-October 98. A database was created to enter clinical details, imaging studies, laparoscopic findings, surgery and outcome. Results: 13 consecutive boys included in the study with 15 impalpable testes. 2 testes could not be located on laparoscopy. 6 testes were located on laparoscopy, 4 near the internal ring and 1 each at the bifurcation of iliac vessels and paravesical region. All 6 underwentfirst-stage Fowler Stephens orchidopexy followed by second-stage in 5 of them. The other 7 underwent conventional or­chidopexy for canalicular testes. Conclusions: Laparoscopy is a safe and effective method of evaluating and treating a child with impalpa­ble testis. Conventional adult equipment used in trained hands is safe for use in normal children older than 2 years.

Background: Urethrovaginal fistula is a dreadful com­plication of obstetric trauma due to prolonged labour or obstetric intervention commonly seen in developing coun­tries. Due to prolonged ischaemic changes, the fistula is resistant to healing. The strategic location of the fistula leads to postoperative impairment of continence mecha­nism. Anatomical repair was previously the commonest mode of surgical management, but was associated with a miserable cumulative cure rate ranging from 16-60%. Hence we tried to study the efficacy of Martius procedure in the management of urethrovaginal fistula. Material and Methods: We studied the outcome of 12 urethrovaginal fistulae, all caused by obstetric trauma, treated surgically with Martius procedure in 8 and with anatomical repair in 4, retrospectively. 9 patients had re­current fistulae while I patient had multiple fistulae. Pa­tients were followed up for the period ranging from 6 months to 4'/2 years for fistula healing, continence and postoperative complications like dvspareunia. Results: Cumulative cure rate ofMartius procedure was 87.5% with no postoperative stress incontinence, while fistula healing rate of anatomical repair was only 25% (I patient out of 4) which was also complicated by Intrin­sic Sphincter Deficiency (ISD). In case of recurrent fistu­lae the success rate of anatomical repair was 0% compared to 83.33% with Martius procedure. Conclusions: Martius procedure has shown much bet­ter overall cure rate compared to anatomical repair be­cause - a) it provides better reinforcement to urethral suture line, b) it provides better blood supply and lymph drainage to the ischaemic fistulous area, c) provides sur­face for epithelialization and, d) helps to maintain conti­nence. Hence we recommend Martius procedure as a surgical modality for the treatment of urethrovaginal fis­tula.

Only a very few reports are available in the world lite­rature and almost no report are available in our country regarding urolithiasis in children. The incidence of uro­lithiasis is much more common in the western part of Orissa compared to other parts. This study was conducted during the last 10 years, i.e., from January 1988 to Janu­ary 1998, to throw light on the different aspects of paedi­atric urolithiasis. The incidence was found to be high (8.41 %) with a male preponderance (male: female, 29: 1). Children below 10 years of age were the common victims. This disease was found to be more common in lower socio-economic status group, which is used to cheaper non-vegetarian diet. In the absence of facilities for ESWL and endoscopic stone removal, open surgery was the choice of the treatment.

The present study was carried out by evaluate the safety and effectiveness of the selective conservative manage­ment of antenatally detected unilateral pelviureteric junc­tion obstruction (ADPUJ) in children who were diagnosed to have unequivocal obstruction upon DTPA renograms performed at 6 weeks of age. The study comprised of 28 patients with ADPUJ. The selective conservative manage­ment was applied to the patients with unilateral ADPUJ who were asymptomatic, had split renal function (SRF) above 40% and had the anterior posterior diameter of the pelvis less than 20 mm at 6 weeks of life. 20 of the 28 patients fulfilled the above criteria and were followed up at 3-monthly intervals with nuclear renograms and ultra­sonography (US). Prophylactic antibiotics were not pres­cribed to these patients. The remaining 8 patients underwent pyeloplasty. None of the patients followed up without surgical intervention deteriorated enough to the SRF of 40% or below during the mean follow-up period of 30 months. Only I of these 20 patients had an episode of urinary tract infection. In conclusion, unilateral ADPUJ managed by selective conservative treatment is safe and these patients do not require any antibiotic chemo­prophylaxis.

Objective: Recurrence of urethral stricture after single internal urethrotomy is quite high, resulting in repeated urethrotomies. This results in a long waiting period for the patient to undergo urethrotomy under anaesthesia. Our aim was to perform urethrotomy under local anaesthesia so that hospital-stay-waiting-period is reduced to the mini­mum. Method: We analysed our patients between Jan '93 to Jan '98, who underwent repeated optical internal ure­throtomy (0.1. U.) under local anaesthesia. A total number of 220 patients of stricture urethra underwent internal ure­throtomy under local anaesthesia as a day care proce­dure using 2% Lignocaine jelly and intravenous Diazepam 10mg. Results: Our results revealed 35% (78 patients) had recurrence who underwent repeated urethrotomies (189) under local anaesthesia, number of urethrotomies depend­ing on the etiology and length of the stricture. None of these patients were admitted in the hospital. Conclusion: We conclude that 0.1. U. can safely be per­formed under local anaesthesia as a day-care procedure and the procedure is well tolerated by the patient without any hospitalisation and anaesthesia risk.

Multicystic kidney is one of the most frequently encoun­tered masses in the newborns, ranking either first or sec­ond in occurrence. Totally 15 cases were managed over the last 5 years. The most common age of presentation was within first month of life, the affliction occurring more on the left side. Commonest mode of presentation was ab­dominal mass. Ultrasonography was the diagnostic inves­tigation of choice. Five cases were diagnosed antenatally. Associated anomalies were found in 8 cases with anovesti­bular fistula, PUJO in contralateral kidney, right con­genital lumbar hernia and oesophageal atresia with TOE. Nephrectomy was the surgical treatment performed along with appropriate management of the associated anoma­lies.

Posterior Urethral Valves (PUV) are one of the com­monest urolgical problems seen in children and the electro­coagulation, which is the most widely preferred modality to ablate the valves, may not be feasible in small-for-date and low-birth-weight neonates as the suitable size resec­toscope/cystoscope may not available. With the availa­bility of Nd: YAG laser at our institute recently, we started performing the laser fulguration instead of electrocoagu­lation of the valves. We reviewed our experience with the emerging role of the Nd: YAG laser in the fulguration of PUV, comparing the results with a historical control group who underwent the classical electrocoagulation of the PUV. The boys (n=50) diagnosed to have PUV by VCUG were confirmed by Wolf 8.5 size cystoscope, underwent Nd: YAG laser fulguration of the valves with a bare fiber, as a day-care procedure without postoperative catheteri­zation. Historical controls (n=50) who had undergone classical electrocoagulation using 9.5 size Wolf resectos­cope served as the controls. The mean age was 1.3 y and 2.6 y in laser and electrocoagulation group respectively. The mean hospital stay of the electrocoagulation group was 3.8 d. Three patients after electrocoagulation devel­oped hematuria and 4 required refulguration whereas in the laser group 5 required refulguration and none devel­oped hematuria. In conclusion, endoscopic laser fulgura­tion of PUV is technically feasible even in neonates and small children. Laser offers excellent results that are com­parable to the time-honored electrocoagulation procedure. This has the additional advantage forfulgurating the PUV in smaller caliber urethra as this can be performed with the smaller available cystoscope that has a side channel, admitting the laser fiber.

Sedoanalgesia is a combination of sedation and local anesthesia. It provides safe operating conditions for a wide variety of patients. We studied this technique in 68 pa­tients undergoing various endourological procedures. We present our findings along with the advantages of this pro­cedure.

Objective: Use of extracorporeal shock waves in the treatment of tendinopathy and other orthopedic diseases. Patients and methods: 35 patients received shock wave therapy using Econolith 2000 lithotripter 19 patients had isolated lateral epicondylitis, 12 medical epicondylitis and 4 plantar fascitis. A total of 120 shock waves were given in the first sitting. Each patient received a total of three sittings with a gap of one week between each of them. Results: Based on the patients' self-assessment, about 75% pain relief was observed in 60% of the patients. Fur­ther, in patients having isolated tendinopathies, the pain relief was better. Conclusion: The study indicated that the application of shock waves is not restricted to the fragmentation of urinary calculi. The shock waves can be effectively used for the pain relief in the common orthopedic diseases. Thus, the urologists can widen the application of lithotripters, in a cost-effective manner, to the other medical speciali­ties.

Cowper's syringocele is an uncommon condition occur­ing in children. Only occassionally it has been reported in adults. Palpable syringocele is a rarity. We report an adult who presented with palpable Cowper's syringocele.

We report 2 cases of basal cell hyperplasia of prostate, which is an uncommon and elusive lesion. It is commonly associated with benign prostatic hyperplasia (BPH) and may sometimes be mistaken for malignancy. The know­ledge about this disease helps in the correct diagnosis and avoidance of unnecessary or overtreatment.

In uraemic patients with low body proteins, healing of the suture line is always a problem with risk of early fail­ure of the arteriovenous fistula (AVF). To tackle this prob­lem, in brachio-cephalic AVF, a fascial flap was interposed between the newly constructed fistula and the cutaneous suture line, at the time of primary surgery. Such a fascial flap will provide a thick covering over the AVF in the event of non-healing of the suture line and thus, avoid any complication resulting from secondary infection due to exposure of the fistula. In addition, the thick viable tissue overlying the fistula will be a good base for taking a split skin graft.

Traditional clinical decision making (Opinion-Based Medicine or The Old Paradigm) is based on individual clinical experience. Wide variability and inconsistencies of traditional clinical decision making have been docu­mented. The movement of Evidence-Based Medicine (The New Paradigm) was started in early 1990s to integrate research evidence into clinical decision-making process with the ultimate aim of providing optimum management to patients. This article briefly discusses the shortcom­ings of Opinion-Based Medicine and describes the prin­ciples, methodology, requisite skills and resources, advantages and limitations of Evidence-Based Medicine.