Upon a review of recently published articles on high-intensity focused ultrasound (HIFU) in the treatment of prostate cancer, we evaluated the current status of HIFU as a primary treatment option for localized prostate cancer and its use as salvage therapy when radiation failed. We also briefly discuss current issues in indications, definition of response, and finally the future of HIFU development.

Circumcision is possibly the most frequently performed elective surgical procedure in men. It can simply be described as the excision of the preputium. There have been several studies about the association between circumcision and urinary tract infections (UTI). Many studies have demonstrated that the frequency of UTI increase in uncircumcised males, especially in the first year of life. This review discusses the embryology of the preputium, epidemiology, indications, complications and benefits of circumcision, as well as operation and anesthesiology techniques. It especially examines the association between UTI and circumcision and the importance of circumcision in congenital urinary system anomalies. In addition, this review examines the associations between circumcision and sexually transmitted diseases, including HIV, and the protective role of circumcision on penile cancer.

Introduction and Objective : Placement of a percutaneous nephrostomy tube for drainage has been an integral part of the standard percutaneous nephrolithotomy (PCNL) procedure. However, in recent years, the procedure has been modified to what has been called 'tubeless' PCNL, in which nephrostomy tube is replaced with internal drainage provided by a double-J stent or a ureteral catheter. The objective of this article is to review the evidence-based literature on 'nephrostomy-free' or 'tubeless' PCNL to compare the safety, effectiveness, feasibility, and advantages of tubeless PCNL over standard PCNL. Materials and Methods : We performed a MEDLINE database search to retrieve all published articles relating to 'tubeless' PCNL. Cross-references from retrieved articles as well as articles from urology journals not indexed in MEDLINE, were also retrieved. Results : The majority of the studies have shown 'tubeless' PCNL to be a safe and economical procedure, with reduced postoperative pain and morbidity and shorter hospital stay. Tubeless PCNL has been found to be safe and effective even in patients with multiple stones, complex staghorn stones, concurrent ureteropelvic junction obstruction, and various degrees of hydronephrosis. The technique has been successful in obese patients, children, and in patients with recurrent stones after open surgery. Conclusion : Tubeless PCNL can be used with a favorable outcome in selected patients (stone burden <3 cm, single tract access, no significant residual stones, no significant perforation, minimal bleeding, and no requirement for a secondary procedure), with the potential advantages of decreased postoperative pain, analgesia requirement, and hospital stay. However, for extended indications, like supine PCNL, multiple, complex and staghorn stones, and concurrent PUJ obstruction, the evidence is insufficient and should come from prospective randomized trials.

Cannabinoids, the active components of Cannabis sativa (marijuana), and their derivatives produce a wide spectrum of central and peripheral effects, some of which may have clinical applications. The discovery of specific cannabinoid receptors and a family of endogenous ligands of those receptors has attracted much attention to the general cannabinoid pharmacology. In recent years, studies on the functional role of cannabinoid receptors in bladder have been motivated by the therapeutic effects of cannabinoids on voiding dysfunction in multiple sclerosis patients. In this review, we shall summarize the literature on the expression of cannabinoid receptors in urinary bladder and the peripheral influence of locally and systemically administered cannabinoids in the bladder. The ongoing search for cannabinoid-based therapeutic strategies devoid of psychotropic effects can be complemented with local delivery into bladder by the intravesical route. A greater understanding of the role of the peripheral CB ₁ and CB ₂ receptor system in lower urinary tract is necessary to allow the development of new treatment for pelvic disorders.

Objectives : To determine the safety, efficacy and long-term outcome of laparoscopic pyeloplasty in pediatric patients. Materials and Methods : A prospective analysis of data of pediatric patients under the age of 15 years, who had undergone laparoscopic pyeloplasty from January 2000 to June 2008 was done. The various parameters analyzed were; operative time, blood loss, need for analgesics, intra/postoperative complications, hospital stay and postoperative outcome. Success was defined on the basis of either improvement in the symptoms/or better drainage on postoperative isotope renography. Results : A total of 82 patients with a mean age of 7.12 years (four months to 15 years) and male to female ratio of 4.3:1 were included in the study. Dismembered pyeloplasty was done in 70 patients and Foley Y-V plasty in 12 patients via transperitoneal approach using three ports in 79 or four ports in three children. Mean operative time was 151 minutes (78-369); mean blood loss was 88.01 ml (50-250) with a mean hospital stay of 5.05 days (2-11). Conversion to open surgery was required in four (4.87%) patients. Follow-up renograms were available in 74 patients who showed improvement in drainage in 69 patients and obstructed pattern in five; of these two patients had significant deterioration in split function. Two patients among the obstructed group underwent redo pyeloplasty by open technique while the rest three elected for conservative approach. At a mean follow-up of 41.58 months (8-75) the overall success rate was 91.89%. Conclusion : Laparoscopic pyeloplasty is effective and safe in children with minimal morbidity and gives excellent long-term results.

Aims : This study was designed to evaluate the prognostic significance of focal chromogranin A (cgA) expression in prostate cancer in a series of cases with autopsy-verified cause of death. Methods and Results : Seventy seven autopsy-verified cases of prostate cancer were identified, 41 cases with metastatic disease and 36 with nonmetastatic disease at autopsy. Immunohistochemical analysis for cgA was performed in 40 cases on the archived diagnostic biopsies taken during the patients' lifetime. After exclusion of a single case of carcinoid tumor, 14 of the 18 (78%) metastatic and none of the 21 (0%) nonmetastatic tumors showed focal neuroendocrine differentiation (NED). The Gleason score and focal cgA expression further increased the accuracy of the prediction of the outcome, as all the cases with focal NED associated with high Gleason score had metastatic disease in contrast to cases without cgA-expression and low Gleason score, all of which were non-metastatic. Conclusions : Focal NED seems to be a powerful negative prognostic parameter in prostate adenocarcinomas. The outcome of the disease in prostate cancer can be accurately predicted based on focal NED of the tumor cells either alone or in combination with Gleason score.

Objective : To assess the feasibility of retrograde ureteroscopic intrarenal surgery (RIRS) as a viable alternate to percutaneous nephrostolithotripsy (PCNL) in treating patients with renal and upper ureteric calculus of 1.6 cm to 3.5 cm stone burden. Materials and Methods : From October 2007 to November 2008, a total of 30 cases of upper ureteric and renal stone of 1.6 cm to 3.5 cm (Average size 2.5 cm) stone burden, for which PCNL would be done otherwise, were treated by RIRS with combined flexible and semi rigid ureteroscope and stones fragmented with holmium laser. The patients were discharged after 24 hours of the procedure and allowed to resume normal work after two days. X ray KUB for radio opaque stones and ultrasound for all the cases were done after three weeks and if any residual fragments of any size were present the patient was taken up for re-look flexible ureteroscopy under anesthesia. Stent and residual fragments were removed. If there was no residue the stent was removed under local anesthesia. Results : Complete clearance was considered if there were no fragments on USG screening after three weeks. Twenty six (86.6%) patients out of 30 had complete clearance in the first sitting and 4 (13.3%) patients needed re-look flexible ureteroscopy. The stone free rate in RIRS is 86.6% in the first sitting and 100% at second sitting. Conclusion : RIRS is superior in terms of less complication, less morbidity and good stone free rate and has an advantage of one day of hospital stay and resuming duties after two days. RIRS is the best option for managing extracorporeal shockwave lithotripsy failed and post PCNL residual calculus. RIRS is definitely a viable alternate for PCNL for upper tract stones up to 3.5 cm.

Introduction : Double J stent has been an important adjunct to laparoscopic pyeloplasty. It is also associated with symptoms and significant morbidity. This study analyses the outcome of transperitoneal laparoscopic pyeloplasty without a double J stent. Materials and Methods : Sixteen patients of ureteropelvic junction obstruction (age range: 1.5-50 yrs) were selected to undergo transperitoneal stentless laparoscopic pyeloplasty after obtaining the informed consent from August 2004 to December 2008. Ten patients were under the age of 14 years (pediatric age group). Some additional steps in the standard technique of laparoscopic pyeloplasty included anatomical spatulation of the ureter to avoid rotation, temporary splinting while suturing ureteropelvic junction and ensuring water tightness of suture line. Preoperative differential renal function, operative time, post operative complications (pain, drain output, fever), hospital stay and renal functional outcomes (Tc ⁹⁹ DTPA) were recorded. Results : The median age of the pediatric age group was eight (1.5-14) years and adult group - 27 (20-50) years. Median operative time was 100 min (72-140) in pediatric and 110 min (90-138) in adult group. The preoperative ipsilateral differential renal function ranged from 16-45% and 16-50% in pediatric and adult groups respectively. Five of the 10 pediatric patients had persistent leak of urine for which stenting was done in four and ureteric re-implantation in one. Only one of the six adult patients (who had secondary UPJO following Endopyelotomy) needed postoperative stenting for persistent urinary leak. Conclusions : Though the need for postoperative stenting is high in smaller children, stentless laparoscopic pyeloplasty can be considered in adult patients with primary ureteropelvic junction obstruction.

Objectives : To assess the accuracy of Gleason grading/scoring on preoperative needle core biopsy (NCB) compared to the radical prostatectomy (RP) specimen. Materials and Methods : Data of NCB and RP specimens was analyzed in 193 cases. Gleason grade/scoring was done on both NCB and RP specimens. Sixteen cases were excluded for various reasons. The Gleason scores of the two sets of matched specimens were compared and also correlated with the PSA, age, and number of needle biopsy cores. The overall change was also correlated with the initial score on NCB. Results : The mean age and PSA were 63.3 ± 2(5.27) years and 18.48 ± 2(28.42) ng/ml, respectively. The average Gleason score increased from 5.51 ± 2(1.52) to 6.2 ± 2(1.42) (P < 0.02). The primary grade increased in 57 (32.2%) cases. Overall, 97 (54.8%) cases had an increase in Gleason score. Five other cases had a change from 3 + 4 = 7 to 4 + 3 = 7. Change in Gleason score was significantly more if the score on NCB was ≤6 or number of needle cores was ≤6. Besides, 28 cases had perineural invasion, 16 had capsular invasion (pT3 _a ), and 4 had vascular invasion on RP specimen. Conclusions : There is a significant upgrading of Gleason score on RP specimens when compared with NCB. This trend may be correlated positively with lower initial Gleason score on preoperative biopsy and the lower number of cores taken.

Objectives : Hydronephrosis is commonly detected during antenatal scans. There are multiple conflicting prognostic factors in the literature with no clear focus on the postnatal outcome. The aim of the study is to assess the outcome of fetal hydronephrosis, based on antenatal sonography. Materials and Methods : Based on the third trimester fetal ultrasound findings, patients were divided into group I (unilateral hydronephrosis) and group II (bilateral hydronephrosis, ureteric dilatation, bladder thickening, etc). Postnatal evaluation and follow-up was performed by a single physician with uniform protocol. The outcomes, spontaneous resolution vs. surgical intervention, were compared between groups. Among group I, further analysis of outcome was done based on 32-week fetal pelvic antero posterior diameter (APD). Results : Among a total of 116 patients in the study group; group I had 78 patients, 7 (9%) required surgery; group II had 38 patients, 21(55%) required surgery. The difference in outcome between the groups was statistically significant (P = 0.002). Among those with unilateral hydronephrosis, none (0/55) with APD <15 mm required surgery, while all patients (4/4) with fetal APD >30 mm required surgery. In those with APD between 15-30 mm, 3/19 required surgery and prolonged follow-up was required to arrive at the decision. The difference in outcome between the subgroups was statistically significant (P < 0.001, Chi-square test). Conclusions : The results of our study show that simple unilateral fetal hydronephrosis runs a benign course. In the presence hydronephrosis larger than 15 mm, bilateral disease, or bladder distension, detailed postnatal evaluation and regular follow-up is warranted to plan a timely intervention. The above data could be used in prenatal counselling of these parents. Further larger studies are warranted to through more evidence.

Objectives : Intratubular germ cell neoplasia (ITGCN) is the precursor lesion for invasive testicular germ cell tumors (TGCTs) of adolescents and young adults. The rising incidence of these tumors has prompted a rigorous investigation of the etiology, diagnosis and management of ITGCN. Bilateral testicular cancer is closely linked with ITGCN, as patients with unilateral testicular cancer are at the highest risk for a future malignancy in the contralateral testicle. Methods : A literature review directed at ITGCN and bilateral testis cancer was performed using the Medline/PubMed database. Our review focused on the pathogenesis, risk factors, diagnosis and treatment regimens utilized. Results : Major advances have been made in the understanding of ITGCN over the past 30 years. There is evidence that TGCTs arise from ITGCN, ITGCN is closely related to fetal gonocytes, and that events in pre- and perinatal period may result in abnormal persistence of fetal gonocytes leading to ITGCN and subsequent TGCT. Controversy exists regarding the need to biopsy men at increased risk of TGCT, as well as the best approach to managing patients with known ITGCN. Bilateral testicular cancer has excellent outcomes in the current era of platinum-based chemotherapy. Conclusion : The optimal management of patients at risk for ITGCN and future TGCT is still a matter of debate. Individualization of management, including biopsy and treatment, should be based on risk factors for TGCT, compliance with potential surveillance, and patient preferences particularly with regard to fertility.

Management of clinical stage I non seminomatous germ cell tumor includes surveillance, primary chemotherapy and retroperitoneal lymph node dissection. Stratifying clinical stage I disease to high- and low-risk groups for harboring micrometastic retroperitoneal disease (pathologic stage B) is based on pathologic characteristics of the primary tumor. The presence of embryonal dominant histology and lymphovascular invasion (high-risk group) predicts for a 50% incidence of retroperitoneal disease. Low-risk group, the absence of either factor, predicts a 20% chance of retroperitoneal disease. Irrespective of risk classification, all treatment modalities have equal survival rates of 99% to 100%, and differ only in their unique short and long-term modalities. The mode of treatment in clinical stage I disease should remain patient driven and is guided by the perceived morbidities of each therapy.

Testicular neoplasm accounts for about 1% of all cancers in men. Over the last 40 years, the incidence of testicular cancer has increased in northern European male populations for unknown reasons. When diagnosed at early stage, testicular cancer is usually curable with a high survival rate. In the past three decades, successful multidisciplinary approaches for the management of testicular cancer have significantly increased patient survival rates. Utilization of tumor markers and accurate prognostic classification has also contributed to successful therapy. In this article, we highlight the most commonly used tumor markers and several potential "novel" markers for testicular cancer as part of the ongoing effort in biomarker research and discovery. In addition, this article also identifies several key prognostic features that have been demonstrated to play a role in predicting relapse. These features include tumor size, rete testis invasion, lymphovascular invasion, and tumor histology. Together with tumor markers, these prognostic factors should be taken into account for risk-adapted management of testicular cancer.

Testicular germ cell tumors and, in particular, seminomas are exquisitely radiation and chemotherapy-sensitive and most presentations are highly curable. In recent years the management focus has been on reducing late sequelae of treatment. For Stage I disease surveillance and adjuvant carboplatin, chemotherapy has become an option. The efficacy of combination chemotherapy has been established for advanced metastatic disease. Through a review of the available literature this article outlines the recent changes in the management of seminoma.

Introduction/Methods : Approximately 30% of nonseminomatous germ-cell tumors (NSGCT) of the testis present with metastatic disease. In 1997, the International Germ Cell Cancer Collaborative Group (IGCCCG) stratified all patients with metastatic NSGCT into various risk groups based on serum tumor markers and presence of visceral disease. We review the literature and present optimal stage-dependent management strategies in patients with favorable-risk metastatic NSGCT. Results : Primary chemotherapy (3 cycles BEP or 4 cycles EP) has been shown to be the preferred modality in patients with Clinical Stage IS (cIS) and in patients with bulky metastatic disease (≥CS IIb) due to their high risk of systemic disease and recurrence. Primary retroperitoneal lymph node dissection appears to be the most efficient primary therapy for retroperitoneal disease <2 cm (CS IIa), with adjuvant chemotherapy reserved for patients who are pathologically advanced (> 5 nodes involved, single node > 2 cm) and for those who are non-compliant with surveillance regimens. Following primary chemotherapy, STM and radiographic evaluation are used to assess treatment response. For patients with normalization of STM and retroperitoneal masses < 1 cm, retroperitoneal lymph node dissection or observation with treatment at disease progression are considered options. Due to risk of teratoma or chemoresistant GCT, masses > 1 cm and extra-retroperitoneal masses should be treated with surgical resection, which should be performed with nerve-sparing, if possible. Conclusions : In patients with favorable disease based on IGCCCG criteria, clinical stage, STM, and radiographic evaluation are used to guide appropriate therapy to provide excellent long-term cure rates (>92%) in patients with metastatic NSGCT.

The basis of treatment for advanced germ cell tumors is chemotherapy and surgical resection of residual disease. Surgery has maintained its role in staging and therapeutic management. Despite these advances, much of the outcomes depend on proper patient selection. Complete removal of all post-chemotherapy residual masses remains the standard of care in the treatment of advanced nonseminomatous germ cell tumors both within and outside of the retroperitoneum.

Recognition of the therapeutic role of retroperitoneal lymph node dissection (RPLND) in the setting of testicular germ cell tumors (GCTs) is of utmost importance. Although the histologic findings of RPLND provide diagnostic and prognostic information, the adequacy of initial RPLND is an independent predictor of clinical outcome. Despite the advent of effective cisplatin-based chemotherapy for testicular GCTs, patients who have undergone suboptimal surgery at the time of initial RPLND are compromised. Despite the initial enthusiasm surrounding anatomic mapping studies, the use of modified RPLND templates has the potential to leave a significant number of patients with unresected retroperitoneal disease. Teratomatous elements are particularly common. Patients with retroperitoneal relapse following initial RPLND should be treated with reoperative RPLND and chemotherapy and can expect long term survival rates nearing 70% when treated in tertiary centers by experienced surgeons.

Currently, the outcome of patients with intermediate- and poor-risk germ cell tumors at diagnosis is optimized by the use of risk-appropriate chemotherapy and post-chemotherapy surgical resection of residual masses. Currently, there is no role for high-dose chemotherapy in the first-line setting. Patients who progress on first-line chemotherapy or who relapse after an initial complete response also have a poor prognosis. In the setting of early relapse, the standard approach at most centers is conventional-dose, ifosfamide-based regimens and post-chemotherapy resection of residual masses. The treatment of patients with late relapse is complete surgical resection whenever feasible. Salvage chemotherapy for late relapse may be used prior to surgery in patients where a complete resection is not feasible. A complete surgical resection of all residual sites of disease after chemotherapy is critical for the prevention of relapse and the long-term survival of patients with advanced germ cell tumors.

A 55-year-old man with Glanzmann's thrombasthenia had recurrent episodes of gross painless hematuria for the past 30 years. His last episode of hematuria occurred a month ago, associated with pain in the right loin and was diagnosed to have a right mid-ureteric calculus. Under adequate platelet cover, he underwent right ureteroscopy. Postoperatively, he had persistent significant hematuria that did not improve despite repeated platelet transfusions. Factor VIIa was also transfused, without much benefit. A ureteroscopy was done, which identified bleeding from within the renal pelvis. CT angiogram confirmed the rupture of an artery supplying the interpole segment of the right kidney. Bleeding settled after angioembolization. Indiscriminate use of platelet transfusions would result in a state of platelet refractoriness. It is also important to suspect an iatrogenic cause for any complication that occurs after a surgical procedure, even if there could be an underlying medical etiology that can be attributed to the development of such complication.

With more experience and better management, the incidence of complications like stone formation after continent urinary diversion is uncommon today. We report a case of large stone bulk in a patient who underwent this surgery 10 years back and who suggested the formation of stones in the pouch herself by sounding them. Proper counseling, regular pouch irrigation and follow-up are essential in any kind of diversion.

A 38-year-old female presented with long stricture in the left upper ureter following a pyeloplasty causing persistent flank pain. A left PCNL with an antegrade endopyelotomy was attempted in view of a concomitant left renal 1.5 cm calculus in the lower calyx but it failed. Subsequently, a buccal mucosal onlay graft was applied on the strictured ureter. Follow-up at 3 months showed good uptake of the graft with patent passage for urine drainage.

We report a rare case of pheochromocytoma of the adrenal gland presenting as Cushing syndrome. A 30 year old woman presented with pain in the left loin and classical Cushingoid features. She was a diabetic and hypertensive on treatment. Magnetic resonance imaging of the abdomen revealed a 3.5 x 3 cm mass in the left adrenal gland. Urine analysis revealed an elevated 24 hr urinary cortisol level. Clinical diagnosis was Cushing syndrome due to functioning left adrenal tumor, and hence left adrenalectomy was performed laparoscopically. Histopathological examination revealed adrenal pheochromocytoma. Immunohistochemical analysis of the tumor was positive for adrenocorticotrophic hormone and chromogranin.

A 5-year-old female presented with continuous dribbling of urine without any voiding stream since birth. Upon investigations, the bladder neck and both ureters were opening into the vaginalized urogenital sinus and the urethra was absent. Coarctation of the aorta was an associated anomaly. To our knowledge, this is the first report in literature of bilateral single-system ectopic ureters opening into vaginalized urogenital sinus. The report highlights the necessity for consideration of continent diversion in such cases because of the absence of the urethra in addition to an incontinent bladder neck and tiny dysfunctional bladder.

Abdominoscrotal hydrocele (ASH) is an uncommon entity. Although various theories on the development of ASH have been proposed, its etiology is still unclear. According to several etiological theories, it is necessary that ASH have communication with the peritoneum. We present a case of bilateral ASH that had no communication with the peritoneum.

Isolated herniation of ureter into thoracic cavity due to a defect in the diaphragm is a very rare entity. We present clinical details and radiographic images of an incidentally detected herniation of right ureter into the thorax in an elderly lady with no previous history of trauma or urinary tract symptoms. This acquired but asymptomatic condition is confirmed by radiologic imaging that reveals the classical loop configuration which is described as the curlicue sign. Further evaluation had revealed mild renal failure but with no definite evidence of obstruction. In view of age and asymptomatic status, patient was offered non-surgical management.

Prostate cancer has now become one of the leading types of cancer in urban India. It is now the third most common cancer in Delhi. As we advance in health care with the resultant increase in longevity, we will be seeing more of advanced carcinoma prostate. Since the early 1980.s, there have been many trials on MAB. However, the question remains whether these agents actually make a difference? The role of MAB is probably limited to the prevention of the ß are reaction in patients on LHRH agonists. The non steroidal antiandrogens have a marginal benefit of increased overall survival by approximately 3% to 5% at 5 ve years. There may be a role for MAB in patients with metastatic carcinoma of prostate, low volume metastases, patients with M 1 disease with absence of metastases in the skull, ribs, long bones, and soft tissues excluding lymph nodes.

Live kidney donation is an excellent way of increasing the donor pool. The introduction of the laparoscopic donor nephrectomy has resulted in an increase in live organ donation in the western hemisphere. There is no data on its impact on organ donation in India. However attractive as it may seem, the procedure is associated with a definite learning curve and does compromise donor safety. The procedure is also expensive in terms of the equipment required. The mini-donor nephrectomy is an excellent alternative, has no learning curve and is ideally suited for donors in India who have a low BMI. The procedure is also relatively inexpensive. We are in need of a donor registry rather than reports from single institutions to fully evaluate the risks and benefits of both procedures.

End-stage renal disease is a significant health problem. The primary use of the autogenous arteriovenous access is recommended by NKF-DOQI (National Kidney Foundation-Dialysis Outcomes Quality Initiative) guidelines. Though basilic vein transposition is well established in multiple failed fistulae's and obese patients, it requires large incision and morbidities like edema and infection. To avoid such compilations we, at our institution, adopted a small incision technique using two small 3-4 cm incisions. This method is inspired by videoendoscopic minimally invasive method used to dissect the basilic vein, thus avoiding extensive dissection and related morbidities.