Trans Urethral Resection of Prostate (TURP) syndrome is one of the commonest and dreaded complications of urological endoscopic surgery. Even in the best of hands, the incidence of TURP syndrome is up to 20% and car­ries a significant mortality rate. This paper highlights the various pathophysiological mechanisms of TURP syndrome, steps to prevent/delay the onset of manifesta­tions and the treatment of established TURP syndrome.

Bacteriological study of pre-operative urine and stone along with chemical analysis of stones have been perforned in 100 cases of urolithiasis. Although the rate of infection accompanying stone formation is more in female (50%) in comparison to male (27.9%) but over­all incidence of stone formation is more in male (86%). The crushed stone core culture was positive in 31 cases (31 %) and out of these cases, 23 cases (74.19%) showed positive urine culture. 15 cases (48.38%) of stone positive culture showed same organism which were also isolated from pre-operative urine culture whereas 8 (25.80%) cases of culture positive stones showed dif­ferent micro-organisms than pre-operative urine cul­ture. Chemical analysis revealed increased incidence of mixed stone composed of calcium oxalate and cal­cium phosphate (51 %). The occurence of pure triple phosphate stone was only 13%. The commonest pathogen recovered from pre-operative urine culture and stone culture was E.coli (32.25% and 21.73%)followed by Pseudomonas (22.58% and 17.39%) from mixed stones composed of calcium oxalate with cal­cium phosphate and triple phosphate. Out of 31 infection stones, 13 stones which were composed mainly of triple phosphate showed highest incidence of infection (84.62%).

Objectives: ESWL is an effective noninvasive method to treat urolithiasis. Only in rare occasions, complica­tions requiring treatment have been described. Methods: We report three acute major complications during and after ESWL using a Siemens Lithostar plus model (Retroperitoneal haematoma - Rupture of spleen - Car­diac arrest) and compare our experience with the literature. Conclusion: The rate of clinically relevant compli­cations is very love. To recognize severe complications laboratory examination and a sonographic control should be performed after each ESWL.

There is a paucity of cost-effectiveness studies in India comparing PCNL and ESWL in the treatment of renal cal­culi. We are dependent on costing studies from western literature, although the nature of expenses in developed countries is quite different from those in India. This study compares the two procedures with regards to cost-effec­tiveness & efficacy in clearing medium-sized renal calculi ( < 2.0 cms) at our institute. All costs borne by the patient & the institute were taken into account, including equip­ment costs, stay charges & cost of travel incurred, for re­peat visits to the institute. The groups compared had similar stone characteristics & were from our early experience with the two methods. All costing was done at 1998 rates by submitting case sheets to a fresh billing. PCNL, was significantly more efficient at clearing calculi (94% vs 69%) than ESWL, but patients needed hospitalization. The re­quirement of ancillary procedures was significantly less with PCNL than ESWL (1 vs 35) and ESWL was more expensive although the difference was not statistically sig­nificant. High initial cost of a lithotripter along with the need for repeated visits to the hospital for clearance of the calculus contribute to the increased cost of ESWL. PCNL ensures clearance of calculi at a single hospital admission with minimal morbidity.

We have studied the efficacy of adjuvant therapy in the form of low dose B.C.G. and interferon alpha 2b. In the present study 7patients with superficial bladder car­cinoma (6 recurrent and I primary) have been treated by TURBT and intravesical instillation of B. C. G. 80 mg plus interferon alpha 2b 10 million units weekly for 8 weeks. All patients accepted the therapy without sig­nificant morbidity and complication. Follow-up,period ranges between 11-16 months and none of the patients have developed recurrence till date. Interferon alpha 2b along with B.C.G. is a good al­ternative agent, for prophylaxis in case of high grade and recurrent bladder tumour

The incidence of Transitional Cell Carcinoma (TCC) of urinary bladder is increasing worldwide. Patients with superficial TCC of urinary bladder can have a survival period of 10 years if they are detected at an early stage and appropriate intravesical adjuvant immunotherapy is instilled in time. A total number of 440 patients of superficial TCC were instilled intravesically BCG & Interferon a-2b as single drug or in combination and followed up. BCG though was most efficient, had high toxic rate while Interferon α-2b was expensive, whereas a low dose combination therapy of both showed excellent result in reducing tumor recurrences & prolonging disease pro­gression free interval. The author reviews his experience of 10 years in man­agement of these malignancies with intravesical immu­notherapy and concludes that a low dose BCG (60mg) with Interferon α-2b (5 million IU) has shown to be very effective in reducing tumor recurrences, prolonging dis­ease-progression-free interval with a very low toxicity in such patients. To achieve this a periodic maintenance dose therapy is absolutely necessary.

Medical management is rapidly becoming a very im­portant part of the armamentarium of the urologist in­volved in the treatment of benign prostatic hyperplasia. The commonest options for medical management include alpha-blockers, 5-alpha reductase inhibitors, and pro­gestational anti-androgens. We present a double-blind randomized controlled trial evaluating the safety and efficacy of terazosin, finasteride and allylestrenol, the prototype drugs in each of these respective categories. A total of 140 patients who satisfied the inclusion and exclusion criteria were inducted into the trial after an informed consent. They were randomized into 4 groups, which received placebo, terazosin, finasteride and allylestrenol respectively for 6 months. Since 29 patients did not complete 6 months of therapy, there were 111 evaluable patients at the end of the study. We found that these 3 drugs produce comparable improvement in symp­tom score (-40%), flow rates (-60%) and PVR (-50%) which is significantly better than that in the placebo group. Both allylestrenol and finasteride bring about a comparable reduction in prostate volume (-23%), which is statistically significant as compared to the placebo and terazosin groups. Terazosin in doses of I and 2 mg/ day was, found to be effiective and well-tolerated in the vast majority of our cases. No adverse effects were seen in the placebo and finasteride groups, while 9.6% in the terazosin group had postural hypotension and 10.7% in the allylestrenol group had some loss of libido, prob­lems which were reversible upon cessation of therapy.

Posterior urethral valves present with a wide spectrum of renal and bladder pathology. These changes may per­sist despite successful treatment of the primary obstruc­tion, leading to a gradual progress towards renal insf ciency. This study reviews retrospectively a series of 70 children with posterior urethral valves who pre­sented at our institute over the last 10 years, with an aim to identify the prognostic factors and help in defining the end result and implicating the correct treatment proto­col. These included age at presentation and intervention (less than or more than 2 years), recurrent urosepsis, pres­ence of vesico-ureteric reflux, renal parenchymal dam­age as seen on ultrasound, vesical dysfunction and the nadir serum creatinine level. 29% of children had renal insufficiency at the end of 3-years' follow-up. Factors important in the progression towards renal insufficiency were evaluated. Factors found to be statistically signifi­cant with a p value <0.05 were age at intervention more than 2 years, recurrent urosepsis, bilateral high grade vesico-ureteric reflex, bilateral parenchymal damage as seen on ultrasonography and nadir serum creatinine of more than 0.8 mg%.

Purpose: Single stage reconstruction of long, com­plex urethral strictures is technically demanding and may require the use of more than one tissue transfer technique. We describe our experience in the manage­ment of such strictures with a variety of urethroplasty techniques. Materials and Methods: Between 1989 and 1999, 25 men (mean age 38.5 years) underwent single stage re­construction of panurethral, multiple segment or focally dense strictures [mean length 11.2 cm (range 8-17 cm)]. 8 patients had combined substitution urethroplasty with a circumpenile fasciocutaneous flap and a free graft of bladder/buccal mucosa or tunica vaginalis _. flap. In 10 patients a single tissue transfer technique was used. 3 patients underwent an augmented roof/floor strip ure­throplasty with a penile skin flap. 4 patients with multi­ple segment strictures (separate pendulous and bulbar) underwent distal onlay flap and proximal anastomotic urethroplasty. Results: The median ,follow-up was 46.5 months (range 6-88 months). The mean postoperative flow rate improved to 22.5 ml/sec. 2 patients developed fistulae requiring repair. Recurrent stricture developed in 5 (20.8%) patients, of which 2 were managed with visual internal urethrotomy, 2 with anastomotic urethroplasty and 1 with a two-stage procedure. Pseudodiverticulum and post-void dribbling were seen in 6 (25%) patients. Conclusions: Successful outcome of single stage re­construction of long complex strictures can be achieved with a combination of various tissue transfer methods. The urologist who has a thorough knowledge of penile skin and urethral vascular anatomy and a wide array of substitution techniques in his armamentarium can un­dertake approach to such strictures.

Objective: To compare the hypo-osmotic swelling test (HOST) of spermatozoa with the standard spermiogram in both fertile and infertile male subjects. Materials and Methods: The HOST was performed on 50 men of proven fertility and 51 infertile men. The results from both the groups were compared with the standard spermiogram. Study Design: Prospective case-control study. Analysis: The statistical analysis was done using the Karl Pearsons coefficient of correlation. Results: The HOST values were higher in the fertile group. The correlation between hypo-osmotic swelling and semen variables was higher in the infertile group than in the fertile group. 2 patients in the infertile group with greater than 50% hypo-osmotic swelling got their spouses pregnant during the study period. Conclusion: The HOST is inexpensive, easy to per­forrn and can be used to evaluate sperm tail function. It can also be used to predict the fertilizing potential of the semen sample.

A ganglioneuroma of adrenal gland in a 34-year-old female presenting as adrenal incidentaloma is described. The significance of this finding is discussed, and litera­ture in English is reviewed to highlight the importance of hormonal evaluation of an incidentaloma.

It is not very uncommon to find accessory renal artery (or arteries) or double ureter and a number of such cases have been reported. The various types of accessory renal arteries, their positions, method of entry to the kidney and its segmentation were studied extensively by David Sykes. ^[1] However, multiple variations in a single subject was not reported so far, with best of our knowledge. During routine dissection it was observed in one of the male cadavers that the kidney presented a number of vari­ations bilaterally. It was found that the right kidney had four (accessory) renal arteries and three renal veins. The hilum extending on to the anterior surface and presented double ureter.

Differentiation between the Wilms' tumor (WT) and the intrarenal neuroblastoma (IRNB) is imperative, as the prognosis and the treatment are different for these condi­tions. It may pose a diagnostic challenge to distinguish them pre-operatively. Over the period of last 10 years (1990-1999), 3 children aged 2 months to 4 years were diagnosed to have IRNB. 2 cases were operated with a provisional diagnosis of WT, but on histology were found to have neuroblastoma. Taking benefit from our previous experience, the third case we encountered with a renal lump and bony metastasis with clinical features not con­sistent with the diagnosis of Wilms' tumor was further investigated. Urinary catecholamines were significantly elevated and there was bone marrow involvement and positive bone scan for multiple bony metastasis. 2 pa­tients are on chemotherapy and follow-up for last 6 months, while 1 died 6 years back after a follow-up of 2 years. Patients who have a renal mass on imaging, with clinical features of rapid deterioration in general condi­tion and evidence of bony secondaries, should undergo work-up for neuroblastoma pre-operatively to confirm the diagnosis.

We report a case of a young adult with an enormous mass lesion arising from the left kidney. His performance status was good despite severe constitutional symptoms. Radical nephrectomy was performed and histopathologi­cally it turned out to be an leiomyosarcoma. He made a good recovery. Surgical extirpation should be carried out to palliate the symptoms specially in young patients even though the prognosis is poor provided the patient has good performance status.

A unique case of a patient of renal cell carcinoma pre­senting as cutaneous chest horn is presented. He had no urologic symptoms at presentation and was subsequently found on evaluation to have a right renal lump. This is the first case of its kind reported in the literature. The case emphasizes the need _. for a careful physical examination in patients presenting with skin tumor

Suprapubic cystostomy is a commonly performed uro­logical procedure. This case report describes a rare and unique complication which occurred due to a gaping and reflexing ureteric orifice.

JJ stent is placed in many patients of calculus dis­ease after percutaneous nephrolithotomy (PCNL). It is also used after Endopyelotomy or ante grade uretero­scopy. Presented here is a simple technique of placing JJ stent antegrade over a stiff Zebra guide wire.

Efforts have always been made to evolve certain prin­ciples to reduce the variability in the management of patients and make medical care more appropriate. These efforts have become almost a movement since 1980s as evidenced in the development of clinical practice guide­lines in all medical disciplines. This article describes the need for clinical practice guidelines and their de­velopment methods and qualities. Advantages and limi­tations of clinical practice guidelines are enumerated. The salient features of various available clinical prac­tice guidelines in urology are also described.