This article is intended as a review of the available clinical data outlining the risks and benefits of testosterone (androgen) replacement therapy, specifically addressing the issue of the relationship between exogenous androgen administration and prostate cancer risk. There is controversy over whether androgen replacement is a risk factor for incident prostate cancer. Our review of current clinical information revealed that to date, no study or review has definitively shown that androgen replacement therapy is an independent risk factor for development of prostate cancer. Androgen administration seems to be beneficial in decreasing fatal cardiovascular events, body fat mass, and insulin resistance. Overall, the current clinical data seems to suggest that androgen replacement is an appropriate therapeutic option for men with symptomatic hypogonadism provided that patients continue to receive regular prostate screenings.

We reviewed the incidence, predisposing factors, presentation and management of complications related to the use of synthetic mesh in the management of stress urinary incontinence and pelvic organ prolapse repair. Immediate complications, such as bleeding, hematoma, injury to adjacent organs during placement of mesh and complication of voiding dysfunction are not discussed in this review, since they are primarily related to technique. A PubMed search of related articles published in English was done from April 2008 to March 2011. Key words used were urinary incontinence, mesh, complications, midurethral sling, anterior prolapse, anterior vaginal repair, pelvic organ prolapse, transvaginal mesh, vault prolapse, midurethral slings, female stress urinary incontinence, mesh erosion, vaginal mesh complications, and posterior vaginal wall prolapse. Since there were very few articles dealing with the management of mesh-related complications in the period covered in the search we extended the search from January 2005 onwards. Articles were selected to fit the scope of the topic. In addition, landmark publications and Manufacturer and User Facility Device Experience (MAUDE) data (FDA website) were included on the present topic. A total of 170 articles were identified. The use of synthetic mesh in sub-urethral sling procedures is now considered the standard for the surgical management of stress urinary incontinence. Synthetic mesh is being increasingly used in the management of pelvic organ prolapse. While the incidence of extrusion and erosion with mid-urethral sling is low, the extrusion rate in prolapse repair is somewhat higher and the use in posterior compartment remains controversial. When used through the abdominal approach the extrusion and erosion rates are lower. The management of mesh complication is an individualized approach. The choice of the technique should be based on the type of mesh complication, location of the extrusion and/or erosion, its magnitude, severity and potential recurrence of pelvic floor defect.

Urinary tract infections (UTIs) represent one of the most commonly acquired diseases among the general population as well as hospital in-patients, yet remain difficult to effectively and consistently treat. High rates of recurrence, anatomic abnormalities, and functional disturbances of the urinary tract all contribute to the difficulty in management of these infections. However, recent advances reveal important molecular and genetic factors that contribute to bacterial invasion and persistence in the urinary tract, particularly for the most common causative agent, uropathogenic Escherichia coli. Recent studies using animal models of experimental UTIs have recently provided mechanistic insight into the clinical observations that question the effectiveness of antibiotic therapy in treatment. Ultimately, continuing research will be necessary to identify the best targets for effective treatment of this costly and widespread infectious disease.

Objective: To analyze the perioperative outcome of the first 190 cases of robot-assisted laparoscopic radical prostatectomy performed at our center from July 2006 to December 2010. Materials and Methods: Operative and recovery data for men with localized prostate cancer undergoing robot-assisted radical prostatectomy at our center were reviewed. All surgeries were performed using the 4-arm da Vinci-S surgical robot. Preoperative data included age, body mass index (BMI), prostate specific antigen (PSA) level, prostate weight, biopsy Gleason score and TNM staging, while operative and recovery data included total operative time, estimated blood loss, complications, hospital stay and catheter time. These parameters were evaluated for the safety and efficacy of this procedure in our center. Results: The mean age of our patients was 65 ± 1.2 years. The mean BMI was 25.20 ± 2.88 and the median PSA was 14.8 ng/ml. Majority of our patients belonged to clinical stage T2 (51.58%). The mean total operative time was 166.44 ± 11.5 min. Six patients required conversion to open procedure and there was one rectal injury. The median estimated blood loss was 302 ± 14.45 ml and the median duration of hospital stay was 4 days. The overall margin positivity rate was 12.63%. Conclusion: Despite our limited robotic surgery experience, our perioperative outcome and complication rate is comparable to most contemporary series. Robot-assisted laparoscopic prostatectomy (RALP) is easy to learn and provides the patient with the benefits of minimally invasive surgery with minimal perioperative morbidity.

Aim: To evaluate the role of virtual cystoscopy (VC) comparing it with cystopanendoscopy (CPE) for detecting bladder tumor(s). Material and Methods: Ethical clearance was obtained from the Institutional ethics committee. After an informed consent 30 patients fulfilling the inclusion criteria were enrolled in the prospective non-randomized clinical study and were evaluated as per protocol with VC performed by a qualified radiologist who was blinded to the findings of CPE performed by a qualified urologist. The results so obtained were analyzed using appropriate statistical tools. Results: The mean age of the patients was 56 years. Sensitivity of VC in detecting bladder lesions was 92%. However, when axial images were also interpreted along with VC, the sensitivity increased to 96% for detecting bladder lesions. The specificity of VC with axial CT was 40% in respect of detecting bladder lesions.VC with axial CT was 85.7% sensitive in identifying multiple bladder tumors. There were no complications on account of performing VC. Minor problems were encountered with VC and CPE in 16.7% and 13.3% patients respectively. Conclusions: VC with axial CT is 96% sensitive in detecting bladder lesions and 85.7% sensitive in detecting the multiplicity of the tumors. VC may be a useful complementary diagnostic tool for the workup of select patients with suspected bladder lesions. However, larger randomized controlled studies are needed to better define the precise clinical and diagnostic role of VC in routine practice. Settings and Design: Prospective Clinical Comparative Non Randomized Clinical Study.

Aims: Port site metastasis (PSM) is an unwelcome consequence of laparoscopy for oncological procedures with uncertain etiology. We present the clinical evidence to prove that PSM is likely to be due to the hematogenous spread of tumor cells. Materials and Methods: Six cases of port site metastasis, four following laparoscopic radical nephrectomy for localized renal cell carcinoma (RCC), one after laparoscopic radical prostatectomy done in two patients and one after laparoscopic partial cystectomy for tumor at bladder dome done in two were studied. One case of metastatic RCC with bilateral gluteal masses and two cases of open radical nephrectomy, with recurrence at the drain and incision site were also studied. Results: During the median follow up of 59 months (range 24-120), 4/136 patients with RCC (1.47%) developed port site metastasis between 7-36 months after surgery. All six cases of PSM had advanced disease and recurrences at other sites, that is, peritoneum, omentum, bones, and lungs. None of the patients had isolated PSM. One patient of metastatic RCC, who did not have any intervention but repeated intramuscular injections of analgesics-developed bilateral gluteal masses, confirmed to be RCC on fine needle aspiration cytology. Two patients had metastasis at the incision site (one at the drain site) with distance, including cutaneous metastases. Conclusions: Port site metastasis did not develop in isolation. There could be a likely existence of circulating tumor cells at the time of surgical trauma of penetrating nature, that is, port site or injection site, which manifest in some patients depending upon their immune response.

Introduction: Disease spectrum of upper tract transitional cell carcinoma (TCC) in Indian patients is not known. Herein, we present data on clinical presentation, pathological characteristics, and the outcome of treatment of upper tract TCC. Materials and Methods: Clinicopathological data of patients who were diagnosed for upper tract TCC between January 2000 and January 2010 were collected from the hospital information system and case records. Preoperative diagnosis was based on contrast-enhanced computerized tomography of the whole abdomen and urine cytology. Cross tab and logistic regression analysis was done on the effect of various clinicopathological characteristics on the outcome and cancer-specific and recurrence survival were derived. Results: There were total 40 patients, 35 (87.5%) of them were male. The mean age was 62.7 ± 7.9 years. The most common symptom was gross hematuria present in 30 (75%). Mean tumor size was 2.8 ± 1.2 cm. Median duration of follow up was 36 (12 to 100) months. Laparoscopic nephroureterectomy was done in 27 patients along with bladder cuff excision and seven patients underwent open surgery. Thirty two (88.8%) patients had invasive T stage and high-grade lesions were seen in 24 (66.6%). Lymphovascular invasion was found only in one case and necrosis in 30 (83.3%). Necrosis was found to be the poor prognostic factor. Five-year recurrence-free and cancer-specific survivals were 36.33% and 26%, respectively. Conclusion: Patients with upper tract TCC present very late with a high-stage disease and a very low 5-year cancer-specific and recurrence-free survivals.

Aims: To investigate the outcomes of the surgical management and longitudinal assessment of patients with subclinical Cushing's syndrome (SCS) and nonfunctioning adrenocortical adenoma (NFA). Materials and Methods: Between the years 1995 and 2008, 73 patients with asymptomatic adrenocortical adenoma were enrolled. They were informed of the risks and benefits of adrenalectomy and conservative management, and then chose the treatment. Results: SCS was observed in 13 patients (17.8%) and NFA in 60 patients (82.2%). Tumor size in SCS was significantly larger than that in NFA (34.6 ± 9.7 mm vs. 24.5 ± 8.0 mm in diameter, P=0.001). Of the SCS patients, 7 also suffered from hypertension (HT), 2 from diabetes mellitus (DM) and 3 from hyperlipidemia (HL). After adrenalectomy, the insulin dose could be reduced in 2 (100%) patients with DM, in 5 (71.4%) of those with HT and in 2 (66.7%) of those with HL. In the NFA surveillance group, 1 (2.6%) case developed into SCS 3 years after the initial presentation and an increase in size of the tumor was observed in 1 (2.6%), with a mean follow-up of 51.2 months. Conclusions: Surgical resection may be beneficial for the control of SCS and is likely to provide improvement of concomitant HT, DM and HL. Although NFA can be managed conservatively, its size and hormonal activities may change longitudinally. Thus, long-term follow-up is necessary for NFA.

Background: Ureteral stents, despite their ubiquitous use, have not been evaluated for their safety and strength after removal from the patient. While literature is available from the industry with regards to manufacturing and specifications of stents, what happens to a stent after it is inserted into the body, still needs to be explored. Materials and Methods: We conducted a methodical study of 153 consecutive patients with urological problems who were stented with inexpensive polyurethane stents. Once removed from the patients, the stents were analyzed for breakload, tensile strength, elongation, pH, decomposition temperature, residue as well as diameter change. Results: There was no significant change in the physical and mechanical properties of the stent after clinical use and the variance was within the acceptable range of biomaterials. There was minimal leaching of material and color change in all stents. Conclusion: The cheap polyurethane stents were found to be safe for use in patients, for the short time periods of in situ stenting. The degradation of physical and chemical properties of the stent was not significant. Thus it can be safely said that the stents currently in widespread use are cost-effective and physically safe for short spans of time.

This retrospective study evaluates the morbidity and outcome of cystectomy and urinary diversion in octogenarians with invasive bladder cancer. Records of all patients older than 80 years who underwent cystectomy during the last 10 years were analyzed retrospectively. Among 565 cystectomies, 11(< 2%) patients were identified and evaluated for intraoperative and postoperative complications and mortality post surgery. The median age was 82 years. One female and ten male patients were selected. Eight patients were hypertensive, three were diabetic, one had coronary artery disease, two had chronic lung disease and one had depression. Seven patients presented with hematuria, two had lower urinary tract symptoms and two presented with renal failure who were optimized for renal function. All patients had ileal conduit as the form of urinary diversion. Simultaneous urethrectomy was done in two patients. Median surgical time was 5 h. Median hospital stay after surgery was 10 days. Four patients had pneumonitis and one patient developed hemiplegia, but all patients were eventually discharged. One patient expired due to stent septicemia within one month after discharge. Follow-up ranged from four months to five years. Three patients expired three years after surgery-one due to disease recurrence and the other two due to unrelated cause. One patient was lost to follow-up and six patients are doing well. Our results support the use of cystectomy in octogenarians with invasive bladder cancer, which has acceptable morbidity and mortality, and offers the best chance for sustained disease-free quality survival.

A rare case of incomplete transverse vesical septum with urinary tract tuberculosis is being reported. A 52-year-old male presented with lower urinary tract and systemic symptoms. On investigation he had anemia, leucocytosis, and high serum creatinine. On cystopanendoscopy, there was a transverse ledge of tissue connecting the two lateral walls of the bladder approximately 4 cm proximal to the bladder neck dividing the caudal vesical cavity into anterior and posterior parts. Also, the left ureteric orifice had double barrel look. To our knowledge this is the first ever reported case of incomplete transverse vesical septum.

Primary male genital lymphomas may appear rarely in testis, and exceptionally in the penis and prostate, but there is not previous evidence of a lymphoma arising from the corpora cavernosa. We report the first case in the literature of a primary diffuse cell B lymphoma of the corpora cavernosa presented with low urinary tract symptoms, perineal pain and palpable mass. Diagnosis was based on trucut biopsy, histopathological studies and computed tomographic images.

Nonspecific aortoarteritis or Takayasu's disease (TD) is a chronic pan endarteritis of unknown origin involving the aorta and its major branches affecting young adults especially women. The disease is more common in eastern Asian countries. Hypertension in these patients generally reflects as renal artery stenosis, which is seen in 28-75% of patients. Surgical revascularization is occasionally needed in patients with failed medical management or endovascular interventions. We report two cases of Takayasu's arteritis in young women where renal revascularization was done using free internal iliac artery hepatorenal bypass graft with excellent control of hypertension in the postoperative period.

The number of patients living with end-stage renal disease (ESRD) is increasing in our country and demand for renal grafts is ever increasing. Cadaver renal transplantation is being established as a viable supplement to live transplantation. We present a case where a mass lesion was encountered in the donor kidney from a cadaver. Enucleation of the lesion was done and we proceeded with the grafting. Histopathological examination showed a 'Renomedullary interstitial cell tumour', a rare benign lesion. Post transplant, the renal function recovered well and the patient is asymptomatic. Such incidental renal masses present an ethical dilemma to the operating surgeon.

Granulomatous inflammation of the prostate is a rare type of inflammation of the prostate. It is of various types, with the non-specific type of granulomatous inflammation being the most common. Xanthogranulomatous prostatitis is a rare type of granulomatous prostatitis of which very few cases have been reported. Histologically it is characterized by the presence of pale-looking foamy macrophages. It can be an incidental finding after transurethral resection of the prostate (TURP), although it may mimic prostatic malignancy clinically, biochemically, and rarely histologically. We report a rare case of xanthogranulomatous prostatitis which presented as a prostatic abscess, a presentation never reported in literature so far. The patient was managed with TURP.

Mullerianosis of the urinary bladder is a rare and morphologically complex tumor-like lesion, composed of several types of mullerian lesions like endometriosis, endocervicosis, and endosalpingiosis. This disease occurs in women of reproductive age group. Implantative and metaplastic origins have been suggested in the pathogenesis.

Combined penoscrotal incarceration is rarely reported in the literature. It is a urological emergency. Depending on the nature of the constricting object, duration of constriction, and with no defined treatment methods, inventiveness is usually required in removing difficult objects. This is a report of a penoscrotal incarceration by four closed steel rings, treated in Northern Ireland with a few minor points reiterated.

A nine and 13-year-old boy, previously diagnosed with 18q syndrome and an 11q deletion, respectively were diagnosed with testicular microlithiasis (TM). Both cases demonstrate that TM occurs in patients with various chromosomal abnormalities

Combined penoscrotal incarceration is rarely reported in the literature. It is a urological emergency. Depending on the nature of the constricting object, duration of constriction, and with no defined treatment methods, inventiveness is usually required in removing difficult objects. This is a report of a penoscrotal incarceration by four closed steel rings, treated in Northern Ireland with a few minor points reiterated.

Female urethral diverticulum is a rare entity with diverse spectrum of clinical manifestations. It is a very rare cause of bladder outlet obstruction and should be considered as a differential diagnosis in females presenting with acute urinary retention associated with a vaginal mass. Strong clinical suspicion combined with thorough physical examination and focused radiological investigations are vital for its diagnosis. Herein we report a case of giant urethral diverticulum presenting with acute urinary retention in a young female. It was managed by excision and urethral closure, and is the largest urethral diverticulum reported till date in the literature.

Alkaptonuria is a rare tyrosine metabolic disorder. A deficiency of homogentisic acid oxidase leads to accumulation of homogentisic acid in the body. Dark-colored urine, cutaneous pigmentations and musculoskeletal deformities are characteristic features. Storage and voiding lower urinary tract symptoms due to prostatic calculi is a rare presentation.

We present images of three cases with false urethral anastomosis following urethroplasty. The likely causes are inadequate posterior urethral dissection and blind use of Hey Grove dilator. We recommend use of antegrade flexible cystoscopy to prevent this complication.

Testicular/paratesticular neoplasms morphologically resembling surface epithelial tumors of ovarian type are rare neoplasms. The criteria for the diagnosis and nomenclature of these tumors parallels those used for ovarian homologues. Pathologists and urologists need to be wary of this uncommon entity, excluding metastatic mucinous adenocarcinoma and herniation of mucinous tumors into paratestis/scrotal sac by careful clinicopathological correlation. Herein, we present the first case of borderline mucinous tumor of testis to be reported from India.

Undescended testis is one of the common surgical disorders in childhood and twenty percent of the undescended testes are nonpalpable. Surgical management is required in almost all cases for the repositioning or removal of the undescended testes and early intervention is preferred for optimal outcome. Use of imaging studies for accurate preoperative localisation of the nonpalpable testis is a wide prevalent practice. However, available evidences have questioned the need of such studies.

Current diagnostic modalities for early prostate cancer (PCa) lack sufficient sensitivity and specificity. Magnetic resonance spectroscopic imaging (MRSI) detects biochemical changes in tissues that may predate histological changes that can be diagnosed on a biopsy. Men with MRSI suggestive of malignancy but negative biopsy may thus be harboring cancer that manifests at a later date. We report the first case in our cohort of men with positive MRSI but negative initial biopsy who, 6 years after the initial MRSI, were detected to have PCa despite a "normal" prostate specific antigen (<4.0 ng/ml).