Introduction: Patients with metastatic hormone sensitive prostate cancer (mHSPC) have traditionally been treated with androgen deprivation therapy (ADT). Recently, there has been a demonstration of a survival benefit with the addition of docetaxel to ADT from three large randomized controlled trials. This review summarizes these trials, draws comparisons between the trials, and attempts to provide critical evidence-based recommendation on the role of docetaxel in mHSPC. Methods: Of the two published (GETUG-AFU, Chemo-Hormonal therapy vs. Androgen Ablation Randomized Trial for Extensive Disease in prostate cancer [CHAARTED]) and one presented trial (STAMPEDE) an analysis of the study design, patient characteristics, outcomes, variables, and a critical comparison between the trials was performed for making practice recommendations. Results: All the three trials demonstrated statistically significant progression free survival with the addition of docetaxel to ADT in mHSPC. However, while CHAARTED trial demonstrated a significant survival benefit with addition of docetaxel to ADT in patients with high volume mHSPC, GETUG-AFU failed to demonstrate statistically significant survival benefit although there was an absolute difference in survival between the two arms, with lower sample size and statistical power compared to CHAARTED. The largest study, STAMPEDE, reported a 22 month survival benefit in patients with M1 disease with statistical significance; with subgroup analysis of high volume and low volume disease patients yet to be reported. Conclusion: After a careful comparison between the trials, we conclude that systemic docetaxel chemotherapy within 4 months of initiating ADT for metastatic, high-volume HSPC should be considered the standard of care for patients with good performance status.

Introduction: The treatment landscape for patients with metastatic castration-resistant prostate cancer (CRPC) is evolving, with recent approvals of immune therapy, novel hormonal therapy, and bone-targeted therapy. Chemotherapy remains an essential component of the armamentarium. Herein, we review current chemotherapy options for patients with CRPC and discuss future challenges. Methods: We reviewed literature for chemotherapy agents in prostate cancer, with special attention to the evidence for efficacy of the currently approved agents. We also reviewed emerging data on biomarkers of response to chemotherapy for CRPC. Results: Taxanes, especially docetaxel and cabazitaxel, have first- and second-line indications for CRPC, respectively, with both providing a survival benefit. Multiple attempts to improve on the single agent efficacy of docetaxel with combination therapy have not generally been successful although platinum combinations are used for resistant phenotypes. Reductions in prostate-specific antigen by ≥30% and reductions in circulating tumor cells (CTCs) to ≤ 5 are associated with improved survival on chemotherapy. Chemotherapy may continue to be effective therapy for patients with biomarkers that are associated with resistance to androgen-directed therapies (androgen receptor splice variant 7 positivity in CTCs or high CTC heterogeneity). Conclusions: Chemotherapy remains an essential component of CRPC therapy, and biomarkers are being identified to define clinical scenarios where chemotherapy may be the optimal therapy choice.

Introduction: Prostate cancer remains a challenge as a target for immunological approaches. The approval of the first cell-based immune therapy, Sipuleucel-T for prostate cancer introduced prostate cancer as a solid tumor with the potential to be influenced by the immune system. Methods: We reviewed articles on immunological management of prostate cancer and challenges that lie ahead for such strategies. Results: Treatments have focused on the identification of novel cell surface antigens thought to be unique to prostate cancer. These include vaccines against carbohydrate and blood group antigens, xenogeneic and naked DNA vaccines, and pox viruses used as prime-boost or checkpoint inhibitors. No single vaccine construct to date has resulted in a dramatic antitumor effect. The checkpoint inhibitor, anti-CTLA-4 has resulted in several long-term remissions, but phase III trials have not demonstrated an antitumor effect or survival benefit. Conclusions: Multiple clinical trials suggest that prostate cancer may not be optimally treated by single agent immune therapies and that combination with biologic agents, chemotherapies, or radiation may offer some enhancement of benefit.

Introduction: Metastatic prostate cancer continues to be a leading cause of morbidity and mortality in men with prostate cancer. Over the last decade, the treatment landscape for patients with castrate-resistant disease has drastically changed, with several novel agents demonstrating an improvement in overall survival in large, multi-institutional randomized trials. Traditional treatment with radioisotopes has largely been in the palliative setting. However, the first in class radiopharmaceutical radium-223 has emerged as the only bone-directed treatment option demonstrating an improvement in overall survival. Methods: Medline publications from 1990 to 2016 were searched and reviewed to assess the use of currently approved radioisotopes in the management of prostate cancer including emerging data regarding integration with novel systemic therapies. New positron emission tomography-based radiotracers for advanced molecular imaging of prostate cancer were also queried. Results: Radioisotopes play a crucial role in the diagnosis and treatment of prostate cancer in the definitive and metastatic setting. Molecular imaging of prostate cancer and theranostics are currently being investigated in the clinical arena. Conclusions: The use of modern radioisotopes in selected patients with mCRPC is associated with improvements in overall survival, pain control, and quality of life.

Introduction: Despite the major improvements in surgical technique and perioperative care, radical cystectomy (RC) remains a major operative procedure with a significant morbidity and mortality. The present study analyzes the early complications of RC and urinary diversion using a standardized reporting system. Materials and Methods: Modified Clavien-Dindo classification was used to retrospectively assess the peri-operative course of 212 patients who had RC with urinary diversion between October 2003 and October 2014 at a single institution. The indications for surgery were muscle invasive urothelial carcinoma, high-grade nonmuscle invasive bladder cancer (BC), and Bacillus Calmette-Guerin-resistant nonmuscle invasive BCs. Data on age, sex, comorbidities, smoking history, American Society of Anaesthesiologists score, and peri-operative complications (up to 90 days) were captured. Statistical analysis was performed using SPSS 20.0 software (Chicago, USA). Results: The mean age was 56.15 ΁ 10.82. Orthotopic neobladder was created in 113 patients, ileal conduit in 88 patients, and cutaneous ureterostomy in 11 patients. A total of 292 complications were recorded in 136/212 patients. 242 complications (81.16%) occurred in the first 30 days, with the remaining 50 complications (18.83%) occurring thereafter. The rates for overall complication were 64.1%. The most common complications were hematologic (21.6%). Most of the complications were of Grade I and II (22.9% and 48.9%, respectively). Grade IIIa, IIIb, IVa, IVb, and V complications were observed in 10.2%, 8.9%, 3.4%, 2.7%, and 2.7% of the patients, respectively. Conclusions: RC and urinary diversion are associated with significant morbidity. This audit would help in setting a benchmark for further improvement in the outcome.

Introduction: Transplant renal artery stenosis (TRAS) is a well-known vascular complication of renal transplantation. The aim of this analysis was to assess the short and midterm outcomes of endovascular therapy to salvage transplant kidney. Methods: We retrospectively analyzed our transplant database from 2000 to 2015. Percutaneous transluminal angioplasty/stenting was done in 24 patients (22 men and two women) with significant TRAS. The mean age was 59 ± 12 years. The parameters analyzed were: Technical success, pre- and post-treatment serum creatinine and number of antihypertensive drugs before and after treatment and vessel patency on Doppler ultrasonography at 3 and 6 months. Results: Overall incidence of TRAS in this study was 5.06%. Incidence of TRAS following live donor transplantation was 4.68% while that in deceased donors was 11.5%. Technical success was 100%. There were no periprocedural deaths. Renal function was improved from 2.32 ± 0.5 mg/dL to 1.72 ± 0.3 mg/dL (P < 0.001) and number of antihypertensive medications after the procedure was reduced from 2.9 ± 0.7 to 2 ± 0.6 (P < 0.001) at 6 months follow-up. One patient developed restenosis within 5 months (4.2%). Clinical success at 6 months follow-up was 79.2%. Conclusions: Endovascular treatment of TRAS has high technical success with minimal complications. It also provides satisfactory clinical success with improvement in overall transplant renal function and renovascular hypertension in early follow-up.

Introduction: Uroflowmetry is the objective method of measuring rate of urine flow. Nomograms are required to observe the change in flow rates at different voided volumes (VVs) and the use of which overcomes the limitation of referencing flow rates to any single VV. The purpose of the present study was to construct the Indian uroflow nomogram for adult healthy males between 15-40 years of age. Methods: A total of 1000 healthy males between 15 and 40 years of age were included in the study. Exclusion criteria were any urinary symptoms or urological intervention. Parameters analyzed statistically were age, peak flow rate (Q _max ), average flow rate (Q _avg ), and VV. A nomogram was drawn for the fitted regression model. Results: The mean age was 27.26 ΁ 6.71 years. The mean Q _max , Q _avg , and VV were 24.32 ΁ 3.50 ml/s, 9.45 ΁ 2.55 ml/s, and 420.93 ΁ 97.89 ml, respectively. The correlation between flow rates and VV was statistically significant, indicating that the higher the VV, the higher the flow rates. A negative significant correlation of Q _max with age was seen in our study. We observed a decline of Q _max by 1 ml/s/decade. The relationship of Q _max with VV is in linear progression up to 600 ml, and then it becomes a plateau and with higher VV it declined. Conclusion: Q _max exhibits significant correlation with VV and age. A nomogram was constructed to attain normal reference values of flow rate over different VVs.

Introduction: Management of renal stones in children with a solitary kidney is a challenge. In the current study, the efficacy and safety of retrograde intrarenal surgery (RIRS) in these children were determined. Patients and Methods: Records of children with renal stones who were treated at our institute between August 2011 and August 2014 were retrospectively assessed. Inclusion criteria were: Children with single renal stone <2 cm size, in a solitary kidney. A 7.5 Fr flexible ureteroscope (FURS) was introduced into the ureter over a hydrophilic guidewire under visual and fluoroscopic guidance - applying a back-loading technique. The stone was completely dusted using 200 μm laser fiber (0.2-0.8 joules power and10-30 Hz frequency). At the end of the maneuver, a 5 Fr JJ stent was inserted into the ureter. The children were discharged home 24 h postoperative - provided that no complications were detected. Results: Fourteen children (3 girls and 11 boys) with median age 9.5 years (range 6-12) were included. The mean stone burden was 12.2 ± 1.5 mm (range 9-20). Stones were successfully accessed in all of the cases by the FURS except for 2 cases in whom a JJ stent was inserted into the ureter and left in place for 2 weeks to achieve passive dilatation. All of the stones were dusted completely. The immediate postoperative stone-free rate (SFR) was 79%, and the final SFR was 100% after 3 weeks. No intraoperative complications were observed. Conclusions: RIRS for renal stone <2 cm in children with a solitary kidney is a single-session procedure with a high SFR, low complication rate, and is a minimally invasive, natural orifice technique.

Introduction: Between the two techniques of laparoscopic nephrectomy, retroperitoneoscopy has certain distinct advantages over transperitoneal access but may be a more difficult technique to learn. We present our experience of training novices in retroperitoneoscopic nephrectomy with a good outcome, making it a standard of care for nephrectomy at our institute. Methods: The aim of this study was to report the initial experience, learning curve, and outcome of retroperitoneoscopic nephrectomy by novices under a mentored approach. The series included four novice urologists. The data from the initial forty retroperitoneoscopic nephrectomies performed by each of them were reviewed. To assess the learning curve for retroperitoneoscopic nephrectomy, we studied changes in key operative parameters (operative time, blood loss, complications, nonprogression by novices, conversion rate) as a function of the case number. Results: Retroperitoneoscopic nephrectomies were successfully completed by novices in 88.1% (141/160) of the patients. Nine cases (5.6%) required the mentor's help because of nonprogression, and ten cases (6%) required conversion to open nephrectomy. The median operative time of all surgeons decreased with increased surgical experience. There was some intersurgeon variation in the learning curve ranging from 10 to 30 cases, but all surgeons showed a significant reduction in operative time across consecutive sets of ten cases. Seven cases required mentor help in the initial series (7/80) and only two in later half of cases (2/80). All minor complications were also significantly less in the later series. Conclusions: The present series represents the effectiveness of training in retroperitoneoscopic nephrectomy of novices by a responsible team and with the standard protocol and surgical steps. Through effective mentoring, the steep learning curve associated with retroperitoneoscopic nephrectomy has been overcome, making it standard of care for nephrectomy at our institute.

Introduction: There are multiple techniques for surgical correction of vesicoureteral reflux (VUR). We compared the outcomes of extravesical versus Cohen's reimplantation for VUR in children. Methods: Records of all children (n = 118) who underwent reimplantation for VUR between 2003 and 2014 were analyzed (male: female = 43:75). Children with secondary VUR, duplication anomalies, and ectopic ureter were excluded from our study. Extravesical reimplantation (EVR) was performed bilateral in 32 children (Group 1a) and unilateral in 19 (Group 1b), while bilateral Cohen's reimplantation was performed in 67 (Group 2). Parameters compared were length of the surgical procedure, average duration of stay in the hospital, postoperative bladder spasms, significant hematuria >72 h, and long-term complications. Results: The mean age at operation was 15 months in Group 1, and 36 months in Group 2. The mean duration of surgery was significantly less (P = 0.0001) in Group 1a (n = 32; mean 104 min; standard deviation [SD] 18 min) compared to Group 2 (n = 67; mean 128 min; SD 15 min). The mean (SD) postoperative stay was significantly lower (P = 0.0001) at 4.5 (1.5) days in Group 1a compared to 6.5 (0.5) days in Group 2. Postoperative bladder spasms were significantly lower (P = 0.03) at 10/32 in Group 1a compared to 37/67 in Group 2. All patients responded well with anticholinergics. Postoperative hematuria and bladder spasms were significantly lower (P = 0.03) in Group 1a compared to Group 2. There was no significant difference in persistent VUR between Group 1 and Group 2. At 1 year follow, none of them had any evidence of ureteral obstruction. Conclusions: EVR has lower operative time, less postoperative discomfort and shorter hospital stay compared to Cohen's reimplantation. Both techniques are equally effective in treating reflux.

Introduction: Laparoscopic or robotic-assisted laparoscopic radical prostatectomy (RALP) is a frequently used approach for localized carcinoma prostate. For intermediate and high-risk cancers, extended pelvic lymph node dissection (e-PLND), is often performed. Conventional e-PLND involves piecemeal retrieval of lymphatic tissue. We describe a novel technique of laparoscopic e-PLND, which involves en-masse removal of pelvic lymph nodes from each side, based on an overlying peritoneal scaffold. Materials and Methods: Fifteen cases of intermediate and high-risk carcinoma prostate underwent laparoscopic radical prostatectomy (LRP) with peritoneal scaffold based e-PLND within a period of 1 year. We describe the surgical techqniue and outcomes in terms of operative time and lymph nodes retrieved. Results: The mean operating times for "peritoneal scaffold" lymphatic dissection was 48 min (38-64). The total number of lymph nodes retrieved was 18 (14-22). There were no cases with postoperative lymph collection or hematoma. Conclusion: The "peritoneal scaffold" technique of e-PLND is a novel technique, which involves having a peritoneal scaffold to bind and hold all the lymphatic tissues together in its anatomical orientation during dissection. This enables complete retrieval of specimen during LRP and RALP.

Management of pelvi-ureteric junction obstruction (PUJO) in a duplex system is technically challenging as dissection at the pelvis may jeopardize the vascularity of the normal moiety ureter. Anastomosing the pelvis to the one single ureter will have a risk of future development of stricture which then will risk both the moieties. Robotic assistance enables appropriate tissue dissection; minimal handling of normal ureter and precision in suturing, overcoming the potential challenges involved in the minimally invasive management of such complex cases. We report the feasibility and efficacy of robot-assisted laparoscopic pyeloplasty in such case.

Transverse testicular ectopia (TTE) is an uncommon anomaly of testicular descent. Herein, we describe a case of TTE with blindly ending vas and persistent Mόllerian duct syndrome in a 2-year-old child. Orchidopexy could be done through the normal orthotopic route after separating it from the Mόllerian structure and dividing the peritoneal fold just distal to the blindly ending vas. The report highlights that laparoscopy is useful for identifying subtle anomalies in addition to its therapeutic role.

Transvaginal evisceration of the bowel has been found to most commonly occur following hysterectomy. To date, the reports of this complication following radical cystectomy are minimal. Herein, we report a case of transvaginal bowel evisceration 45 days following robotic-assisted radical cystectomy (RARC) in a postmenopausal woman.

Treating recurrent vesicovaginal fistula (VVF) is a major clinical problem. We present a technique and special precautions taken during treatment of a small recurrent VVF with the help of combined cystoscopic and/or transvaginal injection of cyanoacrylate in two patients. Except for frequency of micturition in the first patient, postoperative follow-up was uneventful. Endoscopic management with cyanoacrylate is a simple and effective alternative to major reconstructive surgery.

ImmunoglobulinG4 related disease (IgG4RD) is a systemic fibroinflammatory disease recognized recently. This usually presents with multiorgan involvement. We are reporting a case of a35-year-old male patient with isolated IgG4RD of the testis. This patient presented with right testis pain which responded to conservative treatment. However, later, he reported with hard swelling in the right testis which on imaging was suggestive of malignancy and hence underwent radical orchiectomy. Histopathology with immunohistochemical staining confirmed IgG4RD of the testis. To the best of our knowledge, this is the first report of purely isolated case of IgG4RD of testis in English literature.

Cystitis cystica (CC) is aproliferative disorder of bladder urothelium and usually subsides with medical therapy. However, this is not true for severe CC where surgical intervention is required to control breakthrough urinary tract infection (UTI). It may be mistaken as bladder neoplasm or posterior urethral valve, especially in children. Here, we report a case of CC in a 2-year-old boy where we had to excise the large pedunculated intravesical lesion to control breakthrough UTI and ongoing renal damage.