Objective: Intravesical bacillus Calmette-Guerin (BCG) therapy is considered to be the most effective therapy for high-risk superficial cancer of bladder. Reduction in dose has been tried to decrease the toxicity following instillations of BCG while maintaining efficacy. This study compares the efficacy and toxicity of three different doses of modified Danish 1331 strain of BCG in patients with high risk superficial bladder cancers. Materials and Methods: A prospective randomized study was undertaken between January 2000 to March 2005 to include all patients with superficial bladder cancer who received BCG after fulfilling one or more of the appropriate criteria (grade above 1, stage above Ta, size >1 cm, multiple or recurrent). One hundred and six patients received 40 mg, 80 mg or 120 mg Danish 1331 strain BCG weekly for six weeks. The recurrence rates, tumor progression, toxicity and long-term outcome of three different doses of BCG were studied. No maintenance therapy was given. Results: Of the 106 patients, 28 received 40 mg, 37 received 80 mg and 41 received 120 mg of intravesical BCG for six weeks. The mean follow-up was three years (range one to six years). Overall, 77.4% patients responded to a single cycle of BCG, with a recurrence rate of 32.1% in 40 mg, 13.5% in 80 mg and 24.3% in the 120 mg groups. Median time to recurrence was seven months, eight months and nine months in the three groups respectively. Overall, six patients (5.6%) developed disease progression, two (7.1%) in the 40 mg, one (2.7%) in the 80 mg and three (7.3%) in the 120 mg arm. Kaplan - Meier analysis for time to recurrence ( P =0.1839) and time to progression ( P =0.595) was not significantly different in the three treatment arms. Adverse effects were seen in 55.6% patients with most being of class 1 severity. Significantly less patients developed severe adverse effects in the 40 mg group as compared to the higher dose groups. Conclusions: We conclude that 40 mg dose of intravesical BCG is as effective as the standard dose in reducing the risk of recurrence and progression. Moreover this dose is associated with significantly less toxicity.

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Although they may present with significant morbidity, pelvic organ prolapse and stress urinary incontinence are mainly afflicitions that affect quality of life. To appropiately treat these entities, comprehension of the various theories of pathophysiology is paramount. Utilizing a Medline search, this article reviews recent data concerning intrinsic (i.e., genetics, postmenopausal status) and extrinsic factors (i.e., previous hysterectomy, childbirth) leading to organ prolapse or stress incontinence

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Introduction: Hypospadias repair is done in many centers using tubularized incised plate urethroplasty technique. A varying length of distal urethra in almost one-fourth of patients is devoid of corpus spongiosum. Traditionally, this segment is incised proximally till 'healthy' urethra is reached. It makes hypospadias more proximal and thus increases chances of failure. Materials and Methods: We tried to preserve this thin so-called "hypoplastic" urethra in nine patients. The meatus was distal penile in four, mid-penile in four and proximal penile in one patient. Another patient with chordee without hypospadias with hypoplastic urethra underwent chordee correction without sacrificing any length of urethra. Results: No residual chordee was seen in any of the patients. Only two patients (22%) developed subcoronal fistulas needing secondary repair. No patient had urethral diverticulum or stricture. Conclusions: We thus recommend preservation of hypoplastic urethra whenever possible.

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Objectives: Men with nonobstructive azoospermia may father a child through intracytoplasmic injection of testicular sperms. This can result in transmission of genetic defects such as Y chromosome microdeletions which primarily caused the infertility and occur in up to 55% such men. It may not be feasible to screen all patients for Y chromosome microdeletions due to the cost and technical difficulty. A correlation with existing markers such as follicle stimulating hormone (FSH) and testicular histology may help identify a subgroup for screening. We therefore studied the association between regions of azoospermia factor (AZF) deletion, testicular histology and serum FSH level in men with nonobstructive azoospermia. Materials and Methods: One hundred and nine men presenting with primary infertility and diagnosed as nonobstructive azoospermia based on standard guidelines were included in the study. Fasting blood sugar, serum FSH, testosterone and prolactin estimation was done and testicular fine needle aspiration biopsy was performed where clinically indicated. Patients with normal karyotype on standard Q banding (n=82) were evaluated for microdeletions in the Y chromosome. Eight AZF loci which mapped to interval 5 and 6 of the Y chromosome were evaluated. Results: Microdeletions were found in seven of 82 men with normal karyotype (8.5%). Three patients had deletions in both AZFa and AZFb regions with Sertoli cell only (SCO) histology. Two had AZFc deletion with hypospermatogenesis and maturation arrest in one each. Two patients had cryptorchidism. FSH levels were higher (mean 38.77 mIU/ml) in patients with deletions in the AZFa and AZFb regions than in those with AZFc deletions (mean 5.86 mIU/ml). In patients without a deletion, FSH was higher in the group with SCO (mean 18.28 mIU/ml) compared to those with hypospermatogenesis or maturation arrest (mean 6.83 mIU/ml). Conclusions: Serum FSH is raised in patients with severely depleted germ cell function, irrespective of the presence or absence of a microdeletion. The levels may correlate with the region of deletion in that the patients with AZFa and AZFb deletion had a sertoli cell only picture on histology and raised FSH.

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Inguinal block dissection is a necessary component in the treatment of certain cancers. Cancer of the penis is not an uncommon malignancy in the Indian subcontinent and while no one questions the treatment of the primary lesion, the need to remove the inguinal lymph glands concurrently, remains a matter of great controversy. Never the less, the survival of patients with penile cancer depends solely on the presence or absence of metastasis to the inguinal lymph nodes. The hesitation in offering inguinal lymph node dissection in every case is significantly related to the morbidity of the procedure in an attempt to reduce these complications, skin flaps can be used to cover the groin. This article looks at various flaps that can be used in groin reconstruction.

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Context: Role of laparoscopy in nephrectomy for tuberculous kidneys. Aims: Comparative analysis of laparoscopic nephrectomy done for tuberculous nonfunctioning kidney against nephrectomy done for other causes. Settings and Design: Retrospective analysis of hospital data. Materials and Methods: Retrospective analysis of 20 cases of laparoscopic nephrectomy done in our department, which included eight cases of tuberculous nonfunctioning kidney and 12 cases done for other benign diseases. Results: Mean operative time was higher in the tuberculous group compared to the control group (116 min to 87 min). There was no difference between the two groups in terms of complications, wound infection, conversion rate, postoperative ileus and mean hospital stay. No major complications were seen in both the groups. Conclusions: Tuberculous nonfunctioning kidney can be effectively dealt laparoscopically with no increased morbidity. Surgeon should be aware of the difficulties and complications which may be encountered.

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Objectives: Ultrasonography (USG) is the commonest modality for ascertaining prostate volume. Urologists commonly encounter a discrepancy between prostate volume on USG and actual volume of prostate, whereas transrectal ultrasonography (TRUS) gives near correct prostate volume. We undertook a prospective study to compare the relationship between changing bladder volumes to the volume of prostate. Materials and Methods: After approval of the Institutional Ethics Committee and informed consent, 25 patients (age group: 52-78 years) with lower urinary tract symptoms were assessed for prostate volume by USG at different bladder volumes and final comparison was done with TRUS in one setting. Each USG and TRUS was done by one urology resident under the guidance of one qualified radiologist with experience of over 15 years in this field. Equipment used was SIEMENS SONNOLINE ADARA with 3.5 MHz probe for USG and 7.5 MHz Endo p-2 (biplaner) probe for TRUS. First, patients were asked to empty their bladder and post void residual urine was measured along with prostate volume. Patients were given oral fluids and USG was repeated serially at three intervals with bladder volume of 100-200 ml, 200-300 ml and > 300 ml. Finally uroflowmetry was carried out followed by TRUS. Results were recorded in a tabulated form on 'Excel spread sheet'. Results: 1. Measurement of prostate volume increases with increase in bladder volume. 2. Calculated prostate volume at minimal bladder capacity (100-200 ml) was found to be the closest to the volume calculated by TRUS. Conclusion: Minimal bladder volume (100-200 ml) is essential for near correct estimation of prostate volume by USG. With increasing bladder volume, the volume of prostate increases disproportionate to its actual volume.

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Renal cell carcinoma (RCC) can metastasize to practically all organs; however, all routes and patterns are not yet fully understood. Adrenal metastasis is a good example of that. Adrenal metastasis may be ipsilateral or contralateral and usually it is metachronous. We report a rare case of RCC with ipsilateral adrenal gland involvement and isolated synchronous contralateral adrenal metastasis.

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Penile injuries due to bites and stings are under-reported. The extent of injury depends not only on the initial trauma but also on the secondary injuries due to toxins and bacterial infections transmitted by the bite. Wasp bites are on the increase worldwide as humans encroach on their habitat. We report a case of wasp bite to the preputial skin of the penis leading to severe phimosis, difficulty in micturition and localized gangrene requiring emergency circumcision. Analysis of such cases can provide important information on the determinants of severe morbidity that may then be used in injury prevention.

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Villous adenomas are rare in the urinary tract. We herein report the fifth known such case while also making a review of the literature. A 54-year-old woman noticed a mass in her external genitalia and a tumor located on her external urethral orifice. The tumor was excised and pathologically confirmed to be a villous adenoma. Up to now, no sign of recurrence has been observed. However, we should be careful for malignant formation, because villous adenomas in the urinary tract frequently coexist with either adenocarcinoma or urothelial carcinoma.

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There is an increasing trend of laparoscopy in pediatric urological practice with more complex and reconstructive procedures being performed in smaller children. The physiological impact of these procedures is not well documented in the pediatric literature and cannot be simply extrapolated from the adult data. This article reviews the current pediatric literature on the physiological effects of both transperitoneal and retroperitoneal laparoscopy. The clinical implication of these changes and the need for proper monitoring is stressed. As surgeons strive to stretch the indications of laparoscopy in pediatric urological practice, the overall beneficial effects of laparoscopy must be balanced with these potential hemodynamic and respiratory changes.

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Penile cancer is an uncommon cancer involving the glans, prepuce or both in over 75% cases. Historically, the standard treatment of the primary tumor has been a partial or total penectomy. Although these are still widely practiced procedures for control of the disease, as our understanding of the natural history of the disease has evolved, the treatment options have broadened, focusing more and more on penile-preserving techniques such as Mohs's micrographic surgery, wide local excision, subtotal and total glansectomy, laser, brachytherapy, external beam radiotherapy and topical application of chemotherapeutic agents such as 5-Fluorouracil. Penile-preserving options are increasingly being used as a first-line treatment, not restricted to Tis/Ta tumors, but for T1, T2 and even T3 tumors in selected cases. The metastatic stage of the tumor does not influence the treatment of the primary lesion. In this review, we discuss the various penile-preserving options currently available and their role in the management of penile carcinoma of various stages.

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Nodal metastasis is the most important prognostic factor in carcinoma of the penis. Clinical examination is inaccurate for diagnosing nodal involvement. Routine prophylactic block dissection carries a high risk of morbidity and a small but definite incidence of mortality. Procedures such as fine needle aspiration cytology with or without imaging guidance, anatomic sentinel node sampling, medial inguinal lymph node biopsy and dynamic sentinel node mapping, have all been tried, of which the last has proved most useful. Newer investigations like lymphotropic nano-particle enhanced MRI, squamous cell carcinoma antigen estimation and DNA flow cytometry are still experimental. It appears that in spite of numerous tests available for diagnosing metastatic disease in nodes before it becomes clinically apparent, the only test which currently holds promise is dynamic sentinel node mapping using radio isotopes with or without intraoperative colored dye, to identify the draining nodes for sampling. The only other alternative may be to recommend prophylactic node dissection in all T₂, T₃ or T₄ patients or in all patients with Grade 2 or 3 T₁ tumors, in whom the risk of nodal metastases is very high.

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Objective: Is it possible to predict inguinal metastasis in penile cancer? Materials and Methods: This is a retrospective analysis of 90 cases of squamous cell carcinoma of penis. The analysis involved a study of archival specimens by a single consultant pathologist. The grade and depth of invasion of the primary tumor was studied. We tried to establish a correlation with clinical positivity as determined by physical examination, grade of primary tumor, depth of invasion and inguinal lymph node metastasis. Results: Metastatic status was known in 44 of 64 patients with clinically palpable inguinal nodes and 18 of 26 with clinically negative nodes. Of 62, 27 had lymph node metastasis in which 16 were poorly differentiated primary tumor. Inguinal lymph node metastasis was seen in six of nine (66.66%) when depth of invasion was more than 8 mm. Conclusions: In well-differentiated tumors with less than 3mm depth of invasion, active surveillance of the node could be recommended. In the rest, it may be wise in our country to offer prophylactic modified inguinal lymphadenectomy to avoid progression of disease from loss to follow-up. Morbidity can be reduced with a modified inguinal lymph node dissection in a majority and also by using principles of plastic surgery in the remainder.

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The role of cytotoxic chemotherapy in the management of carcinoma of the penis is not clearly defined. Patients may receive chemotherapy in the neoadjuvant setting to help optimize surgery, the adjuvant setting to improve outcomes with surgery and in the setting of advanced disease for palliation. Chemotherapy may also be combined with radiation to increase response rates and improve survival. We have briefly reviewed the possible roles of chemotherapy in the management of carcinoma of the penis and present a retrospective analysis of a cohort of patients who received chemotherapy at our centre for carcinoma of the penis.

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Squamous cell carcinoma (SCC) of the oral cavity with metastasis to the urinary bladder is an unreported phenomenon. There are a few reports of transitional cell carcinoma of the bladder metastasizing to the oral cavity, though very rare. Thus, the possibility should always be borne in mind.

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A unilateral impacted lower ureteric calculus presenting as bilateral urinoma is rare, and spontaneous rupture of the ureter being the cause is even rarer. It is important to distinguish this uncommon condition from the much commoner condition of urinary extravasation from forniceal rupture. We are reporting a case of left lower ureteric calculus causing spontaneous rupture at the upper ureter presenting as bilateral retroperitoneal urinoma.

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The concept of sentinel lymph node was originally described in penile cancer. With technical developments and refinements it may have a role in staging men with penile cancer whose inguinal nodes are impalpable. We examined the current evidence supporting dynamic sentinel lymph node biopsy (DSLB). In particular we compared the false-negative rate compared to conventional inguinal lymph node dissection. Further, we discuss the advantages of the minimally invasive approach. Pioneering work in the Netherlands appears to be reducing the false-negative rates to acceptable levels. However, longer follow-up is necessary before recommending DSLB for cases of penile cancer with impalpable lymph nodes. Dynamic sentinel lymph node biopsy has great potential for avoiding the morbidity associated with inguinal lymph node dissection. More mature data is necessary prior to advocating its introduction outside of randomized controlled studies.

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