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   2016| April-June  | Volume 32 | Issue 2  
    Online since March 22, 2016

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Demography and disease characteristics of prostate cancer in India
Krishnamoorthy Hariharan, Venugopal Padmanabha
April-June 2016, 32(2):103-108
DOI:10.4103/0970-1591.174774  PMID:27127351
Introduction: The incidence of prostate cancer has shown significant variation across the globe. Though the prevalence and characteristics of this disease have been extensively studied in many countries, data regarding the true incidence of prostate cancer in India is limited. Materials and Methods: MEDLINE publications from 1990 to 2014 were searched and reviewed and compiled to assess the demographic profile of prostate cancer in India and characteristics unique to this disease in India. Results: The limited data available on prostate cancer showed significant differences in incidence, precipitating factors, and disease characteristics of prostate cancer in India. Conclusions: Since India would be having more number of cases of prostate cancer than most others in the years to come, adequate population-based data regarding the demography and disease characteristics of this disease are of paramount importance in this country.
  15,590 1,071 23
Is surgeon intuition equivalent to models of operative complexity in determining the surgical approach for nephron sparing surgery?
Pranav Sharma, Barrett Z McCormick, Kamran Zargar-Shoshtari, Wade J Sexton
April-June 2016, 32(2):124-131
DOI:10.4103/0970-1591.179191  PMID:27127355
Introduction: The choice of approach for partial nephrectomy often depends on surgical complexity. We aimed to determine if surgeon intuition was equivalent to markers of operative complexity, such as RENAL nephrometry and Mayo adhesive probability (MAP) score, in determining the surgical approach for partial nephrectomy (PN). Materials and Methods: We retrospectively identified 119 masses removed for suspected renal cell carcinoma from January 2012 to September 2014 by a single surgeon who intuitively chose treatment with one of three surgical approaches: Open PN (OPN), robotic-assisted transperitoneal PN (RATPN), or robotic-assisted retroperitoneal PN (RARPN). Clinicodemographic characteristics, pathological features, and postoperative outcomes were compared for each approach. Logistic regression was performed to identify independent predictors of open surgical resection, our primary endpoint. Results: Fifty-four tumors (45%) were resected via OPN, 40 (34%) via RATPN, and 25 (21%) via RARPN. OPN was performed in patients with more comorbidities (P = 0.02), lower baseline renal function (P < 0.01), more solitary kidneys (P < 0.01), and more multifocal disease (P < 0.01). Patients undergoing OPN had higher median nephrometry scores compared to RATPN and RARPN patients (8 vs. 7 vs. 7, respectively; P = 0.03), but MAP scores were no different among all three groups (P = 0.36). On multivariate analysis, higher nephrometry scores (odds ratio: 1.41, 95% confidence interval: 1.10-1.81; P = 0.007) were independently associated with open surgical resection. Nephrometry score was predictive of OPN (area under curve = 0.64, P = 0.01) with a score of 6.5 having the highest sensitivity and specificity (76% and 42%, respectively). Conclusions: RENAL nephrometry score was associated with surgical approach intuitively chosen by an experienced surgeon, but the presence of adherent perinephric fat did not correlate with decision-making.
  10,377 134 4
Ultra-mini-percutaneous nephrolithotomy: A minimally-invasive option for percutaneous stone removal
Madhu Sudan Agrawal, Ketan Agarwal, Tarun Jindal, Manoj Sharma
April-June 2016, 32(2):132-136
DOI:10.4103/0970-1591.174778  PMID:27127356
Introduction: Percutaneous nephrolithotomy (PCNL) has witnessed rapid advancements, the latest being ultra-mini-percutaneous nephrolithotomy (UMP), which makes the use of 11-13F sheaths as compared to 24-30F sizes used in conventional PCNL. This miniaturization aims to reduce morbidity and improve patient outcomes. We evaluated the safety and efficacy of UMP and report our ourtcomes. Patients and Methods: A total of 120 patients underwent UMP from July 2012 to March 2014. These patients had a single unilateral renal stone measuring between 8 and 20 mm. All patients underwent UMP using a 3F nephroscope, 7.5F inner sheath, and 11F or 13F outer metallic cannula, which served as the Amplatz sheath. Stone fragmentation and clearance were achieved with holmium laser. No nephrostomy or stent was used routinely. Results: Complete stone fragmentation was achieved in 114 out of 120 patients (95%) using UMP; whereas the remaining 6 were converted into mini-PCNL using a 12.5F nephroscope and 15F Amplatz sheath. The mean operative time was 39.7 ± 15.4 min, and the mean postoperative hospital stay was 22.3 ± 2.2 h. Postoperatively, 6 (5%) patients had residual fragments measuring ≤4 mm. At the 2 weeks follow-up, the stone-free status was >99% (119/120). There were no significant postoperative complications. Conclusion: This study shows UMP to be an effective and safe procedure for managing stones up to 20 mm. This procedure offers an attractive alternative to shock wave lithotripsy and retrograde intrarenal surgery for managing small stones.
  7,296 346 4
Reconstructive surgery for hypospadias: A systematic review of long-term patient satisfaction with cosmetic outcomes
Julie Adams, Aivar Bracka
April-June 2016, 32(2):93-102
DOI:10.4103/0970-1591.179178  PMID:27127350
Introduction: Research on long-term results of hypospadias has focused on surgical techniques and functional outcomes, and it is only recently that patient satisfaction with appearance and psychosocial outcomes have been considered. The aim of this study was to provide an evidence-based systematic review of adolescent and adult patient perceptions of cosmetic outcomes following childhood surgery for hypospadias. Methods: A systematic review was performed in accordance with the PRISMA and PICO guidelines, and studies assessed using the Oxford Centre for Evidence-Based Medicine system. MEDLINE, PsycInfo, EMBASE, and CINAHL databases were searched from 1974 to 2014 for clinical studies containing patient perceptions of appearance, deformity, and social embarrassment following hypospadias surgery. Results: A total of 495 publications were retrieved, of which 28 met the inclusion criteria. Due to study design/outcome measure, heterogeneity data were synthesized narratively. Results indicate (i) patient perceptions of penile size do not differ greatly from the norm; (ii) perceptions of appearance findings are inconsistent, partially due to improving surgical techniques; (iii) patients who are approaching, or have reached, sexual maturity hold more negative perceptions and are more critical about the cosmetic outcomes of surgery than their prepubertal counterparts; (iv) patients report high levels of perceptions of deformity and social embarrassment; and (v) there is a lack of data using validated measurement tools assessing long-term patient perceptions of cosmetic outcomes, particularly with patients who have reached genital maturity. Conclusions: Protocols for clinical postpuberty follow-up and methodologically sound studies, using validated assessment tools, are required for the accurate assessment of cosmetic and psychological outcomes of hypospadias surgery.
  7,021 304 9
Selective indication for check cystogram before catheter removal following robot assisted radical prostatectomy
Rajiv Yadav, Somendra Bansal, Narmada P Gupta
April-June 2016, 32(2):120-123
DOI:10.4103/0970-1591.174776  PMID:27127354
Introduction: With the improvement in anastomotic technique, it is rare to find anastomotic site leak after robot-assisted radical prostatectomy (RARP). It may not always be necessary to do regular check cystogram before catheter removal. We evaluated our 230 consecutive RARP patients and their cystograms to determine the indications for selective use of cystogram before catheter removal. Materials and Methods: We reviewed our prospectively collected RARP database of 230 consecutive patients. Cystography was performed at low pressure by gravity instillation of diluted contrast through the catheter. Patients were observed under fluoroscopy in lateral oblique position for any contrast leak at the site of anastomosis. All patients were followed for a minimum of 6 months, and the longest follow-up was 5 years. Results: A total of 207 patients (90%) underwent catheter removal on postoperative day 7. Nine patients (3.9%) had extravasation on initial cystogram. Two patients with leak had a history of transurethral resection of prostate (TURP) and seven other had bladder neck reconstruction for wide bladder neck. Three patients with minimal leak did not require catheter replacement. In rest of the 6 patient with leak, continued catheter drainage was done. No significant difference in the intraoperative variables, blood loss, duration of drain, length of hospital stay, and continence outcomes was noted between the patients with leak compared to rest of the patients. None of the patient needed any procedure/intervention related to the surgery and none developed bladder neck stenosis. Conclusion: In usual circumstances, catheter removal can be done safely on a postoperative day 7 without routine cystography. Selective use of check cystogram can be done in the case where bladder neck reconstruction is performed or those had a prior TURP and a wide bladder neck.
  6,588 145 3
Management of venous hypertension following arteriovenous fistula creation for hemodialysis access
Varun Mittal, Aneesh Srivastava, Rakesh Kapoor, Hira Lal, Tarun Javali, Sanjoy Sureka, Nitesh Patidar, Sohrab Arora, Manoj Kumar
April-June 2016, 32(2):141-148
DOI:10.4103/0970-1591.174779  PMID:27127358
Introduction: Venous hypertension (VH) is a distressing complication following the creation of arteriovenous fistula (AVF). The aim of management is to relieve edema with preservation of AVF. Extensive edema increases surgical morbidity with the loss of hemodialysis access. We present our experience in management of VH. Methods: A retrospective study was conducted on 37 patients with VH managed between July 2005 to May 2014. Patient demographics, evaluation, and procedures performed were noted. A successful outcome of management with surgical ligation (SL), angioembolization (AE), balloon dilatation (BD) or endovascular stent (EVS) was defined by immediate disappearance of thrill and murmur with resolution of edema in the next 48-72 h, no demonstrable flow during check angiogram and resolution of edema with preservation of AVF respectively. Results: All 8 distal AVF had peripheral venous stenosis and were managed with SL in 7 and BD in one patient. In 29 proximal AVF, central and peripheral venous stenosis was present in 16 and 13 patients respectively. SL, AE, BD, and BD with EVS were done in 18, 5, 4, and 3 patients, respectively. All patients had a successful outcome. SL was associated with wound related complications in 11 (29.73 %) patients. A total of 7 AVF were salvaged. One had restenosis after BD and was managed with AE. BD, EVS, and AE had no associated morbidity. Conclusions: Management of central and peripheral venous stenosis with VH should be individualized and in selected cases it seems preferable to secure a new access in another limb and close the native AVF in edematous limb for better overall outcome.
  5,695 243 5
Extended lymph node dissection in robotic radical prostatectomy: Current status
Sameer Chopra, Mehrdad Alemozaffar, Inderbir Gill, Monish Aron
April-June 2016, 32(2):109-114
DOI:10.4103/0970-1591.163303  PMID:27127352
Introduction: The role and extent of extended pelvic lymph node dissection (ePLND) during radical prostatectomy (RP) for prostate cancer patients remains unclear. Materials and Methods: A PubMed literature search was performed for studies reporting on treatment regimens and outcomes in patients with prostate cancer treated by RP and extended lymph node dissection between 1999 and 2013. Results: Studies have shown that RP can improve progression-free and overall survival in patients with lymph node-positive prostate cancer. While this finding requires further validation, it does allow urologists to question the former treatment paradigm of aborting surgery when lymph node invasion from prostate cancer occurred, especially in patients with limited lymph node tumor infiltration. Studies show that intermediate- and high-risk patients should undergo ePLND up to the common iliac arteries in order to improve nodal staging. Conclusions: Evidence from the literature suggests that RP with ePLND improves survival in lymph node-positive prostate cancer. While studies have shown promising results, further improvements and understanding of the surgical technique and post-operative treatment are required to improve treatment for prostate cancer patients with lymph node involvement.
  4,467 275 -
Molecular cystoscopy: Micro-RNAs could be a marker for identifying genotypic changes for transitional cell carcinoma of the urinary bladder
Nilay Mitash, Shalini Agnihotri, Balraj Mittal, Swasti Tiwari, Anil Mandhani
April-June 2016, 32(2):149-153
DOI:10.4103/0970-1591.174775  PMID:27127359
Introduction: Normal-looking mucosa may harbor genetic changes preceding a visible tumor. This study was aimed at exploring the role of the quantitative expression of micro-RNAs (miRNAs) in bladder cancer tissue in comparison with normal mucosa and healthy controls (HCs) as a molecular marker. Materials and Methods: Between October 2011 to December 2012, tissue from the bladder tumor of 21 patients (cases tumor, CT), normal mucosa (case control, CC) of the same patients (n-21) and normal bladder mucosa from 10 HCs were obtained. miRNAs of angiogenesis, endothelial mesenchymal transition and apoptosis were quantified using stem-loop RT Taq Man polymerase chain reaction. Statistical analysis was performed using the Chi square and independent sample T tests by using SPSS version 16. Results: The mean age of the patients and controls were 55.41 ± 11.03 and 52.14 ± 13.04 years. miR-21, miR-205, miR-126, miR-10b and miR-200a were highly expressed in CT (P < 0.027, <0.048, <0.025, <0.029 and < 0.005) as compared with HC. Expression of miR-21 and miR-129 were both correlated with grade and stage (P = 0.001 and < 0.009, respectively) and the level of expression was different in the same grade of non-muscle invasive tumors. The fold change of miR129, miR205 and miR200a was significantly higher in the normal-looking mucosa of bladder tumor patients than the HC (P < 0.005). Conclusion: Expression of miR129, miR205 and miR200a in the normal-looking mucosa of bladder cancer patients was significantly higher than the normal mucosa of a HC. This may help in predicting recurrence and formulating the follow-up strategy.
  4,212 171 3
Do we need new patient reported measures to evaluate lower urinary tract dysfunction?
Tristan R Keys, Ziya Kirkali, Gopal Badlani
April-June 2016, 32(2):91-92
DOI:10.4103/0970-1591.179177  PMID:27127349
  4,193 123 -
Instrument malfunction during robotic surgery: A case report
Shivanshu Singh, Girdhar S Bora, Sudheer S Devana, Ravimohan S Mavuduru, Shrawan K Singh, Arup K Mandal
April-June 2016, 32(2):159-160
DOI:10.4103/0970-1591.174781  PMID:27127362
Robotic assistance is the new dimension of minimally invasive surgery. Despite being the state-of-the-art technology, newer technical problems still occur during robotic surgeries which are not addressed in the trouble shooting manual. We report one such problem being encountered with the tip cover accessory of monopolar scissors. In the current report, we discuss the technical fault and its correction. We feel that this problem needs to be registered into the trouble-shooting manual to prevent such incidents in future.
  4,071 139 -
Successful management of renal mucormycosis with antifungal therapy and drainage
Sudheer K Devana, Girdhar S Bora, Ravimohan S Mavuduru, Pankaj Panwar, Nandita Kakkar, Arup K Mandal
April-June 2016, 32(2):154-155
DOI:10.4103/0970-1591.179192  PMID:27127360
We report a case of isolated extensive renal mucormycosis in an immunocompetent adult, who was successfully managed conservatively without surgical debridement. To the best of our knowledge, this is the first case where antifungal therapy alone was sufficient even with such an extensive involvement.
  3,994 183 3
Analysis of outcome following robotic assisted radical prostatectomy for patients with high risk prostate cancer as per D'Amico classification
Narmada Prasad Gupta, Anandan Murugesan, Anand Kumar, Rajiv Yadav
April-June 2016, 32(2):115-119
DOI:10.4103/0970-1591.179187  PMID:27127353
Introduction: Prognosis of prostate cancer depends on the risk stratification. D'Amico classification, the most commonly used risk stratification method is based on three factors, i.e., prostate specific antigen (PSA), Gleason grade and clinical stage. The impact of presence of multiple risk factors on prognosis after radical prostatectomy has not been studied in Indian patients. We analyzed the outcome of patients with high-risk disease undergoing robotic-assisted radical prostatectomy (RARP), as per D'Amico classification. Materials and Methods: Our study is a review of the data of all patients with high-risk prostate cancer who underwent RARP between July 2010 and January 2015. Preoperative, perioperative and outcome data were analyzed for patients with high-risk disease as per D'Amico classification. Results: Of 227 patients who underwent RARP, 90 (39.6%) were in the high-risk group. PSA > 20 ng/ml was the most common risk factor, present in 50 (55.6%) patients. All three risk factors were present in 3 patients, and single risk factor was present in 65 patients. Nine (10%) patients had lymphnode involvement, 18 (20%) had positive margin, and 38 (41.1%) had extraprostatic extension (EPE). Among these adverse outcomes, only EPE showed significant association with multiplicity of risk factors. At 12 months, 27.8% had biochemical recurrence (BCR). 92% of patients were continent at 12 months. Conclusion: About 92% of patients with high-risk disease were continent at 12 months, whereas less than one-third of the patients had BCR. EPE was the only outcome associated with multiplicity of risk factors. Adjuvant treatment is not required in two-thirds of patients.
  3,795 166 2
Steroid-responsive IgG4-related disease with isolated prostatic involvement: An unusual presentation with elevated serum PSA
Vikas Jain, Praveen Kumar Pandey, Chhagan Bihari
April-June 2016, 32(2):166-168
DOI:10.4103/0970-1591.174784  PMID:27127365
Autoimmune prostatitis is known to occur as a part of multisystem fibro-inflammatory disorder known as IgG4 related disease (IgG4 RD). The usual presentation is with symptoms of gastro-intestinal disease with prostatic involvement presenting as lower urinary tract symptoms. The disease responds to corticosteroids. We report an asymptomatic young man who was diagnosed to have IgG4 related prostatitis on TRUS-guided prostate biopsy done for elevated serum PSA, in the absence of any other systemic involvement. The treatment with steroid resulted in normalization of S PSA levels.
  3,832 128 -
Plateau pattern of detrusor contraction: A surrogate indicator of presence of external sphincter dysfunction during micturitional phase of urodynamic study
Mayank Mohan Agarwal, Saurabh Jain, Ravimohan Mavuduru, Shrawan K Singh, Arup K Mandal
April-June 2016, 32(2):137-140
DOI:10.4103/0970-1591.174777  PMID:27127357
Introduction: Dysfunctional voiding results from a disturbance in the coordination between sphincter relaxation and detrusor contraction. Video urodynamic studies with electromyography (EMG) are used for diagnosis but have limitations of availability and interpretation. We identified a plateau type voiding detrusor pressure tracing pattern in these patients with a potential of helping diagnosis. Materials and Methods: Urodynamic data and tracings of adult patients having been diagnosed with external urethral sphincter dysfunction (EUSD) were retrospectively analyzed. The urodynamic studies comprised of pressure flow studies, micturitional urethral pressure profilometry, and voiding cystourethrogram (VCUG). Diagnosis of EUSD was based on the presence of intermittent or continuous narrowing in the region of EUS on VCUG along with a urethral-vesical pressure gradient of >20 cmH 2 O in males and >5 cmH 2 O in females. Results: A total of 25 patients (14 men and 11 women) with a mean age 36.6 ± 16.5 years, presented with lower urinary tract symptoms (international prostate symptom score 18 ± 5) and were diagnosed with EUSD on urodynamics/cystourethrography. The cause of EUSD was neurogenic DESD in four, dysfunctional voiding in 20 and voluntary pelvic floor squeeze in one. Resting maximum urethral closure pressure at EUS was 142.2 ± 38.3 cmH 2 O in both sexes. Three patients had detrusor overactivity. EMG activity during voiding was high in 10 patients, low in three, inconclusive in seven, and not performed in three. A "plateau type pattern" of detrusor contraction was observed in all the patients. This was qualitatively different from the roughly bell-shaped curve of detrusor contraction in men with prostatic obstruction (n = 14) and women with stress urinary incontinence (n = 11). Conclusions: Patients with EUSD have a characteristic plateau pattern of detrusor contraction on urodynamics which can be used as a surrogate for urodynamic diagnosis of nonrelaxing EUSD.
  3,782 155 1
Adrenocortical carcinoma with inferior vena cava thrombus: Renal preserving surgery
Rahul Yadav, Vimal Dassi, Anant Kumar
April-June 2016, 32(2):161-163
DOI:10.4103/0970-1591.174782  PMID:27127363
Adrenocortical carcinoma with tumor thrombus extending via an adrenal vein into the inferior vena cava is uncommon. We describe a left side kidney-preserving surgery in such a patient where, after transection of the main renal vein at the point of insertion of the adrenal vein, the left kidney was being drained by lumbar and gonadal veins.
  3,780 120 1
Patient-reported outcomes: The next step?
Anil Mandhani
April-June 2016, 32(2):89-90
DOI:10.4103/0970-1591.179165  PMID:27127348
  3,738 125 -
Urethral duplication with unusual cause of bladder outlet obstruction
Vivek Venkatramani, Arun Jacob Philip George, J Chandrasingh, Arabind Panda, Antony Devasia
April-June 2016, 32(2):156-158
DOI:10.4103/0970-1591.174780  PMID:27127361
A 12-year-old boy presented with poor flow and recurrent urinary tract infections following hypospadias repair at the age of 3 years. The evaluation revealed urethral duplication with a hypoplastic dorsal urethra and patent ventral urethra. He also had duplication of the bladder neck, and on voiding cystourethrogram the ventral bladder neck appeared hypoplastic and compressed by the dorsal bladder neck during voiding. The possibility of functional obstruction of the ventral urethra by the occluded dorsal urethra was suspected, and he underwent a successful urethro-urethrostomy.
  3,617 133 -
Pseudoaneurysm secondary to transvesical prostatectomy
Lucio Dell'Atti, Roberto Galeotti
April-June 2016, 32(2):164-165
DOI:10.4103/0970-1591.174783  PMID:27127364
Pseudoaneurysms associated with the internal pudendal artery is rare and may occur as a complication of prostatic surgery or or pelvic trauma. We present images of the first case in literature of an isolated pseudoaneurysm secondary to transvesical prostatic adenomectomy, which was successfully treated by transarterial coil embolization. This complication can be difficult to diagnose, manage, and cause significant postoperative bleeding. Management requires as a multidisciplinary approach.
  3,140 99 1
Peri-incisional catheters through open surgical wound in converted nephrectomies: A novel modification of transverse abdominis plane block
Amit Kumar Mittal, Nitesh Goel, Jitendra Kumar Dubey, Prashant Bansal, Amitabh Singh
April-June 2016, 32(2):169-170
DOI:10.4103/0970-1591.179194  PMID:27127366
  2,977 97 1
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