The clinical conundrum of a catecholamine secreting giant adrenal myelolipoma.

Adrenal myelolipomas are uncommon tumours of unknown aetiology. They arise from the adrenal cortex and comprise lipomatous and myeloid elements. They are considered to be functionally inert, and metabolic evaluation is not mandatory for them. Adrenal myelolipomas can rarely be functionally active, and patients may present with hypertension, electrolyte imbalance or features of Cushing's syndrome. The association of these tumours with catecholamine secretion is exceptionally rare. We describe a case of a functional adrenal myelolipoma associated with catecholamine secretion in a 55-year-old female patient with a history of hypertension. The surgical excision of the mass resulted in normalisation of the urinary catecholamine levels and resolution of the hypertension.

Unusual presentation of castrate-resistant prostate cancer with urethral and inguinal nodal metastasis.

Metastatic involvement of the urethra is a rare finding in patients with carcinoma prostate. The signs and symptoms overlap with those of a primary urethral malignancy. The diagnosis is made following a biopsy of the suspected lesions. We describe the case of a 66-year-old patient with carcinoma prostate who presented with penile pain, 18 months after the treatment with androgen deprivation therapy. Ga-68 prostate-specific membrane antigen positron emission tomography/computed tomography helped in the identification of the urethral and inguinal nodal metastasis, which was confirmed histologically. We also discuss the management of this unusual clinical scenario.

Pulmonary lymphangitis carcinomatosa in a patient with carcinoma of urinary bladder.

Pulmonary lymphangitis carcinomatosa occurs due to dissemination of cancer cells in pulmonary lymphatics. It is only rarely seen with urological malignancies and portends a grave prognosis. Its presence in patients with urothelial carcinoma of the urinary bladder is uncommon. We present a case of a nested variant of transitional cell carcinoma of the urinary bladder associated with pulmonary lymphangitis carcinomatosa. We also discuss the symptoms and radiological features that might aid in timely diagnosis of this entity.

Solitary fibrous tumor of the ovary.

Solitary fibrous tumors commonly occur in the pleura and are rare elsewhere, especially in the female genital system. We present a case of a solitary fibrous tumor arising from the ovary in a young female in the reproductive age group. The tumor could be excised laparoscopically. We also describe the histopathological and immunohistochemical features that can help establish its diagnosis.

Impact of travel distance to the treatment facility on overall mortality in US patients with prostate cancer.

BACKGROUND: The objective of this study was to investigate the impact of travel distance to the treating facility on the risk of overall mortality (OM) among US patients with prostate cancer (PCa). METHODS: In total, 775,999 patients who had PCa in all stages and received treatment with different strategies (radical prostatectomy, radiation therapy, observation, androgen-deprivation therapy, multimodal treatment, and chemotherapy) were drawn from the National Cancer Data Base from 2004 through 2012. Independent predictors of travel distance (intermediate [12.5-49.9 miles] and long [49.9-249.9 miles] vs short[<12.5 miles]) and its effect on OM were calculated using multivariable regression analyses. Additional analyses evaluated the distance effect on OM in selected subgroups. RESULTS: In total, 54.5%, 33.4%, and 12.1% of patients traveled short, intermediate, and long distances, respectively. Residency in rural areas and the receipt of treatment at academic/high-volume centers independently predicted long travel distance. Non-Hispanic black men and Medicaid-insured men were less likely to travel long distances (all P < .001). Overall, traveling a long distance (hazard ratio, 0.87; 95% confidence interval, 0.83-0.92; P < .001) was associated with lower OM risk compared with traveling a short distance. This held true among non-Hispanic white men; privately insured and Medicare-insured men; those who underwent radical prostatectomy, received radiation therapy, and received multimodal strategies; and those who received treatment at academic/high-volume centers (P < .01), but not among non-Hispanic black men (P = .3). Long travel distance was associated with an increased OM in Medicaid-insured patients (P < .001). CONCLUSIONS: An OM benefit was observed among men who traveled long distances for PCa treatment, which is likely to be a reflection of centralization of care and more favorable patient-level characteristics in those travelers. Furthermore, the survival benefit mediated by long travel distances appears to be influenced by baseline socioeconomic, treatment, and facility-level factors. Cancer 2017;123:3241-52. © 2017 American Cancer Society.

Ultra-mini-percutaneous nephrolithotomy: A minimally-invasive option for percutaneous stone removal.

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.

Transrectal ultrasonography (TRUS)-guided pelvic plexus block to reduce pain during prostate biopsy: a randomised controlled trial.

OBJECTIVE: To assess the role of pelvic plexus block (PPB) in reducing pain during transrectal ultrasonography(TRUS)-guided prostate biopsy, compared with the conventional periprostatic nerve block (PNB). PATIENTS AND METHODS: A prospective, double-blind observational study was conducted with patients being randomised into three groups. Group-1 (47 patients) received intrarectal local anaesthesia (IRLA) with 10 mL 2% lignocaine jelly along with pelvic plexus block (PPB) with 2.5 mL 2% lignocaine injection bilaterally. Group-2 (46 patients) received IRLA with periprostatic nerve block (PNB). Group-3 (46 patients) received only IRLA without any type of nerve block. The patients were requested to rate the level of pain from 0 to 10 on a visual analogue scale (VAS) at two time points: VAS-1: during biopsy procedure and VAS-2: 30 min after the procedure. RESULTS: The mean age of the patients, mean volume of the prostates and mean serum PSA values were comparable among the three groups. The mean pain score during biopsy was significantly less in the PPB group [mean (range) sore of 2.91 (2-4)] compared with the PNB group [mean (range) score of 4 (3-5)], and both these groups were superior to the no nerve block group [mean score of 5.4 (3-7)]. There was no significant difference between the mean pain scores, 30 min after the procedure among the three groups with the mean (range) scores being 2.75 (2-4), 2.83 (2-4) and 2.85 (2-4), respectively. CONCLUSION: PPB is superior to conventional periprostatic nerve block (PNB) for pain control during TRUS-guided biopsy and both are in turn superior to no nerve block.

Misinterpretation of the international prostate symptom score questionnaire by Indian patients.

INTRODUCTION: The international prostate symptom score (IPSS) is commonly used in the evaluation of the severity of symptoms of patients with prostatic enlargement. It is a self-administered questionnaire. It has not been validated in any Indian language and an English version is used which can be difficult to interpret by our patients who do not have English as their primary language. In this study, we evaluate the patient's ability to understand the IPSS by comparing the scores when the IPSS questionnaire was self-administered versus when it was administered using the assistance of a clinician. MATERIALS AND METHODS: Patients who presented with lower urinary tract symptoms suggestive of benign prostatic hyperplasia, who had passed at least twelfth grade of school and had a reasonable command over English were included in the study. They were allowed to self-administer the IPSS questionnaire following which a clinician, blinded to these scores, assisted the patient in filling the questionnaire. For each question, the score in both the questionnaires was noted and kappa agreement statistical test was used to assess the agreement between the two scores. RESULTS: A total of 87 patients were included in the study. It was found that none of the questions had a perfect agreement of scores in the self-administered and the assisted administration. CONCLUSION: Our results show that our patients misinterpret the IPSS questionnaire. This problem can lead to significant errors in interpretation of the symptom severity.

Robot-Assisted Video Endoscopic Inguinal Lymph Node Dissection for Penile Cancer: An Indian Multicenter Experience.

Objective: To report outcomes of multicenter series of penile cancer patients undergoing robot-assisted video endoscopic inguinal lymph node dissection (RA-VEIL). Materials and Methods: In this retrospective analysis from 3 tertiary care centers in India, consecutive intermediate-/high-risk carcinoma penis (CaP) patients with nonpalpable inguinal lymphadenopathy and/or nonbulky (<3 cm) mobile inguinal lymphadenopathy undergoing RA-VEIL were included. Patients with matted/bulky (>3 cm) and fixed lymphadenopathy were excluded. Demographic, clinical, and intraoperative data were recorded. Perioperative complications were graded by the Clavien-Dindo classification (CDC). The International Society of Lymphology (ISL) {0-III} grading was used for the assessment of lymphedema. Incidence and pattern of recurrences were assessed on follow-up. Results: From January 1, 2011, to September 30, 2023, 115 patients (230 groins) underwent bilateral RA-VEIL for CaP. The median age of the cohort was 60 (50-69) years. Clinically palpable (either unilateral or bilateral) inguinal lymphadenopathy was seen in 54 patients (47%). The "per groin" median operative time was 120 (100-140) minutes with median lymph node yield of 12 (9-16). No complications were recorded in 87.8% groins operated, with major complications (CDC 3) seen in 2.6% groins. At a median follow-up of 13.5 months, 13 patients had documented recurrences and there were 10 cancer-related deaths. No port-site recurrences were observed. No/minimal lymphedema (ISL 0/I) was seen in 94% legs. Conclusion: RA-VEIL demonstrates safety and oncologic efficacy in penile cancer patients presenting with clinically nonpalpable and/or nonbulky inguinal lymphadenopathy, with favorable functional outcomes.

Complications and adverse events in lymphadenectomy of the inguinal area: worldwide expert consensus.

BACKGROUND: Inguinal lymph node dissection plays an important role in the management of melanoma, penile and vulval cancer. Inguinal lymph node dissection is associated with various intraoperative and postoperative complications with significant heterogeneity in classification and reporting. This lack of standardization challenges efforts to study and report inguinal lymph node dissection outcomes. The aim of this study was to devise a system to standardize the classification and reporting of inguinal lymph node dissection perioperative complications by creating a worldwide collaborative, the complications and adverse events in lymphadenectomy of the inguinal area (CALI) group. METHODS: A modified 3-round Delphi consensus approach surveyed a worldwide group of experts in inguinal lymph node dissection for melanoma, penile and vulval cancer. The group of experts included general surgeons, urologists and oncologists (gynaecological and surgical). The survey assessed expert agreement on inguinal lymph node dissection perioperative complications. Panel interrater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α. RESULTS: Forty-seven experienced consultants were enrolled: 26 (55.3%) urologists, 11 (23.4%) surgical oncologists, 6 (12.8%) general surgeons and 4 (8.5%) gynaecology oncologists. Based on their expertise, 31 (66%), 10 (21.3%) and 22 (46.8%) of the participants treat penile cancer, vulval cancer and melanoma using inguinal lymph node dissection respectively; 89.4% (42 of 47) agreed with the definitions and inclusion as part of the inguinal lymph node dissection intraoperative complication group, while 93.6% (44 of 47) agreed that postoperative complications should be subclassified into five macrocategories. Unanimous agreement (100%, 37 of 37) was achieved with the final standardized classification system for reporting inguinal lymph node dissection complications in melanoma, vulval cancer and penile cancer. CONCLUSION: The complications and adverse events in lymphadenectomy of the inguinal area classification system has been developed as a tool to standardize the assessment and reporting of complications during inguinal lymph node dissection for the treatment of melanoma, vulval and penile cancer.

The risk of radiation exposure to assisting staff in urological procedures: a literature review.

Fluoroscopy is an integral part of urology and is used for various procedures, such as extra-corporeal shock wave lithotripsy, percutaneous nephrolithotomy, uretero-renoscopy, and ureteral stenting. This technique exposes the urologist and assistants to radiation, which is known to have deleterious effects. Although there have been studies that determine the amount of exposure and the risks to the operating urologist, the risk to the assisting staff remains largely undetermined. A literature review was conducted to determine the risk of radiation exposure during urological procedures, with emphasis on data concerning assisting staff. Data from nine major studies is presented in this article.

A retrospective analysis of the factors associated with increased risk of readmission within 30 days after primary transurethral resection of bladder tumor.

Background: Transurethral resection of bladder tumor (TURBT) is associated with perioperative morbidity of 5% to 10%, which can lead to unplanned readmissions. In this study, we aimed to identify the factors that lead to an increased risk of unplanned readmissions within 30 days of primary TURBT. Materials and methods: A retrospective study was conducted to identify patients who underwent primary TURBT at our institute from 2011 to 2019. Clinical and demographic factors, history of smoking, antiplatelet drugs intake, comorbidities, tumor size (<3 or >3 cm), multifocality, and histopathological type were abstracted. Patients who were readmitted were identified, and reasons for admission were recorded. Results: A total of 435 patients were identified. The median age of the patients was 66 years. From 378 male patients (86.9%), 110 (25.3%) and 37 (8.5%) had a history of smoking and antiplatelet agents intake, respectively. In the cohort, 166 patients (38.2%) were diabetic, 239 (54.9%) were hypertensive, 72 (16.6%) had chronic obstructive pulmonary disease, and 78 (7.9%) had hypothyroidism. A total of 206 patients (47.4%) had a tumor >3 cm; multifocality was seen in 140 (32.2%) patients, whereas muscle invasive tumors were present in 161 patients (37%). A total of 22 patients (5.06%) had readmissions within 30 days, with hematuria being the most common etiology. On univariate and multivariate analyses, a history of smoking (p = 0.006 and p = 0.008, respectively) or antiplatelet agents intake (p < 0.001 and p < 0.001, respectively) was significantly associated with increased unplanned readmission. Conclusions: Our study revealed smoking and antiplatelet agents intake as factors leading to an increased risk of unplanned readmissions.

Comparison of the efficacy and safety of topical diltiazem and nitroglycerine for pain relief during transrectal ultrasound guided biopsy of the prostate.

INTRODUCTION AND OBJECTIVE: Transrectal ultrasound biopsy of prostate is a painful procedure. The introduction of the rectal probe is one of the major contributors to the pain associated with this procedure. Drugs that relax the anal sphincter should theoretically decrease this pain. This study was done to compare the efficacy and safety of two topical medications that relax the anal sphincter, diltiazem and nitroglycerine, in decreasing the pain associated with transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS: 66 patients who were to undergo their first prostate biopsy were randomized to receive either 2 mL of 2 % topical diltiazem or 2 mL of 0.2 % topical nitroglycerine or placebo 20 minutes before prostate biopsy. All patients also received 15 mL of intrarectal lignocaine. A 10-point visual analogue score was used to record the pain immediately after the insertion of the probe, during biopsy and at the end of the procedure. RESULTS: The pain scores due to probe insertion, during biopsy and at the end of the procedure in patients who received topical diltiazem or nitroglycerine were significantly lower compared to the placebo group (p < 0.001). There were no significant differences in the pain scores between the patients receiving diltiazem compared to those receiving nitroglycerine. Higher incidence of headache and fall in blood pressure was noted in patients who received nitroglycerine compared to those receiving diltiazem. CONCLUSION: Topical diltiazem and nitroglycerine are equally effective in reducing the pain associated with transrectal prostatic biopsy. Diltiazem is safer compared to nitroglycerine.

Catheter-induced urethral erosion.

Indwelling bladder catheters are often placed when a patient requires voiding assistance. Long-term use of these catheters has been associated with significant morbidity This case presentation describes a complete erosion of the glans, urethra, and penile skin, up to the penoscrotal junction, as an outcome from long-term use of an indwelling bladder catheter. Appropriate nursing interventions can prevent this devastating health care outcome.

Para-aortic nodal metastasis of mesenteric perivascular epithelioid cell tumor (PEComa).

Perivascular epithelioid cell tumors (PEComas) are a group of tumours of mesenchymal origin having a characteristic pathological presence of the epitheloid cell around blood vessels. They are uncommon tumours and hence their exact etiology and pathogenesis remain unclear. They can occur at any part of the body but the common sites of involvement are the gastrointestinal system and the genitourinary system. The isolated involvement of the intestinal mesentery is very rare, with only a few cases reported in the literature till date. The involvement of lymph nodes by these tumours is exceptionally rare. We report a hitherto undescribed case of mesenteric PEComa in a young female who developed para-aortic nodal metastasis.

Prevalence of hepatitis B virus and hepatitis C virus among blood donors at a tertiary care hospital in India: a five-year study.

BACKGROUND: Hepatitis B virus (HBV) and hepatitis C virus (HCV) are important transfusion-transmissible infections. This study was performed to assess the prevalence of HBV and HCV seropositivity among blood donors at a tertiary care hospital-based blood bank in India. STUDY DESIGN AND METHODS: The blood donation records over 5 years (2005-2009) were reviewed, retrospectively, for the prevalence and yearly trends of HBV and HCV seropositivity. RESULTS: A total of 94,716 donations were received. The overall number of HBV-seropositive donations was 1353 and that for HCV was 537, with the prevalence rates of 1.43% for hepatitis B surface antigen (HBsAg) and 0.57% for HCV. The seropositivity rate was higher in the replacement donors compared to the voluntary donors. The annual rates showed decreasing trends in case of HBsAg, but in case of HCV, there was a linear increase. CONCLUSIONS: Our study raises serious concerns regarding the HBV and HCV prevalence in our country. Although HBV showed decreasing trends, it cannot be relied upon because the donors were screened only for HBsAg. HCV is clearly on the rise. Stringent measures need to be taken on urgent basis including dissemination of information, strict screening of blood, inclusion of antibody to hepatitis B core antigen and other sensitive markers to the screening protocol, and better donor recruitment.

Laparoscopic and robotic video endoscopic inguinal lymphadenectomy by the lateral approach.

INTRODUCTION: Video endoscopic inguinal lymphadenectomy (VEIL) improves on open inguinal node dissection because it offers decreased morbidity. In conventional VEIL, port placement is along the long axis of the femur, above the knee joint. In the laparoscopic approach, this placement is fraught with problems because the camera hits the knee, the surgeon must reach over the camera, and sword fighting occurs between the instruments. In the robotic approach, external collisions are likewise not uncommon because of a lack of optimal spacing between the robot's arms. Here, we describe our lateral approach technique that can be used for both laparoscopic and robotic platforms and can help solve the problems presented by conventional VEIL. METHODS: A retrospective review was performed to examine the records of all patients who had undergone VEIL at our institution for management of squamous cell carcinoma of the penis. Patients who had undergone lateral VEIL were identified. The clinical factors, surgery details, time to discharge and drain removal, postoperative complications, and nodal pathology were recorded. RESULTS: A total of 30 VEILs-26 laparoscopic and 4 robotic-were performed by the lateral approach. On clinical examination, none of the patients had clinically palpable nodes. The mean operative time on one side was 100 minutes (range, 80-140 minutes). The blood loss was minimal in all cases, and there were no conversions to open procedures. The mean time to drain removal was 7 days (range, 5-12 days). Two patients developed bilateral lymphoceles. CONCLUSIONS: Lateral VEIL is feasible and can be used as an alternative to conventional VEIL.

Laparoscopic management of isolated metachronous adrenal metastases in a patient with esophageal cancer: a case report.

BACKGROUND: The presence of isolated metachronous adrenal metastasis in patients with esophageal cancer is rare. There is significant controversy regarding the management of such patients. Adrenal metastasectomy has been shown to be of benefit in some reports. Minimally invasive approach, although the gold standard for adrenalectomy, has not been used commonly in a postesophagectomy setting owing to the anticipated technical difficulties. We describe one such case wherein this approach helped in early recovery and long-term survival. CASE PRESENTATION: A 59-year-old male of Asian ethnicity presented with an isolated left adrenal nodule, 3 years after an Ivor Lewis esophagectomy for a lower esophageal adenocarcinoma. The biopsy of the nodule was suggestive of metastatic adenocarcinoma. The patient underwent laparoscopic excision of the left adrenal gland. CONCLUSION: Adrenal metastasectomy, in postesophagectomy patients can provide good oncological control. Laparoscopic approach, though technically challenging, can provide results equivalent to those of open surgery, albeit with less morbidity.

Simplifying Laparoscopic Nephrectomy for Beginners: Double Window Technique With En Bloc Hilar Stapling.

Laparoscopic nephrectomy is a commonly performed procedure. As with any surgical procedure, this too has a significant learning curve. The management of renal hilum is the most critical part of this surgery. It requires a meticulous intra-hilar dissection to identify the renal artery and vein. The kidneys are extremely vascular structures and any injury to these vessels during dissection can result in life-threatening bleeding. Hence, it is obvious that beginners most often face difficulty and apprehension at this step of the laparoscopic nephrectomy. We describe a simple technique of laparoscopic nephrectomy which includes the creation of two windows, one at the lower pole and the second at the upper pole, isolation of the hilum, and en bloc stapling of the renal hilar vessels. This method safeguards against collateral damage to the surrounding structures. It also avoids the need for intra-hilar dissection, hence decreasing the chances of vascular injuries.

The use of preoperative neutrophil-lymphocyte ratio and lymphocyte-monocyte ratio in predicting survival and groin node involvement of patients with squamous cell carcinoma of penis.

INTRODUCTION: The association between inflammation and malignancies is being recognized. In this study, we assessed the use of preoperative neutrophil-lymphocyte ratio (NLR) and lymphocyte-monocyte ratio (LMR) in predicting cancer-specific survival (CSS) and inguinal node involvement in patients with carcinoma penis. METHODS: Sixty-nine patients operated for squamous cell carcinoma penis with inguinal node dissection between 2012 and 2020 were identified. We recorded the type of surgery (partial/total penectomy), T stage, grade, lymphovascular invasion (LVI), perineural invasion (PNI), pathological status of inguinal nodes and nodal stage (pN1-3), extranodal extension (ENE), and CSS. The hemogram performed within 2 weeks of surgery was used for calculating NLR and LMR. RESULTS: Partial penectomy was the most common surgery (65.22%) and pT2 was the most common stage (53.62%). Grade 2 was seen in 66.67%, LVI in 34.78%, PNI in 37.68%, 52.17% had inguinal node involvement with pN3 being the most common (36.23%), and 36.23% had ENE. Kaplan-Meier analysis revealed that NLR of >3 and the LMR ≤3 indicated an inferior CSS (P = 0.05 and 0.04, respectively). T stage, inguinal node involvement, LVI, pN stage, and ENE were also associated with inferior CSS (P < 0.05). On multivariate analysis, T stage was significantly associated with CSS (P = 0.02). The NLR >3 and LMR ≤3 were also significantly associated with the presence of pathological inguinal node involvement (P = 0.001 and 0.026). CONCLUSION: NLR and LMR may help in predicting CSS and inguinal node involvement in patients of carcinoma penis.