Is low-dose tadalafil better than tamsulosin? A randomized controlled trial in shockwave lithotripsy for solitary upper tract calculi.

OBJECTIVE: To ascertain whether low-dose tadalafil (5 mg) is more efficient than tamsulosin (0.4 mg) in facilitating calculus expulsion in those receiving extracorporeal shockwave lithotripsy for solitary upper urinary tract calculi. PATIENTS AND METHODS: This was a triple-blinded, prospective, superiority, randomized controlled, single-centre trial. A total of 250 patients with solitary renal or ureteric calculus measuring 6-24 mm were randomized (1:1) to receive either 0.4 mg tamsulosin or 5 mg tadalafil daily for 30 days or until calculus clearance, whichever was earlier. RESULTS: There was no difference in the primary outcome, namely, calculus expulsion rate at 30 days (tamsulosin vs tadalafil, n (%) 99 [81.1%] vs 98 [80.3%] respectively, 95% confidence interval = 0.8% [-9.0, 10.7], P = 0.874). Similarly, a lack of difference was also noted in the secondary outcome, number of days to expulsion (tamsulosin vs tadalafil, geometric mean [SD] 13.59 [2.39] vs 13.74 [2.39] respectively, P = 0.928). Four patients discontinued the drug due to adverse drug reactions in the tadalafil group. CONCLUSIONS: Low-dose tadalafil is not superior to tamsulosin in improving calculus expulsion when used as an adjunct to shockwave lithotripsy. In this study, we also noted that tadalafil was less tolerated.

Pelvic fracture urethral injury in adolescents - Predictors of outcomes and surgical complexity.

INTRODUCTION: Pelvic fracture urethral injury (PFUI) is more severe in younger individuals. The adolescent group is prone to protracted morbidity due to severity of the injury and its impact on lifestyle. Hence, treatment options and data on outcomes are crucial in planning management. The adolescents are a subgroup in several series of PFUI, but literature exclusively studying this group is sparse. MATERIALS & METHODS: A retrospective review of all adolescents (aged between 10 and 19 years as defined by WHO) who underwent surgical repair for PFUI between January 2005 and December 2019 was conducted. Success was defined as a bell-shaped urine flow curve and Qmax of >15 ml/s, no evidence of re-stricture (on cystoscopy/MCU), and no re-intervention. Measurements of the length of the urethral defect and bulbar urethra were done using a digital scale by the radiologist from micturating cystourethrogram (MCU). The Gapometry/Urethrometry (GU) index was calculated as the ratio of the length of the urethral defect to that of the bulbar urethra. Data was analysed using SPSS software version 20.0 and Stata Version 16. The primary outcome was the success of anastomotic urethroplasty. Secondary outcomes were evaluating factors predicting operative complexity (simple perineal versus elaborate perineal approach). RESULTS: We studied 22 patients, out of which 8 were referred following prior failed intervention elsewhere. The mean age was 16.5 + 2.7 years. All the patients were treated using a perineal approach with an overall success rate of 90.9%. Two patients had a failure and were managed with Endoscopic Internal Urethrotomy (EIU), and urethral dilatation. The median follow-up was 24 months. All 8 patients with prior failed interventions had a successful outcome. Twelve patients required inferior pubectomy (elaborate perineal approach). The median length of the urethral defect (2.3 cm IQR- 1.45,3.30 vs. 1 cm, IQR-0.65, 1.6) and the mean GU index (0.45 ± 0.18 cm vs. 0.25 cm ± 0.12 cm) were significantly higher in those who required an elaborate perineal approach. CONCLUSIONS: The perineal approach for surgical repair (anastomotic urethroplasty) of pelvic fracture urethral injury has a favourable success rate of 90.9% in adolescents. Re-do anastomotic urethroplasty for prior failed repairs also had a high success rate of 100%. Cases requiring an elaborate perineal approach were associated with a significantly higher Gapometry/Urethrometry Index (>0.45) and length of the urethral defect (>2.3 cm). This information may assist in patient counselling and preparation for additional steps during repair.

Effect of hypospadias on sexual function and reproduction.

Hypospadias is a highly prevalent congenital anomaly. The impact of the defect and operative interventions on sexual and reproductive function has been addressed by few publications. It is essential to know the possible outcomes of intervention for appropriate counseling, operative planning, and follow-up. English articles indexed in Pubmed dealing with the long-term sexual and reproductive outcome following hypospadias repair from 1965 to 2007 were reviewed. To our knowledge, there was no prospective trial comparing the impact of various techniques on sexual outcome. There is considerable discordance in literature regarding the effects on sexual function. A few publications report patient and partner dissatisfaction with the appearance of genitalia. Sexual dissatisfaction is often attributed to penile size. Ejaculatory disturbances range between 6 and 37% of operated individuals. There is no convincing evidence for impaired fertility. The long-term follow-up is essential to identify problems and to address them appropriately. Literature documenting the outcome of specific operative procedures and analysis based on severity of hypospadias will be informative. The long-term follow-up of the newer techniques which are more commonly used are awaited.

Testicular microlithiasis: Is there an agreed protocol?

This review addresses the issues on etiopathogenesis of testicular microlithiasis (TM), associated clinical entities, evaluation and follow-up of patients with TM. A literature search of Medline/PubMed was carried out using the keywords 'testicular microlithiasis' and 'testicular calcifications' for published data in English language on TM from 1970 to 2006. TM is an uncommon entity among adult males, resulting from intratubular calcifications. The reported incidence of TM is highly variable. With the increasing frequency of ultrasound examination in scrotal and testicular conditions and with the advent of high frequency transducers, TM is increasingly being reported. TM is associated with many benign and malignant conditions of testes but the possible association of TM with testicular cancer has been a matter of concern. Though a few sporadic cases of testicular malignancies have been reported, it is believed that a conservative approach is warranted in the absence of high risk factors, in view of the low risks for invasive cancers. There is no uniform protocol for the evaluation and follow-up of the patients with TM. Those with high risk factors like contralateral testicular tumour, chromosomal anomalies, gonadal dysgenesis, cryptorchidism and definite ultrasound pattern of TM should be advised to have further evaluation. Incidentally detected asymptomatic TM during ultrasound examination does not warrant aggressive measures and it can be followed with self examination.

Transitional cell carcinoma of the renal pelvis with venous tumor thrombus.

Renal cell carcinoma (RCC) is the most common malignancy that results in venous tumor thrombosis. Transitional cell carcinoma of the renal pelvis with renal or vena cava thrombus is extremely rare. Fewer than 40 cases have been reported. We report a similar case of a patient who underwent radical nephrectomy with a preoperative diagnosis of RCC.

Erectile dysfunction.

With phosphodiesterase inhibitors, a safe and effective oral therapy has emerged for erectile dysfunction. Increasing awareness, particularly through the media, is inducing more men to seek help for this condition. Erectile dysfunction is defined as the persistent inability to achieve or maintain an erection adequate for satisfactory sexual activity. The prevalence increases with age. Basic and clinical research is identifying the neurovascular and humoral control of the mechanisms. The initial evaluation should differentiate erectile dysfunction from premature ejaculation and loss of libido. Myocardial insufficiency, hypogonadism and peripheral neuropathy should be looked for. Initial laboratory investigations should be restricted to identifying previously undetected medical illness that may directly contribute to erectile dysfunction. Discussing the available options with the couple is an important aspect. If erectile dysfunction is secondary to other treatable disorders these should be treated simultaneously. When other diseases that require intervention are ruled out and if there are no contraindications, therapy may be initiated with a phosphodiesterase inhibitor. In selected cases, psychosexual therapy may be beneficial. If phosphodiesterase inhibitors are contraindicated, vacuum constriction devices may be tried. Further options include intracavemosal injection, intraurethral instillation, penile revascularization and prosthesis. The availability of effective and well-tolerated oral medications has dramatically changed the clinical approach to erectile dysfunction. Pharmacotherapy is the preferred cost-effective first-line therapy in the vast majority of patients. A stepped-care approach is followed in the primary care and family practice settings. Appropriate urological, endocrine and psychiatric referrals, and shared decision-making with the couple will enable effective treatment of men with erectile dysfunction.

Hidden penile fracture: An unusual presentation and review of literature.

Penile fractures, a not so uncommon urological emergency, mostly present with a characteristic history and physical examination. Here, we present an atypical case where even in the absence of physical findings, a characteristic history led us to penile exploration and timely repair, highlighting the importance of careful history-taking in these cases.

Cutaneous Fusarium infection in a renal transplant recipient: a case report.

INTRODUCTION: Fungal infections in the immunocompromised host are fairly common. Of the mycoses, Fusarium species are an emerging threat. Fusarium infections have been reported in solid organ transplants, with three reports of the infection in patients who had received renal transplants. To the best of our knowledge, this is the first case of an isolated cutaneous lesion as the only form of infection. CASE PRESENTATION: We report the case of a 45-year-old South Indian man who presented with localized cutaneous Fusarium infection following a renal transplant. CONCLUSION: In an immunocompromised patient, even an innocuous lesion needs to be addressed with the initiation of prompt treatment.

Contrast induced nephropathy in urology.

Intravenous contrast agents have a distinct role in urological imaging: to study precise anatomical delineation, vascularity, and to assess the function of the renal unit. Contrast induced nephropathy (CIN) is a known adverse effect of intravenous contrast administration. The literature on incidence, pathophysiology, clinical features, and current preventive strategies available for CIN relevant to urologists was reviewed. A search of the PubMed database was done using the keywords nephropathy and media, prevention and control or prevention Contrast media (explode), all adverse effects, and kidney diseases (explode). An online search of the EMBASE database for the time ranging from 1977 to February 2009 was performed using the keywords ionic contrast medium, adverse drug reaction, major or controlled clinical study, human, nephrotoxicity, and kidney disease. Current publications and data most relevant to urologists were examined. CIN was the third most common cause of hospital-acquired renal failure. The incidence is less common with intravenous contrast administration as compared with intra-arterial administration. The pathogenesis of contrast mediated nephropathy is due to a combination of toxic injury to renal tubules and medullary ischemic injury mediated by reactive oxygen species. CIN most commonly manifests as a nonoliguric and asymptomatic transient decline in renal function. Patients who developed CIN were found to have increased mortality, longer hospital stay, and complicated clinical course. An overview of risk factors and risk prediction score for prognostication of CIN are elaborated. Preventive strategies including choice of contrast agents, maximum tolerated dose, role of hydration, hydration regime, etc. are discussed. The role of N- acetyl cysteine, Theophylline, Fenoldapam, Endothelin receptor antagonists, iloprost, atrial natriuretic peptide, and newer therapies such as targeted renal therapy (TRT) are discussed. A working algorithm based on current evidence is proposed. No current treatment can reverse or ameliorate CIN once it occurs, but prophylaxis is possible.

Eosinophilic ureteritis presenting as bilateral upper ureteric strictures.

During evaluation for loin pain a 54-year-old man was found to have bilateral upper ureteric strictures with hydroureteronephrosis on imaging. Renal function tests were normal. There was no peripheral eosinophilia but an excision biopsy of the stricture revealed eosinophilic ureteritis. As the patient had a previous history of cellulitis with epididymitis and came from an endemic area, filariasis should be considered as a possible triggering etiology.