Intraoperative ultrasonography (IOUS)-guided vs conventional laparoscopic nephrectomy: a randomised control trial.

OBJECTIVES: To assess the efficacy of routine use of intraoperative ultrasonography (IOUS) in improving perioperative outcomes in patients undergoing IOUS-guided laparoscopic nephrectomy (IOUS-LN) and conventional laparoscopic nephrectomy (C-LN). PATIENTS AND METHODS: This was a parallel-arm, single-blinded, randomised controlled trial (CTRI/2021/12/038906). All patients undergoing LN, either for benign or malignant causes, were included. Patients undergoing partial/cytoreductive nephrectomy, with venous thrombus were excluded. In the study arm, IOUS-guided renal vascular assessment was performed after colon mobilisation and a standard LN was performed in the control arm. The primary outcome was intraoperative duration. The secondary outcomes were blood loss, need for open conversion, blood transfusion, perioperative complications, duration of Intensive Care Unit (ICU) stay and length of hospitalisation (LOH). The patients were followed for 3 months after surgery. RESULTS: A total of 104 patients were included, with 52 in each arm. Demographic characteristics were comparable in both arms. A significant reduction in the operative duration (mean [sd] 181.69 [40.8] vs 199.7 [41.8] min, P = 0.02) was seen in the IOUS-LN group. The difference in blood loss showed no significant difference when compared between both groups (median [interquartile range] 84.55 [74-105.5] vs 99.95 [78.5-111] mL, P = 0.08). On subgroup analysis, the reduction in the operative duration was significant in patients who underwent laparoscopic simple nephrectomy (LSN; mean [sd] 194.4 [42.5] vs 221.2 [36.4] min, P = 0.01), whereas comparable operative durations were seen in patients undergoing laparoscopic radical nephrectomy (LRN; mean [sd] 168.96 [35.3] vs 178.3 [35.9] min, P = 0.34). Similar conversion rates were seen in both groups (P = 0.98) along with blood transfusions (P = 0.78). The LOH, ICU stay, and complications were similar in both groups. Significantly less blood loss (P = 0.03) was noted with IOUS in patients undergoing LSN. IOUS did not influence any outcomes in patients undergoing LRN. CONCLUSION: Intraoperative ultrasonography significantly reduced the operative duration in LN, but with no significant reduction in the volume of blood loss. Significant reduction in intraoperative duration and blood loss was seen in patients who underwent LSN on subgroup analysis.

Long-term Sexual Function and Quality of Life in Women Following Substitution Urethroplasty.

PURPOSE: To assess the long-term quality of life (QOL) and sexual function (SF) in women who underwent either dorsal on-lay (DO) or ventral inlay (VI) urethroplasty for urethral stricture disease. METHODOLOGY: Between January 2016 and September 2022, women who underwent either dorsal on-lay (DO) or ventral inlay (VI) urethroplasties and had at least a six-month follow-up been included. Using the Female Sexual Function Index (FSFI) and WHO-QOL bref questionnaires, the QOL and SF were evaluated. Scores were compared between the two groups after being examined for internal validity. A sub-group analysis was carried out based on the procedure's success. RESULTS: With follow-up periods ranging from 6 to 86 months, 25 patients who received VI urethroplasty and 10 patients who underwent DO urethroplasty were included. Both scores demonstrated strong internal consistency. The cumulative QOL and FSFI scores were comparable in both groups (p = 0.53 and p = 0.83, respectively). Significantly high scores were noted in the physical health domain (76.5 ± 9.9 vs 62.33 ± 10.97; p = 0.03; (95% CI = 0.72-24.4)) and the environmental domain (75.75 ± 3.84 vs 66.00 ± 4.24; p = 0.01 (95% CI = 2.64-16.85) in patients with successful VI and DO urethroplasties respectively. Addictions, low socioeconomic status and protracted symptom duration were associated with low QOL scores. Old age was related to low FSFI scores. CONCLUSION: Substitution urethroplasty, despite the approach, showed good QOL and SF scores. Long symptom duration, addictions, and poor socioeconomic status were associated with low QOL whereas old age independently influenced low FSFI scores.

Emergency endovascular and percutaneous urological interventions: A pictorial review.

Emergency endovascular and percutaneous urological interventions encompass various diagnostic and therapeutic procedures to address various genitourinary conditions. These urological interventions are life-saving in addressing complications following biopsy, post-nephrectomy, post-transplant, and post-trauma. Compared to other surgical fields, there are relatively fewer urological emergencies. However, they require prompt radiological diagnosis and urgent interventions. This pictorial essay emphasizes various urological emergencies and urgent interventional management.

Pelvic lymph node dissection before or after laparoscopic radical cystectomy: An ambispective study comparing ease of surgery and operative outcomes.

Introduction: It is unclear when pelvic lymph node dissection (PLND) should be performed during laparoscopic radical cystectomy. Proponents of PLND performed before cystectomy claim that early PLND skeletonizes the urinary bladder's vascular pedicles, making cystectomy easy. Others contend that an early cystectomy provides space and flexibility during subsequent PLND. This first-of-its-kind study compared PLND before and after cystectomy for the ease of performing surgery (total operative time, cystectomy time, and PLND time) and the operative outcomes (number of lymph nodes removed, blood loss, and complication rates). Methods: This ambispective cohort study included a predetermined sample size of 44 patients. The first 22 patients underwent PLND after cystectomy (Group 1), and the following 22 underwent PLND before cystectomy (Group 2). The primary outcome was total operative time. Secondary outcomes included cystectomy time, PLND time, number of lymph nodes removed, blood loss, and complication rates. Results: The baseline characteristics were similar in both groups. The total operative time (344.23 ± 41.58 min vs. 326.95 ± 43.63 min, P = 0.19), cystectomy time (119.36 ± 34.44 min vs. 120.91 ± 35.16 min, P = 0.53), PLND time (126.82 ± 18.75 min vs. 119.36 ± 23.34 min, 0.25), number of dissected lymph nodes (13.27 ± 4.86 vs. 14.5 ± 4.76, P = 0.40), and blood loss (620.45 ± 96.23 ml vs. 642.27 ± 131.8 ml, P = 0.20) were similar in the two groups. The complication rates categorized by Clavien-Dindo grading were identical in the two groups. Conclusions: PLND done after cystectomy was comparable to PLND done before cystectomy regarding the ease of surgery and the operative outcomes.

Socio-economic, education, and insurance-related factors associated with the treatment completion rates in patients with nonmetastatic urinary bladder cancer: A Retrospective cohort study.

Introduction: Among urological malignancies, the diagnosis and treatment of urinary bladder cancer (UBC) incurs the highest cost per patient. Our objective was to broaden the current understanding of how demographic, socioeconomic, education, and insurance-related factors influence UBC management. Methods: Between January 2017 and December 2019, all patients with nonmetastatic bladder cancer were included. The demographic, treatment, and follow-up details were retrieved from a prospectively maintained database, and the Modified Kuppuswamy Index was used to evaluate the patients' socioeconomic level. Patients were divided into the completed treatment group, or the incomplete treatment group based on adherence to the initially intended treatment plan. Patients who presented with benign disease or metastases were not included. Results: Eighty-nine patients did not complete the initially intended course of treatment out of 132 patients who needed additional management after the initial transurethral resection. Comparable risk factors and demographic profiles existed in both groups. Patients with intermediate-risk disease are more likely to fail to adhere to the initial intended treatment (odds ratio [OR] = 0.09; 95% confidence interval [CI]: 0.02-0.30). On logistic regression analysis, upper socioeconomic status (OR = 6.8; 95% CI: 0.35-132.1) patients and patients with higher educational status of graduation or above (OR = 3.62; 95% CI: 0.75-17.43) had higher chances of treatment completion. Education status significantly impacted treatment completion on multivariate analysis (P = 0.01). Patients who utilized employer-funded insurance had better treatment compliance (OR = 4.1; 95% CI: 0.90-18.7). The compliance was unaffected by smoking, occupation, or other demographic factors. Conclusion: Patients with low economic status, low levels of education, and who need adjuvant intravesical therapy had considerably greater treatment dropout rates.

Diversity of native larvivorous fish fauna during pre- and post-tsunami in Car Nicobar, Andaman & Nicobar Islands, India.

BACKGROUND & OBJECTIVES: Malaria is a serious public health problem in Car Nicobar Island, Andaman & Nicobar Islands, India. Using larvivorous fishes has proved to be the cheapest method for vector management approach, with long suppression of mosquito population. This study aims to scale-up the diversity of larvivorous fishes and their potential larvivoracity to evolve an appropriate biological intervention strategy against the immature stages of malaria vectors. METHODS: During 2003 (pre-tsunami) and 2014-2016 (post-tsunami), an ecological descriptive survey was carried out in the water bodies around Car Nicobar Island. Fishes were captured using fishing nets and cast nets; and placed in plastic jars and preserved in formalin solution. Fishes were identified and classified according to the available keys. Their abundance and data on the current conservation status was recorded and analyzed. Their potential larvivoracity was graded according to their feeding intensity. RESULTS: Pre-tsunami, a total of 27 larvivorous fish species belonging to 11 orders, 23 families and 23 genera were identified. Order Perciformes and the family Cyprinidae were the most ascendant group constituting 51.9 and 11.1%, respectively. While, 80.8% of species were preferred to inhabit the freshwater region, only 37% of species were surface feeders (SF). According to the conservation, assessment and management plan (CAMP, 1998), 44.4% species were at lower risk least concern (LRlc), while 55.6% species were at least concerned (LC) as per the IUCN, 2017 categorization. However, after the tsunami, 17 fish species had gone extinct and 10 fish species were found to remain alive in the local water bodies. INTERPRETATION & CONCLUSION: Post-tsunami, the larvivoracity analysis indicated that Ophiocara aporos, Ophiocara procephala, Valamugil seheli, Channa punctata, Kuhlia rupestris, Khulia mugil, and Terapon jarbua possess high-level larvivorous potentiality in nature and are recommended for vector control in the study area. These fish species were facing several anthropogenic threats, such as human interference, loss of habitat, trade, overexploitation, and fishing. Therefore, it is important to protect the water bodies from external impact and implement the conservation strategies. Further, periodic fish fauna surveys, identification of breeding sites, scale-up of the larvivorous potentiality at the field level, creating public awareness through health education on establishment of larvivorous fish ponds and planning for mass rearing of the native fish species should be adopted as part of vector management approach in the endemic malarious region of Car Nicobar Island.

Thrombus Masquerading a Double J Ureteric Stent.

Renal cell carcinoma (RCC) is the most common renal parenchymal malignancy found in adults. When these tumors are located centrally in the kidney and do not enhance well on contrast imaging, they may be mistaken to be urothelial in origin, and the diagnosis is established on histopathology. We present an interesting case of RCC with an atypical vermiform thrombus projecting into the urinary bladder.

Peripheral Merozoite Surface Proteins Are Targets of Naturally Acquired Immunity against Malaria in both India and Ghana.

Development of a successful blood-stage vaccine against Plasmodium falciparum malaria remains a high priority. Immune-epidemiological studies are effective tools for the identification of antigenic targets of naturally acquired immunity (NAI) against malaria. However, differences in study design and methodology may compromise interstudy comparisons. Here, we assessed antibody responses against intact merozoites and a panel of 24 recombinant merozoite antigens in longitudinal cohort studies of Ghanaian (n = 115) and Indian (n = 121) populations using the same reagents and statistical methods. Anti-merozoite antibodies were associated with NAI in both the Indian (hazard ratio [HR] = 0.41, P = 0.020) and the Ghanaian (HR = 0.17, P < 0.001) participants. Of the 24 antigen-specific antibodies quantified, 12 and 8 were found to be protective in India and Ghana, respectively. Using least absolute shrinkage and selection operator (LASSO) regression, a powerful variable subselection technique, we identified subsets of four (MSP6, MSP3.7, MSPDBL2, and Pf12) and five (cMSP33D7, MSP3.3, MSPDBL1, GLURP-R2, and RALP-1) antigens that explained NAI better than the individual antibodies in India (HR = 0.18, P < 0.001) and Ghana (HR = 0.31, P < 0.001), respectively. IgG1 and/or IgG3 subclasses against five antigens from these subsets were associated with protection. Through this comparative study, maintaining uniformity of reagents and methodology, we demonstrate that NAI across diverse geographic regions may result from antibodies to multiple antigenic targets that constitute the peripheral merozoite surface protein complexes.

Molecular forms of Anopheles subpictus and Anopheles sundaicus in the Indian subcontinent.

BACKGROUND: Anopheles subpictus and Anopheles sundaicus are closely related species, each comprising several sibling species. Ambiguities exist in the classification of these two nominal species and the specific status of members of these species complexes. Identifying fixed molecular forms and mapping their spatial distribution will help in resolving the taxonomic ambiguities and understanding their relative epidemiological significance. METHODS: DNA sequencing of Internal Transcribed Spacer-2 (ITS2), 28S-rDNA (D1-to-D3 domains) and cytochrome oxidase-II (COII) of morphologically identified specimens of two nominal species, An. subpictus sensu lato (s.l.) and An. sundaicus s.l., collected from the Indian subcontinent, was performed and subjected to genetic distance and molecular phylogenetic analyses. RESULTS: Molecular characterization of mosquitoes for rDNA revealed the presence of two molecular forms of An. sundaicus s.l. and three molecular forms of An. subpictus s.l. (provisionally designated as Form A, B and C) in the Indian subcontinent. Phylogenetic analyses revealed two distinct clades: (i) subpictus clade, with a single molecular form of An. subpictus (Form A) prevalent in mainland India and Sri Lanka, and (ii) sundaicus clade, comprising of members of Sundaicus Complex, two molecular forms of An. subpictus s.l. (Form B and C), prevalent in coastal areas or islands in Indian subcontinent, and molecular forms of An. subpictus s.l. reported from Thailand and Indonesia. Based on the number of float-ridges on eggs, all An. subpictus molecular Form B were classified as Species B whereas majority (80%) of the molecular Form A were classified as sibling species C. Fixed intragenomic sequence variation in ITS2 with the presence of two haplotypes was found in molecular Form A throughout its distribution. CONCLUSION: A total of three molecular forms of An. subpictus s.l. and two molecular forms of An. sundaicus s.l. were recorded in the Indian subcontinent. Phylogenetically, two forms of An. subpictus s.l. (Form B and C) prevalent in coastal areas or islands in the Indian subcontinent and molecular forms reported from Southeast Asia are members of Sundaicus Complex. Molecular Form A of An. subpictus is distantly related to all other forms and deserve a distinct specific status.

Delayed haemolysis after treatment with intravenous artesunate in patients with severe malaria in India.

BACKGROUND: Parenteral artesunate is the treatment of choice for severe malaria. It is safe, efficacious and well tolerated anti-malarial. However, delayed haemolysis has been reported in travellers, non-immune individuals and in African children. METHODS: A prospective, observational study was carried out in admitted severe malaria patients receiving parenteral artesunate. The patients were followed up until day 28 for monitoring clinical as well as laboratory parameters for haemolytic anaemia. RESULTS: Twenty-four patients with severe malaria receiving injection artesunate were enrolled in the study. Post-artesunate delayed haemolysis following parenteral artesunate therapy was observed in three of 24 patients (12.5%, 95% confidence interval 4.5-31.2%). Haemolysis was observed in two more patients possibly due to other reasons. The haemoglobin fall ranged from 13.6 to 38.3% from day 7 to day 28 in these patients. CONCLUSION: The possibility of delayed haemolysis should be considered while treating the severe malaria patients with parenteral artesunate. The study highlights the need for further studies in different epidemiological settings.

Cytophilic Antibodies Against Key Plasmodium falciparum Blood Stage Antigens Contribute to Protection Against Clinical Malaria in a High Transmission Region of Eastern India.

Background: The collection of clinical data from a tribal population in a malaria-endemic area of India suggests the occurrence of naturally acquired immunity (NAI) against Plasmodium falciparum malaria. Methods: Quantity and functionality of immunoglobulin G (IgG) antibodies against intact merozoites and recombinant proteins were assessed in a 13-month longitudinal cohort study of 121 individuals, 3-60 years of age. Results: Opsonic phagocytosis of merozoites activity was strongly associated (hazard ratio [HR] = 0.34; 95% confidence interval [CI] = .18-.66; P = .0013) with protection against febrile malaria. Of the different IgG subclasses, only IgG3 antibodies against intact whole merozoites was significantly associated with protection against febrile malaria (HR = 0.47; 95% CI = .26-.86; P = .01). Furthermore, a combination of IgG3 antibody responses against Pf12, MSP3.7, MSP3.3, and MSP2FC27 was strongly associated with protection against febrile malaria (HR = 0.15; 95% CI, .06-.37; P = .0001). Conclusions: These data suggest that NAI may, at least in part, be explained by opsonic phagocytosis of merozoites and IgG3 responses against whole merozoites, and in particular to a combination of 4 antigens is critical in this population. These results may have implications in the development of a subunit malaria vaccine. Opsonic phagocytosis of Plasmodium falciparum merozoites was associated with protection against clinical malaria in an India population. Antibody profiling identified four merozoite antigens (Pf12, MSP3.7, MSP3.3, and MSP2) as targets of protective Immunoglobuline G3 antibodies.

Ventral-inlay buccal mucosal graft urethroplasty for female urethral stricture.

INTRODUCTION: The aim of the study is to present our initial experience with ventral-inlay buccal mucosal graft urethroplasty (VI-BMGU) in female urethral stricture disease (USD). METHODS: Between May 2016 and June 2018, 12 women with USD underwent VI-BMGU. All women were evaluated preoperatively with the American Urological Association (AUA) symptom score, uroflowmetry, calibration with a 12 Fr catheter, and ultrasonography with postvoid residual (PVR) urine measurement. Intraoperative confirmation of stricture was done with a 6 Fr cystoscope. Postoperatively, the women were followed at 3, 6, and 12 months after surgery with AUA symptom score, uroflowmetry, and PVR estimation. Increase in AUA symptom score, maximum flow rate (Qmax) <12 ml/s, and failure to calibrate with 18 Fr catheters were considered as indicative of recurrence of the disease. RESULTS: The mean age of the patients was 41 years. The mean follow-up period was 18 months. All women voided successfully after catheter removal. There was an improvement in AUA symptom score and Qmax and a reduction in PVR at 3, 6, and 12 months. One woman had recurrence of stricture at 6 months and was treated by urethral dilatation followed by the institution of a self-dilatation regimen. The success rate was 92% in our case series. CONCLUSIONS: VI-BMGU is a simple and safe method of urethroplasty in women. Studies with a larger sample size and a longer follow-up are required to document the long-term success of this procedure.

Native larvivorous fish diversity as a biological control agent against mosquito larvae in an endemic malarious region of Ranchi district in Jharkhand, India.

BACKGROUND & OBJECTIVES: Mosquitoes are responsible for transmitting several diseases, including malaria, dengue, chikungunya, filariasis, and yellow fever, etc. Release of larvivorous fishes is one of the cheapest method of vector management approach, with long suppression of mosquito population. The present study identifies the native larvivorous fishes and evaluates their potential larvivoracity for biological control of mosquito larvae in an endemic malarious region. METHODS: During the year 2012-13, an ecological descriptive study was carried out in diverse aquatic habitats of fish species found in different areas of Ranchi district, in Jharkhand state of India. Fishes were captured using fishing nets, and identified and classified according to the available keys. Their larvivorous potential was graded according to their feeding potential. Data on current conservation status as well as their abundance were also recorded and analysed. RESULTS: In total, 30 larvivorous fish species belonging to seven orders, 10 families and 21 genera were identified. Order Cypriniformes and the family Cyprinidae were the most ascendant group constituting 66.7 and 60%, respectively. The grading assessment of larvivorous potential for different fish species revealed that, Colisa fasciatus possess maximum larvivoracity (+ + + + +). According to the conservation, assessment and management plan (CAMP, 1998), 60% species were at lower risk near threat (LRnt), while 86.7% species were at least concerned (LC) as per the IUCN, 2017 categorisation. All fish species preferred to inhabit in freshwater. Maximum species occurrence was found in the river (63.3%). Only 30% species were bottom feeders (BF). INTERPRETATION & CONCLUSION: The larvivoracity and habitat distribution analysis indicated that C. fasciatus, Oreochromis mossambica, Esomus danricus, Oryzias melastigma, Puntius sophore, P. ticto, Rasbora daniconius, R. elegans, Aplocheilus panchax, and Danio (B) rerio possess high-level larvivorous potentiality in nature and are recommended for malaria control in the study area. There is an increasing pressure on the fish fauna, of facing several threats, such as fishing, human interference, loss of habitat, overexploitation, pollution, siltation, trade, and diseases. Therefore, periodic survey and monitoring of fish biodiversity, demarcation of breeding sites, field level research study on the efficacy of these fishes, and public awareness on establishment of larvivorous fish ponds should be adopted as a part of the vector management approach in the endemic malarious region of Ranchi district in Jharkhand, India.

Malaria epidemiology in an area of stable transmission in tribal population of Jharkhand, India.

BACKGROUND: Malaria remains an important health problem in India with approximately 1 million cases in 2014. Of these, 7% occurred in the Jharkhand state mainly in the tribal population. METHODS: This study was conducted in Dumargarhi, a tribal village about 42 km east of Ranchi city, Jharkhand, from May 2014 to September 2016. Four point prevalence surveys were carried out during consecutive high (October-December) and low (June-August) transmission seasons. Malaria cases were recorded from April 2015 to April 2016 through fortnightly visits to the village. Adult mosquito densities were monitored fortnightly by manual catching using suction tube method. RESULTS: The study area consists of five hamlets inhabited by 945 individuals living in 164 households as recorded through a house-to-house census survey performed at enrollment. The study population consisted predominantly of the Munda (n = 425, 45%) and Oraon (n = 217, 23%) ethnic groups. Study participants were categorized as per their age 0-5, 6-10, 11-15 and >15 years. There were 99 cases of clinical malaria from April 2015 to April 2016 and all malaria cases confirmed by microscopy were attributed to Plasmodium falciparum (94 cases) and Plasmodium vivax (5 cases), respectively. During the high transmission season the mean density of P. falciparum parasitaemia per age group increased to a peak level of 23,601 parasites/µl in the 6-10 years age group and gradually declined in the adult population. Malaria attack rates, parasite prevalence and density levels in the study population showed a gradual decrease with increasing age. This finding is consistent with the phenomenon of naturally acquired immunity against malaria. Three vector species were detected: Anopheles fluviatilis, Anopheles annularis, and Anopheles culicifacies. The incoherence or complete out of phase pattern of the vector density peaks together with a high prevalence of parasite positive individuals in the study population explains the year-round malaria transmission in the study region. CONCLUSIONS: The collection of clinical data from a well-characterized tribal cohort from Jharkhand, India, has provided evidence for naturally acquired immunity against malaria in this hyperendemic region. The study also suggests that enforcement of existing control programmes can reduce the malaria burden further.