Survival outcomes of postchemotherapy retroperitoneal lymph node dissection for nonseminomatous germ cell tumors: A retrospective cohort study from a single tertiary center in South India.

Introduction: Chemotherapy, postchemotherapy retroperitoneal lymph node dissection (pcRPLND), and metastasectomy remain the standard of care for the management of advanced nonseminomatous germ cell tumor (NSGCT). Methods: We retrospectively studied 73 patients who had pcRPLND at a single tertiary-care center (2003-2022). Surgical and clinicopathological features and oncological outcomes are presented. Results: The mean age was 28.27 years (15-48). Three-fourths had Stage III disease at diagnosis. International Germ Cell Cancer Collaborative Group risk stratification was 54.54% and 21.21% in intermediate risk, and poor risk, respectively. Sixty-two patients had Standard, 7 had Salvage and 4 underwent Desperation pcRPLND. Eleven patients (15.06%) required adjunctive procedures. Thirteen patients (17.8%) had ≥ class 3 Clavien-Dindo complications and postoperative mortality occurred in 5 (6.8%) patients. The histopathologies (HPE) of the pcRPLNDs were necrosis, teratoma, and viable tumor in 39.7%, 45.2%, and 15.1%, respectively. Seven patients underwent metastasectomy. An 85% size reduction in the size of RPLN predicted necrosis. There was 71.4% concordance between pcRPLND and metastasectomy HPEs. The median follow-up was 26.72 months (inter-quartile range - 13.25-47.84). The 2-year recurrence-free survival (RFS) rate was 93% (95% confidence interval [CI]-83%-97%) and the overall survival (OS) rate was 90% (95% CI-80%-95%). This is the largest series of pcRPLND for NSGCT in India to our knowledge. Conclusion: Although most of the cohort belonged to stage III, an RFS and OS rate of >90% at 2 years was achieved. We believe that successful management of postchemotherapy residual masses in NSGCT is contingent on the availability of multidisciplinary expertise and is therefore best done at tertiary-care referral centers.

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.

Whole and cortical kidney volume predict 5-year post-nephrectomy eGFR in Indian living kidney donors.

AIM: To study the additional utility of pre-nephrectomy whole and cortical kidney volumes (WKV, CKV) in predicting long-term post-nephrectomy kidney function in Indian living kidney donors (LKDs). METHODS: This retrospective cohort study included all LKDs who underwent nephrectomy between 1 January 2006 and 31 December 2015 at our centre, had pre-nephrectomy height, weight and computed tomography (CT) angiography with arterial and nephrographic phase documented, and 5-year post-nephrectomy creatinine values measured. Correlation between body surface area (BSA) adjusted pre-nephrectomy total CKV, WKV and pre-nephrectomy CKD EPI eGFR; BSA-adjusted remnant pre-nephrectomy CKV (rCKV), WKV (rWKV) and 5-year post-nephrectomy CKD EPI creatinine eGFR (5yeGFRCr ); predictors of 5yeGFRCr < 70% of pre-nephrectomy CKD EPI creatinine eGFR (pre-eGFRCr ), and an equation to predict 5yeGFRCr from pre-nephrectomy variables were calculated. RESULTS: A total of 196 LKDs (74% female, mean age 41.7 ± 11.0 years) were included in the study. Total WKV showed higher correlation with pre-nephrectomy eGFR than CKV, the highest with CKD EPI cystatin eGFR. Remnant WKV showed higher correlation than rCKV with post-nephrectomy eGFRCr and this increased over time. Older age, lower rWKV or rCKV, higher BSA, and higher pre-eGFRCr identified LKDs with 5yeGFRCr < 70% of pre-eGFRCr , with rCKV identifying a higher proportion (4.5%) of such LKDs. A model including rWKV or rCKV predicted 5yeGFRCr better than one including age, gender, BSA and pre-eGFRCr alone. CONCLUSION: Inclusion of pre-nephrectomy remnant CKV and WKV into models for 5yeGFRCr and sub-optimal post-nephrectomy adaptation in Indian LKDs improves their accuracy. CKD EPI cystatin eGFR correlates better with functional renal mass.

A comparison of DAP and RENAL scoring systems in the achievement of trifecta in laparoscopic partial nephrectomy.

PURPOSE: The concept of 'trifecta' outcome postulated for radical prostatectomy has been adopted for partial nephrectomy, the gold standard for management of small renal masses. We sought to evaluate the role of nephrometry scores in predicting outcomes in terms of the trifecta. We compared two scoring systems for renal tumour complexity (RENAL and DAP) in the prediction of trifecta outcomes. MATERIALS AND METHODS: Sixty-nine patients who underwent laparoscopic PN (LPN) were evaluated in a single-centre retrospective study (2010-2017). RENAL and DAP scores were measured. Parameters relevant to the trifecta were tabulated. RESULTS: When comparing the two scoring systems in terms of warm ischaemia time (WIT), the DAP score could predict with statistically significant accuracy the completion of resection within 25 mins of WIT. Tumours were more evenly distributed according to anatomical characteristics with the DAP scoring system than with the RENAL scoring system. When comparing these systems in terms of complications, neither predicted complications based on complexity with significant accuracy. A low RENAL score predicted trifecta achievement in three-fourth (71.4%) of patients, while a medium RENAL score predicted trifecta achievement in half (54%) of patients. DAP score predicted trifecta achievement in all tumours with a low score, two-third (66%) in medium and less than half (42%) with a high score. Predictions based on DAP were accurate and significantly so (p = 0.024). CONCLUSIONS: DAP score predicted the outcomes of LPN in terms of trifecta significantly better than the RENAL score. In our experience, the DAP score was able to distribute tumour complexity among its groups more effectively than the RENAL score. There is early evidence that the DAP score may be more useful than the RENAL score for decision-making in nephron sparing surgery. This is especially pertinent for small renal masses at the upper limits of tumour complexity for which minimally invasive techniques can be safely applied.

Efficacy of 1 versus 3 days of intravenous amikacin as a prophylaxis for patients undergoing transurethral resection of the prostate: A prospective randomized trial.

INTRODUCTION: There are no uniform guidelines on the duration of antibiotic prophylaxis for transurethral resection of the prostate (TURP). The objective of this study was to evaluate the efficacy of 1 day versus 3 days of intravenous amikacin as prophylaxis, before TURP. MATERIALS AND METHODS: In this prospective randomized control trial, patients with sterile preoperative urine culture were randomized to receive either 1 day (Group A) or 3 days (Group B) of intravenous (IV) amikacin. All patients had their catheter removed on the 3rd day and a midstream urine culture was obtained on the 4th day. The follow-up was scheduled at 1 week and at 1 month. The rate of bacteriuria on the 4th postoperative day was analyzed as the primary outcome. The secondary outcomes included symptomatic urinary tract infection (UTI), its risk factors, and other complications at 1 month. RESULTS: Of the 338 patients randomized, 314 patients were evaluable until day 7 and 307 until 1 month. Bacteriuria rate at day 4 (Group A: 8.8% [95% confidence interval (CI): 4.2-13.2]; Group B: 4.4% [95% CI: 1.2%-7.7%], P = 0.124, Fisher's exact test) was similar in both the groups. At 1 month, the rate of symptomatic UTI was also similar in both the groups (3.5% [95% CI: 0.8-6.9] vs. 1.7% [95% CI: 0.2-4.2], P = 0.344, Fisher's exact test). Bacteriuria (colony-forming unit, >104/ml) at day 4 was a significant risk factor for developing symptomatic UTI (P = 0.006). Antibiotic resistance was higher in Group B (P = 0.002) (Group A: 7.1% [95% CI: 6.3-20] vs. Group B: [71%, CI: 38-104], P = 0.0021, Fisher's exact test). CONCLUSION: One day is possibly noninferior to 3 days of IV amikacin as prophylaxis in patients undergoing TURP with respect to bacteriuria and symptomatic UTI, with an added advantage of lower antibiotic resistance.

Tamsulosin and placebo vs tamsulosin and tadalafil in male lower urinary tract symptoms: a double-blinded, randomised controlled trial.

OBJECTIVE: To compare the efficacy and safety of tamsulosin vs the combination of tamsulosin and tadalafil in male lower urinary tract symptoms (LUTS). PATIENTS AND METHODS: This was a double-blinded, parallel-arm randomised controlled trial. Men aged >45 years with moderate LUTS and a maximum urinary flow rate (Qmax ) of 5-15 mL/s were included. One arm received 0.4 mg tamsulosin only (Group-A), while the second received 5 mg tadalafil with tamsulosin (Group-B). The primary outcome was the International Prostate Symptom Score (IPSS). Secondary outcomes were IPSS quality of life (QoL) score, five-item version of the International Index of Erectile Function (IIEF-5) score, Qmax , and post-void residual urine (PVR). Block randomisation was used. Placebo was used for blinding and allocation concealment. Intention-to-treat analysis was used for outcome measures. RESULTS: Of the 183 men screened, 140 were randomised (71 in Group-A, 69 in Group-B); 116 (82.85%) (61 in Group-A, 55 in Group-B) completed the study. Baseline characteristics were comparable. The improvements in the IPSS, IPSS QoL score, IIEF score and Qmax were -1.69 (95% confidence interval [CI] -1.4 to -2.0), -0.70 (95% CI -0.60 to -0.80), 3.8 (95% CI 3.4-4.2) and 1.8 mL/s (95% CI 1.1-2.4) respectively, in favour of the combination group. The difference in PVR was not significant. There were no serious adverse events (AEs). The dropout rate due to AEs was 2.85%. Myalgia (five patients) was the commonest AE in the combination group. CONCLUSION: The combination of tamsulosin and tadalafil produced significantly better improvements in LUTS, QoL, erectile function and Qmax compared to monotherapy with tamsulosin, without an increase in AEs.

The Impact of Narrow Band Imaging in the Detection and Resection of Bladder Tumor in Transitional Cell Carcinoma of the Bladder: A Prospective, Blinded, Sequential Intervention Randomized Controlled Trial.

OBJECTIVE: To determine the impact of Narrow Band Imaging (NBI) in detection and resection of tumors during transurethral resection of bladder cancer. MATERIALS AND METHODS: This was a single center randomized prospective interventional study with a sequential intervention design. Patients with bladder tumors were randomized into 2 arms where they were resected under white light (WL) first followed by NBI in arm A, or NBI followed by WL in arm B. The number of patients in whom additional lesions were detected by the second light source, in both arms, was analyzed. The feasibility of initial resection of tumor under NBI was also studied. RESULTS: A total of 110 patients were randomized. Of 54 patients in arm A (WL first) additional lesions were identified at the second look in 20 patients (37%). In contrast, of 56 patients in arm B (NBI first), additional lesions were identified in 5(9%) patients. This difference of 28% was statistically significant (P value <.001). In arm B (NBI first), there were 7 breaches in protocol, and all these patients had high risk (more than or equal to 3 in number or 3 cm in size) tumors (P value <.002). CONCLUSION: Narrowband imaging is superior to WL in the detection of tumors, thus allowing a more complete resection. However, initial resection under NBI is difficult due to poor visibility, especially for high-risk tumors.

Renal transplantation into optimized abnormal lower urinary tract - Impact on graft outcomes, patient survival, and complications.

INTRODUCTION: Literature regarding the outcomes of renal transplant in patients with abnormal lower urinary tracts (LUTs) is conflicting. The study aimed to determine the graft outcomes and complications of renal transplantation in an optimized abnormal LUT as compared to those with a normal LUT. MATERIALS AND METHODS: In this single-center retrospective-matched cohort study, we identified 31 patients with an optimized abnormal LUT in our transplant database between 2006 and 2016 (Group A) and selected an equal number of matched controls (Group B). The primary outcome was graft survival, and secondary outcomes were overall survival and complications. RESULTS: The median age was 24 years (range: 12-45), and the median duration of follow-up was 36 months in both groups. On Kaplan-Meier analysis, the estimated mean graft survival was 106 months (confidence interval [CI]: 91-120) in Group A versus 128 months (CI:117-139) in Group B (P = 0.47, log-rank analysis). On subgroup analysis of Group A, augmented bladders had the poorest mean survival (81 months, CI: 56-106), P = 0.09). The mean estimated patient survival was comparable between Group A and B (109 months, CI: 96-122 versus 139 months, CI: 134-144), P = 0.13). Infective complications (27 episodes vs. 1) and re-admissions (77 vs. 30) were significantly higher in Group A (P = 0.04 and P < 0.01). Clean intermittent catheterization was a risk factor for infections (63% vs. 37%, P = 0.033, odds ratio: 5). CONCLUSIONS: The graft and overall survival was comparable at 3 years in both groups. Infective complications were higher in Group A.

Positive ureteric margins at radical cystectomy: Can it be predicted at initial transurethral resection of bladder tumour?

OBJECTIVE: To identify primary tumour-related factors at transurethral resection of bladder tumour (TURBT) that may predict positive distal ureteric margins (PUM) at the time of radical cystectomy (RC). PATIENTS AND METHODS: A retrospective, cohort study was conducted using our institution's data from June 2007 to June 2016. Patients who underwent TURBT followed by RC for non-metastatic urothelial carcinoma (UC) of the bladder were identified. In all, 211 patients underwent RC for UC during the study period. The patients were divided into two groups: Group-I (n = 17) with PUM and Group-II (n = 194) with negative ureteric margins. Univariate and multivariate analyses were performed to determine the predictors of PUM. RESULTS: On univariate analysis, multifocality, tumours involving the ureteric orifice, trigonal tumours, presence of carcinoma in situ (CIS), and lymphovascular invasion at TURBT, were significantly more common in Group-I. On multivariate analysis, tumour involvement in the ureteric orifice(s) and presence of associated CIS significantly predicted PUM. CONCLUSIONS: Primary tumour-related factors on initial TURBT that predicted PUM (at RC) were involvement of the ureteric orifice(s) and presence of associated CIS. These results may help to select patients who can be selectively offered intraoperative frozen section analysis.

Gossypiboma mimicking a retroperitoneal tumor.

"Gossypiboma" denotes a mass of cotton that is retained in the body after surgery. An image is presented of a retroperitoneal mass in a lady who had a right nephrectomy 8 years earlier for a nonfunctioning kidney. Clinical examination and plain abdominal radiography were not contributory. Contrast-enhanced abdominal computed tomography revealed a well-defined, heterogeneous, spherical, soft-tissue mass, 13 × 9 × 9 cm in size, in the retroperitoneum, with a dense enhanced wall, abutting the right psoas and posterior abdominal wall. Exploration revealed an abdominal sponge surrounded by foreign body granuloma adherent to surrounding structures. Gossypiboma can mimic a tumor and is a diagnostic challenge.

A novel computer based stent registry to prevent retained stents: Will patient directed automated short message service and letter generator help?

OBJECTIVE: The objective of this study was to evaluate the feasibility of a computer based stent registry with patient directed automated information system to prevent retained double J stents. MATERIALS AND METHODS: A stent registry system was developed in collaboration with our Computerized Hospital Information Processing Service Department. This computer based stent registry with patient directed automated information system was integrated with the existing clinical work station. We reviewed the records retrospectively and assessed the feasibility of the system in reminding clinicians and patients regarding the stent and its date of removal. RESULTS: In a short run at our department, this new system appeared feasible, with patients promptly responding to the short message service and letter alerts. CONCLUSIONS: Computer based stent registry with patient directed automated information system is feasible in a clinical setting. A prospective study is needed for evaluation of its efficacy in preventing retained stents.

Acute gastric dilatation: a rare complication of nephrectomy.

We report the first case of acute gastric dilatation after simple extraperitoneal nephrectomy for benign disease.

Maximal androgen blockade for advanced prostate cancer.

Prostate cancer has now become one of the leading types of cancer in urban India. It is now the third most common cancer in Delhi. As we advance in health care with the resultant increase in longevity, we will be seeing more of advanced carcinoma prostate. Since the early 1980.s, there have been many trials on MAB. However, the question remains whether these agents actually make a difference? The role of MAB is probably limited to the prevention of the beta are reaction in patients on LHRH agonists. The non steroidal antiandrogens have a marginal benefit of increased overall survival by approximately 3% to 5% at 5 ve years. There may be a role for MAB in patients with metastatic carcinoma of prostate, low volume metastases, patients with M 1 disease with absence of metastases in the skull, ribs, long bones, and soft tissues excluding lymph nodes.

Management of adult choledochal cysts--a 15-year experience.

BACKGROUND: Choledochal cyst, a common surgical problem of childhood, can have a delayed presentation in adults. The clinical course in adults differs from that in children because of a higher incidence of associated hepatobiliary pathology. METHODS: The clinical data of 57 adults with choledochal cyst managed in a general surgical unit between January 1988 and March 2003 were analysed. RESULTS: The male:female ratio was 1:1.38 and the mean age was 34.5 years; 71.9% of the cysts belonged to Todani type I, 26.3% to type IV and 1.8% to type V. Abdominal pain and recurrent cholangitis were the commonest presentations followed by acute pancreatitis, palpable mass and bronchobiliary fistula. Anomalous pancreaticobiliary ductal junction was demonstrated in 14% of the cases. In all, 37% of the patients had undergone either wrong or suboptimal surgical procedures prior to presentation. All patients underwent complete excision of the cyst and hepaticojejunostomy. Two patients required cholangiojejunostomy and three patients required resection of the involved segments of the liver in addition. There were three anastomotic leaks and two postoperative deaths. Two anastomotic leaks resolved spontaneously while the third required surgical intervention. Forty-eight patients were available for follow-up and have remained symptom-free over a mean period of 17.6 months. CONCLUSIONS: Choledochal cyst should be considered in all patients below 40 years of age presenting with biliary colic, pancreatitis or recurrent cholangitis with associated dilatation of bile duct. Complete excision of the cyst with restoration of biliary-enteric communication by hepaticojejunostomy form the basis of ideal treatment.