The future of the artificial kidney.

End-stage renal disease (ESRD) is increasing worldwide. In India, diabetes mellitus and hypertension are the leading causes of chronic kidney disease and ESRD. Hemodialysis is the most prevalent renal replacement therapy (RRT) in India. The ideal RRT must mimic the complex structure of the human kidney while maintaining the patient's quality of life. The quest for finding the ideal RRT, the "artificial kidney"- that can be replicated in the clinical setting and scaled-up across barriers- continues to this date. This review aims to outline the developments, the current status of the artificial kidney and explore its future potential.

Systemic Bacillus Calmette-Guerin infection secondary to inadvertent intravenous injection.

Disseminated BCG infection (BCG-osis) secondary to intravesical BCG given for high-risk non-muscle invasive bladder cancer has been reported. We report the successful management of two cases of BCG-osis secondary to inadvertent intravenous BCG injection. Both cases are recurrence-free at the follow-up of 12 and 18 months, respectively. There is only one such case reported in English literature so far to the best of our knowledge.

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.

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.

Transperineal laser ablation as a new minimally invasive surgical therapy for benign prostatic hyperplasia: a systematic review of existing literature.

Introduction: Transperineal laser ablation (TPLA) of the prostate is a new, minimally invasive technique for benign prostatic hyperplasia (BPH) with promising effectiveness and safety outcomes. This systematic review aims to provide an update of existing literature. Methods: A literature review was performed in Pubmed/MEDLINE, Embase, Cochrane Library, and clinicaltrials.gov from January 2000 up to April 2023. Data extraction and risk of bias were performed independently by three authors. Results: A total of 11 studies were included, among which 9 were observational, 1 randomized controlled trial, 1 animal study, while 2 of them were comparative (1 with prostatic artery embolization and 1 with transurethral resection of the prostate). Functional outcomes were improved in the majority of studies both for objective (maximum flow rate and post-void residual) and subjective outcomes (improvement of International Prostate Symptom Score and quality of life). Complication rates ranged between 1.9% and 2.3% for hematuria, 3.7% and 36.3% for dysuria, 1.9% and 19% for acute urinary retention, 0.6% and 9.1% for orchitis/urinary tract infections, and 0.6% and 4.8% for prostatic abscess formation. Regarding sexual function, >95% of patients retained their ejaculation while erectile function was maintained or improved. Conclusion: TPLA of the prostate is an innovative, minimally invasive technique for managing patients with BPH. Existing studies indicate an effective technique in reducing International Prostate Symptom Score and quality of life scores, post-void residual reduction, and increase in Qmax, albeit the measured improvements in terms of Qmax are not equal to transurethral resection of the prostate. Although sexual function is maintained, the mean catheterization time is 7 days, and no long-term data are available for most patients.

Management of proximal migration of double-J stents after Anderson-Hynes pyeloplasty in children.

INTRODUCTION: Proximal migration of double J stents after pediatric pyeloplasty is rare. Although retrograde removal of migrated stents is more common, the small calibre of the pediatric ureter may necessitate antegrade retrieval. Many techniques are described for the same in adults however, pediatric literature is sparse. We aim to describe the management of proximally displaced stents after pediatric pyeloplasty. MATERIALS AND METHODS: This retrospective study included all children (<17 years age) who underwent retrieval of proximally displaced DJ stents after pyeloplasty between 2007 and 2019 at a single institution. The retrograde technique employed ureteroscopic retrieval with a grasper while in the antegrade technique, an access sheath was placed percutaneously into a calyx and Nephroscopic retrieval was performed. RESULTS: There were 8 children (6 boys and 2 girls) of which 4 were infants. Median age was 3.5 (0.5-12) years and median follow-up was 7.5 (4-47) months. Two children had been referred with displaced stents after pyeloplasty from other centres. The incidence of proximal stent migration was 6/1644 (0.4%). Open pyeloplasty had been performed in seven while one child had undergone laparoscopic pyeloplasty. The lower coil of the migrated stent was in the renal pelvis in 6 (complete) and ureter in 2 (partial migration). Those with partial migration underwent successful ureteroscopic retrieval. Three infants required Antegrade stent removal while ureteroscopic retrieval was successful in an older child with complete stent migration. Nephrectomy for loss of function and redo pyeloplasty for pelvi-ureteric stricture was performed in one each. One child had self-limiting fever (Clavien 1) after stent removal. All had normal drainage on renogram after 6 months. The cause of proximal stent migration was likely to be an inadequate lower coil (<180°) in 5 children and a capacious pelvis with narrow ureter in one infant. The cause could not be ascertained in two children who were referred from other centres. The management algorithm for retrieval of proximally migrated DJ stents, is depicted in Fig. 3. CONCLUSIONS: Proximal migration of DJ stent after pyeloplasty is a rare complication which may be safely managed with a stepwise approach using both Antegrade and retrograde techniques. Accurate stent length, adequate distal coil and appropriate placement are essential to avoid stent migration.