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.

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.

Efficacy and role of Xpert® Mycobacterium tuberculosis/rifampicin assay in urinary tuberculosis.

INTRODUCTION: The aim was to study the accuracy of Xpert® (Cepheid Inc., Sunnyvale, CA, USA) Mycobacterium tuberculosis/rifampicin (MTB/RIF) assay as compared to a composite gold standard (urine culture, imaging, and biopsy) and to asses its utility as the initial test compared to smear microscopy to diagnose urinary tuberculosis. METHODS: This prospective study included adult patients suspected to have urinary tuberculosis from March 2014 to December 2017. Three urine samples were collected from each patient and were subjected to Xpert MTB/RIF assay, acid-fast bacillus (AFB) smear microscopy, and liquid media (BACTEC Mycobacteria Growth Indicator Tube [MGIT] 960) culture. Imaging and tissue biopsies were performed as clinically indicated. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated using the bootstrap method for 95% confidence intervals for the Xpert assay. RESULTS: Xpert MTB/RIF assay was found to be superior to the currently best available light-emitting diode fluorescent smear microscopy as the initial test for urinary tuberculosis (sensitivity of 69.09% vs. 32.72%). The Xpert MTB/RIF polymerase chain reaction test was found to have a moderate sensitivity (69.09%) and high specificity (100%) as compared to the composite reference standard. The sensitivity of liquid AFB culture MGIT 960 as compared to the reference standard was 90.32%. CONCLUSIONS: Xpert MTB/RIF assay on an early morning first void urine specimen can replace smear microscopy as the initial diagnostic test for urinary tuberculosis.

Perioperative complications and postoperative outcomes of partial nephrectomy for renal cell carcinoma: Does indication matter?

INTRODUCTION: The aim of the study was to determine whether perioperative complications and postoperative outcomes varied with the indication of partial nephrectomy (PN). MATERIALS AND METHODS: We reviewed data of 184 consecutive PN for suspected renal cell carcinoma operated between January 2004 and December 2013. Complications using the Clavien-Dindo classification were compared between surgeries for absolute indications (chronic renal failure, bilateral tumors, or solitary kidney), those for relative indications (comorbid illnesses with the potential to affect renal function) and elective indications (patients without risk factors). Complex tumors were defined as size >7 cm, multiple, hilar, and endophytic tumors. RESULTS: Patients with an absolute indication had larger tumors (P = 0.001) and tumors of a higher pathological T-stage (P = 0.03). Minor complications (Clavien 1 and 2) occurred in 25.4% patients in the elective arm versus over 40% in the other arms (P = 0.049). Major complications (Clavien 3+) were less common in the elective arm (3.2% cases vs. 12.7% in the relative arm and 13.8% in the absolute arm) with a trend to significance (P = 0.09). On multivariate analysis, absolute indication (odds ratio [OR] = 2.4, P = 0.04) and surgery for a complex renal mass (OR = 2.5 times, P = 0.03) remained significant predictors of minor complications. Major complications were more common in the relative (OR = 5.5, P = 0.057) and absolute indication arm (OR = 5.231, P = 0.051) with a trend toward significance. CONCLUSIONS: Elective indication was associated with fewer complications than PN for relative or absolute indications.

Urine and serum fetuin-A levels in patients with urolithiasis.

INTRODUCTION: Fetuin-A is a glycoprotein secreted by liver and has been shown to inhibit extraosseous mineralization. Urolithiasis may be a manifestation in the urinary tract due to fetuin deficiency in urine. The objective of this study was to compare the 24-h urine and serum fetuin-A levels of patients with and without urolithiasis. METHODS: Serum and 24-h urine fetuin-A levels were measured in 41 patients with bilateral, multiple, or recurrent urinary tract calculi (Group A) and 41 matched controls with no calculi (Group B). Fetuin levels were measured by enzyme linked immunosorbent assay. Serum and urine fetuin-A levels in the two groups were compared. RESULTS: The median (range) 24-h urine fetuin-A value in Group A was 11.9 (1.12-221) mg/day and in Group B was 37.7 (1.28-125) mg/day. This difference was statistically significant (Mann-Whitney test, P = 0.0169). The median (range) serum fetuin-A in Group A was 0.67 (0.05-2.68) g/L and in Group B was 0.99 (0.01-5.5) g/L. The difference between serum values in the two arms was not statistically significant (Mann-Whitney test, P = 0.1817). However, the serum creatinine-adjusted mean log serum fetuin and urine fetuin were significantly different in the two arms (P = 0.003). The mean ± standard deviation (range) serum creatinine in Group A was 0.98 ± 0.25 (0.56-1.58) mg% and in Group B was 0.83 ± 0.16 (0.58-1.18) mg% (two sample t-test, P = 0.0031). CONCLUSIONS: Patients with urolithiasis have lower urine fetuin-A and creatinine-adjusted serum fetuin-A levels.

Urethral duplication with unusual cause of bladder outlet obstruction.

A 12-year-old boy presented with poor flow and recurrent urinary tract infections following hypospadias repair at the age of 3 years. The evaluation revealed urethral duplication with a hypoplastic dorsal urethra and patent ventral urethra. He also had duplication of the bladder neck, and on voiding cystourethrogram the ventral bladder neck appeared hypoplastic and compressed by the dorsal bladder neck during voiding. The possibility of functional obstruction of the ventral urethra by the occluded dorsal urethra was suspected, and he underwent a successful urethro-urethrostomy.

Extracorporeal shock wave lithotripsy in Indian children: Predictors of outcome and validation of pre-treatment nomograms.

BACKGROUND: Although multiple variables have been shown to affect outcomes in pediatric lithotripsy (ESWL), there is no consensus on the same. Nomograms combine multiple variables and provide an objective prediction of outcomes. Two nomograms have been previously described and validated in two studies from the same geographical area. External validation in multiple settings is needed, as a nomogram's performance may vary with time, geographical area and clinical scenario. OBJECTIVES: This study aimed to identify variables influencing pediatric ESWL outcomes, validate published nomograms and describe the clinical and metabolic profile of Indian children treated with ESWL. DESIGN: This retrospective cohort study included all children who underwent ESWL from 2002 to 2019 at a single centre. ESWL was performed under general anaesthesia. Mid and lower ureteric calculi were treated in prone and the rest in supine position. 1500-2000 shocks were delivered at a voltage of 12-16 kV. Data pertaining to patient characteristics, metabolic evaluation, imaging, ESWL details and post-procedure outcomes were obtained from the hospital information system and these variables, along with Onal and Dogan scores, were correlated with stone clearance. Cut-offs for Onal and Dogan scores were determined using receiver operator characteristic (ROC) curve analysis and compared with area under the curve (AUC). Complications, ancillary procedures and metabolic abnormalities were recorded. RESULTS: A total of 66 children (76 renal units) were included. Mean age was 5.5 years (Range 6 months-14 years) and median stone size, 12 mm (IQR 9, 15.25). Average treatment sessions were 1.8 ± 0.99. Median shocks in the stone-free group and those who failed treatment were 1750 (IQR 1500, 3000) and 3250 (IQR 1750, 4750) respectively. The remaining variables are depicted in Table 1. The stone free rate was 63.2%. Fragments <4 mm were seen in 19 (25%). Efficacy Quotient was 40. The AUC for Dogan nomogram (cut-off <199.5) was 0.761 while that for Onal nomogram (cut-off <2.5) was 0.762 and 0.771 after one and three shocks respectively. On multivariate analysis, age, multiple calculi, Onal and Dogan scores were predictive of clearance. Dogan score had higher specificity. Complications were seen in 16 (21%) and ancillary procedures needed in 7 (9.2%). Metabolic abnormalities were seen in 84.8%, the commonest being hyperoxaluria. Mixed stones were most frequent. CONCLUSIONS: Lithotripsy in children is safe and effective. Older age, presence of multiple calculi, higher Onal and Dogan scores are predictive of treatment failure.

Satisfaction and genital perception after orchiectomy for prostate cancer: does the technique matter? A randomized trial.

OBJECTIVES: Bilateral extracapsular or total orchiectomy (BEO) for prostate cancer is presumed to have psychological consequences after the surgery due to perception of an empty scrotum. Bilateral subcapsular orchiectomy (BSO) was designed to preserve perception of palpable testes. We compared the patients' satisfaction and genital perception following BEO and BSO. MATERIALS AND METHODS: Prostate cancer patients eligible for androgen deprivation therapy who opted for orchiectomy were enrolled in prospective randomized study. Patients with bleeding disorder or uncorrected coagulopathy, poor performance score, and psychiatric problems were excluded. Outlook to life and own health in-general, overall satisfaction to the procedure and genital perception was evaluated using modified Fugl-Meyer questionnaire (FMQ) which was administered before and after 3 months of the surgery. Patients were randomized to BEO and BSO groups at the time of surgery using block randomization. Primary outcome was to compare the genital perception of testicular loss and patients' satisfaction to BSO and BEO. Secondary outcomes included testosterone and PSA control, operative time, and complications. RESULTS: Total 35 patients were enrolled in each group which was comparable. There was no difference in PSA control at 3 months. Mean operative time and blood loss were significantly lesser in BEO group. FMQ score at 3 months did not show significant difference. Majority of the patients in both groups were satisfied with procedure and the aesthetic value of scrotum after surgery. However, 84% in BSO group did not feel that testes were removed on self-examination, as compared to 28% in BEO group. Majority patients in both groups did not report physical or psychological discomfort from change in scrotal content. CONCLUSIONS: Results showed that patients' satisfaction and genital perception following BSO and BEO were similar. Feeling of remaining intrascrotal contents after BSO did not had added psychological advantage in terms of perception of genitalia.

Can rectal catheters be avoided during paediatric urodynamic studies?

Objective: To determine if the interpretation of urodynamic studies (UDS) in children without a rectal catheter may be similar to multi-channel studies, as UDS in children are challenging and can sometimes be difficult to interpret. Patients and methods: In this retrospective pilot study, 115 paediatric pressure-flow studies were included. A blinded investigator was given two sets of UDS traces. The first set had the vesical trace of all children and the second set had the multi-channel trace. The agreement between the interpretations of both the sets was tested by Cohen's κ, and sensitivity, specificity, and predictive values were expressed with 95% confidence intervals (CIs). The voiding pattern was compared and Pearson's correlation coefficient was used to analyse the pressure at maximum urinary flow (Qmax). Results: The most common indications for UDS were neurogenic bladder and posterior urethral valves. The interpretation of compliance and detrusor overactivity by single-channel analysis had a positive predictive value of 92.1% (95% CI 84.7-96.1%) and 89.4% (95% CI 78.3-95.6%), respectively, and a negative predictive value of 100% and 97.1% (95% CI 89.5-99.2%) respectively, in comparison to multi-channel analysis. Children with underactive detrusor were identified reliably by analysing the straining pressure pattern and flow curve. Amongst children who voided, the pressure at Qmax showed a moderate correlation (Pearson's coefficient = 0.53) between the two groups. Conclusion: Rectal catheters may be avoided in a carefully selected group of children undergoing UDS who only need filling phase assessment. Abbreviations: DO: detrusor overactivity; EBC: expected bladder capacity; Pabd: abdominal pressure; Pdet: detrusor pressure; PUV: posterior urethral valve; (N)(P)PV: (negative) (positive) predictive value; Pves: vesical pressure; Qmax: maximum urinary flow rate; UDS: urodynamic studies; UI: urinary incontinence.

Chromophobe renal cell carcinoma: A report of two cases with unusual histological features.

We report two cases of chromophobe renal cell carcinoma with unusual histological features; one case of eosinophilic variant of chromophobe renal cell carcinoma and another case with extensive metaplastic ossification.

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.

Surgical revascularization of bilateral renal artery stenosis due to fibromuscular dysplasia.

Fibromuscular dysplasia (FMD) is a noninflammatory disease affecting small- and medium-sized arteries of the renal and the carotids. It affects the renal arteries in nearly 60%-75% cases. The primary clinical manifestation of renal FMD is hypertension. Medial fibroplasia represents the most common dysplastic lesion. We report two cases who presented with hypertension and renal insufficiency and on evaluation was found to have bilateral renal artery stenosis. Stenting of the renal vessels was not possible due to the narrowed caliber of the vessel and inability to cannulate the renal arteries. They underwent renal artery revascularization with a splenorenal end to end anastomosis. The renal parameters and blood pressure of both the patients stabilized subsequently. Renal revascularization can be a good option for patient having failed angioplasty with stenting.

Can we predict the need for intervention in steinstrasse following shock wave lithotripsy?

INTRODUCTION: Steinstrasse (SS) is a known complication of shock wave lithotripsy (SWL). Although the majority of SS clears spontaneously, about 6% require intervention. This study was carried out to identify the factors that determine the need for intervention in SS. MATERIALS AND METHODS: This was a retrospective study of all patients who developed steinstrasse following SWL at our center. They were divided into two groups: a) Those cleared spontaneously and b) Those required intervention. The two groups were compared with regard to demographic profile, stone factors and factors related to steinstrasse. RESULTS: Out of 2436 cases of SWL, 89 (3%) formed steinstrasse. The majority of the patients (35%) who required intervention had stone sizes of 10-14 mm. Coptcoat type III steinstrasse required significantly more interventions for clearance (P = 0.001). The site and the size of the SS was not a predictor of intervention for SS. CONCLUSIONS: Early intervention is warranted in patients with steinstrasse where the lead fragment is >5 mm (Coptcoat type III).

Exstrophy-epispadias complex presenting in adulthood: a single-center review of presentation, management, and outcomes.

OBJECTIVE: To study the presentation, management, and outcome of patients with exstrophy-epispadias complex, who present in adulthood (aged >18 years). MATERIALS AND METHODS: A retrospective review of the electronic medical records of patients with exstrophy-epispadias complex managed from January 2001 to December 2010 was undertaken. Patients aged >18 years at presentation, with detailed medical records were selected. They were classified into 2 groups: group A (previously untreated) and group B (residual defects or complications after childhood surgery). RESULTS: Thirty-nine patients with exstrophy-epispadias complex presented to our institution over this 10-year period. Of these 26 were adults (aged >18 years; range, 18-48 years). Detailed medical records could be obtained for 21 of them and they were included. Group A consisted of 4 patients--2 male and 2 female. All underwent cystectomy; 2 had an ileal conduit and 2 had ureterosigmoidostomy (Mainz II). All had improved quality of life and a stable renal function at follow-up. Group B consisted of 17 patients. Mean number of surgeries attempted previously was 4.4 (range, 2-13). Presentation was varied but primarily involved incontinence of urine (n = 12). Four patients were lost to follow-up, 2 were managed conservatively, and 11 underwent a surgical procedure. All patients returned to normal activity with an improvement in the quality of life postoperatively. CONCLUSION: Exstrophy-epispadias complex is difficult to manage in resource-poor settings associated with illiteracy and poverty. However, successful rehabilitation and an improved quality of life are possible even in cases presenting in adults.