A study on immunohistochemical expression of HER2/Neu and p63 and its association with grade and invasiveness in case of bladder carcinoma.

INTRODUCTION: Bladder cancer is a global disease, ranks as the fourth most prevalent cancer. The incidence and prevalence increase with age. Grade and aggressiveness have been found to be related with different genetic expression and mutation. AIMS: To evaluate any relation of grade and invasiveness of urothelial cancer with varied expression of immune histochemical marker p63 and her2/neu. MATERIALS AND METHODS: The present study was a hospital based prospective cross-sectional study. This Study was conducted from July 2021 to April 2023 in the Urology department of a tertiary care hospital. Total 90 patients undergoing trans urethral resection of bladder tumour (TURBT) were included in this study. RESULT: It was found that, patients who had decreased p63 expression had high grade in tumours (93.1%) compared to patients who were expressing normal p63 (32.8%) and this was statistically significant (p < 0.0001). Tumours with decreased p63 also appeared to be more invasive, 62.1% were found to be muscle invasive. Tumours with her2 neu expression found to be more aggressive in nature, 85.7% had high grade features and 53.6% were muscle invasive. CONCLUSION: Our findings suggest that immunohistochemical expression of HER2/neu positive and decreased p63 expression were associated with high grade and invasiveness in case of bladder carcinoma.

Role of multiparametric MRI in predicting muscle invasiveness in urinary bladder neoplasms with pathological correlations.

Urinary bladder cancer (BC) is one of the most frequent malignancies and the ninth most common malignancy worldwide. The objective of this study is to assess the role of multiparametric magnetic resonance imaging (mp-MRI) in predicting the invasiveness of urinary bladder space occupying lesions. Thirty-five patients diagnosed with bladder masses underwent an mp-MRI study. The results of three image sets were analysed and compared with the histopathological results as a reference standard: T2-weighted image (T2WI) plus dynamic contrast-enhanced (DCE), T2WI plus diffusion-weighted images (DWI), and mp-MRI, including T2WI plus DWI and DCE. The diagnostic accuracy of mp-MRI was evaluated using receiver operating characteristic curve analysis. We discovered a highly significant correlation between muscle invasiveness as staged by HPE (Histopathological examination) and mp-MRI utilising a VI-RADS score >3 (p 0.001) with a sensitivity of 100% and a specificity of 85.7%. With a diagnostic accuracy of 77.14%, a sensitivity of 92.31%, a specificity of 72.72%, a positive predictive value of 66.67%, and a negative predictive value of 94.11%, In terms of muscle invasiveness, there is good concordance between HPE staging and mp-MRI utilising the VI-RADS score. The mean apparent diffusion coefficient (ADC) values were higher in low grades than in high grades. The ROC curve study revealed a very strong correlation between HPE grade and ADC (p = 0.045). In 77.14% of patients, Mp-MRI correctly identified the local T stage. Mp-MRI is imaging biomarker for invasiveness and grade of tumour. The tumours with high grade are more invasive. However, the diagnostic accuracy of mp-MRI in determining muscle invasiveness is not very high and it overstages the disease in some cases (33.3%). Its clinical usefulness in determining muscle invasiveness before TURBT and histopathological examination can be questioned.

Calcutta position: A new modified supine decubitus for supine PCNL.

INTRODUCTION: PCNL (percutaneous nephrolithotripsy) is considered the gold standard treatment for renal stone more than 2 cm. In today's scenario, supine PCNL is considered equally effective as prone PCNL. The ideal position for supine PCNL is still debatable. We hereby describe our initial experiences of supine PCNL in a novel position. METHODS AND MATERIALS: This prospective study includes 60 patients who underwent supine PCNL in the 'Calcutta position' in our institute from August 2021 to August 2022. Successful procedure was defined as a complete stone free rate or a clinically insignificant residual stone (<4 mm). RESULTS: Average Operative room (OR) occupancy time was 130.9 ± 19.63 min. The immediate stone free rate was 84.2%, 71.4% and 37.5% for single, multiple and staghorn calculus respectively. Complications include fever, requirement of blood transfusions and renal colic. The average hospital stay was 83.6 ± 17.42 h. Eight patients (13.3%) required secondary procedures like extracorporeal shock wave lithotripsy (ESWL) or relook PCNL. At 3 months average stone free rates were 92%, 85%, 75% for single, multiple and staghorn calculus respectively. We performed supine PCNL in Calcutta position in obese, kyphoscoliosis, poliomyelitis, autosomal polycystic kidney disease (ADPKD), malrotated kidney and diverticular stone with comparable success. CONCLUSION: Supine PCNL in Calcutta position is a safe and effective option for nephrolithiasis management. Apart from the inherent advantages of supine PCNL it also has the advantages of better C-Arm and nephroscope manoeuvrability. Supine PCNL in Calcutta position was performed in a variety of scenarios with comparable results.

Comparative effect of intraurethral clobetasol and tacrolimus in lichen sclerosus-associated urethral stricture disease.

Background: Management of urethral stricture related to lichen sclerosus (LS) is now gradually changing from surgical to nonsurgical due to availability of anti-inflammatory agents such as corticosteroids and calcineurin inhibitors. We determined the clinical impact of these agents in such patients on outpatient department basis in terms of improvement in symptoms on International Prostate Symptom Score (IPSS), external skin appearance, and maximum urinary flow rate (Qmax). Materials and Methods: Eighty patients of meatal stenosis and penile urethral stricture with histopathologically proven LS were divided into two groups, and clinical and predetermined parameters such as Qmax, IPSS, and changes in external appearance were compared between these groups after 3 months of topical and intraurethral application of clobetasol and tacrolimus with self-calibration. Results: A significant intragroup difference was noted in IPSS (P < 0.001) as well as Qmax (P < 0.001); postintervention intergroup difference in IPSS was not significant (P = 0.94) and however postintervention intergroup difference in Qmax was significant in favor of clobetasol (P = 0.007). A significantly increased number of additional procedures were done in the group receiving intraurethral tacrolimus (P = 0.0473) with significantly less number of skin complication in the group with topically applied clobetasol (P = 0.003). Conclusion: Though both clobetasol and tacrolimus, improved symptom score, Qmax and local external appearance yet topical and intra-urethral clobetasol application via urethral self calibration seems to be better option for lichen sclerosus related urethral stricture in terms cost and local complications.

Thulium laser enucleation of bladder tumour (Thulebt): Changing paradigm in the management of nonmuscle invasive urinary bladder carcinoma.

OBJECTIVES: To analyse the safety and efficacy of Thulium laser en bloc enucleation of bladder tumour (ThuLEBT) in comparison to transurethral resection of bladder tumour (TURBT) for treatment of non-muscle invasive bladder cancer (NMIBC). METHODS: Prospective observational study involving 30 patients in each group of ThuLEBT and TURBT admitted in tertiary care centre from 1st January 2021 to December 2021. RESULTS: Significant difference was found in terms of less operative time (p-0.01468), less intraoperative blood loss, a lower incidence of obturator nerve reflex (p-0.00006), bladder perforation (p-0.0455) and bladder irrigation (p-0.0027), better acquisition of detrusor muscle (p-0.0466), less recurrence rate (p-0.0455) in favour of ThuLEBT over TURBT group. The analysis also demonstrated faster postoperative recovery in terms of the duration of catheterisation, bladder irrigation and hospitalisation time in ThuLEBT group. CONCLUSIONS: ThuLEBT is an efficient and safe treatment for non-muscle invasive bladder cancer and it can be a better alternative choice in place of TURBT.

Supine PCNL in autosomal dominant polycystic kidney disease.

AIMS AND OBJECTIVES: Standard percutaneous nephrolithotomy (PCNL) has routinely been performed in prone position in autosomal dominant polycystic kidney disease (ADPKD) with nephrolithiasis. The objectives of our present study is to ensure optimum access to the renal collecting system, reducing operative time, and anesthetic morbidity during supine PCNL in ADPKD with nephrolithiasis. METHODS: Seven patients were selected randomly. There were no preference for age, gender, size, location and laterality of stone, or BMI . All the patients fit into the AUA guideline criteria for management by percutaneous nephrolithotomy. Preoperative, perioperative, and follow up data were collected prospectively. RESULTS: Seven patients underwent supine PCNL in approximately 2.5 year in modified supine position. There was no intraoperative, post operative, or on follow up complications in any patient. In all the patients stones were cleared completely in single sitting. CONCLUSIONS: Supine PCNL in ADPKD with nephrolithiasis is an alternative with similar outcomes to the standard prone PCNL. It provides an additional benefit of performing the procedure in a single position, which is known to reduce total operating time, less anesthesia related complications, less neuromusculoskeletal injury, and reduce physical strain on operating.

Spectrum of lower urinary tract symptoms after renal transplant among adult non-urologic anuric patients and their management in a tertiary care center.

INTRODUCTION: Lower urinary tract symptoms (LUTS) in a post-transplant patient can lead to several complications including recurrent UTI and deterioration of the graft kidney function. The aim of this study is to investigate the spectrum of LUTS, possible complications resulting from it and its management after renal transplant in pre-transplant anuric patients operated in our tertiary care institute. MATERIALS AND METHODS: It was a retro-prospective observational study done on post-transplant patients operated in this institute from December 2016 to December 2020. Among 165 patients operated during this period 50 male and 21 female patients were finally included in this study. Urinary symptoms were evaluated using the IPSS Questionnaire. Pre and post-surgery Uroflowmetry findings were compared. Urodynamic assessment was done at least 6 months after surgery to determine the cause behind such symptoms. The data was analyzed with the help of standard statistical methods and SPSS 21 software. RESULTS: The most common LUTS among the post renal transplant patients were frequency and nocturia. There was a marked improvement in voided volume and urinary flow in most of the patients. In 11 male and 7 female patients LUTS symptoms were moderate to severe and were seldom associated with recurrent UTI and graft compromise. A cautious approach in these patients helped in early diagnosis of the etiology behind LUTS, which were treated accordingly. CONCLUSION: LUTS should be carefully evaluated before renal transplantation. Postoperatively moderate to severe LUTS symptoms should be thoroughly investigated so that graft compromise and related complications can be prevented by early intervention.

Evaluation of renal space occupying lesions with multiparametric MRI and its correlation with histopathology findings- an observational study.

The term multiparametric MRI, is a useful tool in reference to an approach that takes advantage of the added value of different MR imaging acquisitions to yield anatomic and pathophysiologic information about renal space occupying lesions and to evaluate patients with different tumors, including genitourinary malignancies. The role of multiparametric MRI is continuously growing because of its ability to detect and characterize renal space occupying lesions as well as to assess response to treatment. An observational study was carried out in 50 patients who presented with renal mass, based on clinical suspicion and prior imaging diagnosis of neoplastic renal space occupying lesion. Total renal space occupying lesions were 50, of which, 38 were males & 12 were females. The age range of the study population was 30-80 years. In our study, Agreement analysis between mpMRI diagnosis and HPE diagnosis of different RCC subtypes was statistically significant. So, multiparametric MRI had a role in differentiating the subtypes of RCC which had fair agreement with HPE. The present study results state that the renal mass lesions has different ADC values for different lesions because of the change in tissue contents and there was a statistically significant difference in ADC values between low and high-stage RCCs. Histologic and radiologic profiles of renal space occupying lesions and diverse subtypes of RCC can be used as biologic indicators of clinical behavior, response to treatment, and prognosis.

Surgical outcomes of supine PCNL in spinal deformity patients: A tertiary care hospital experience.

AIMS AND OBJECTIVE: Percutaneous nephrolithotomy (PCNL) is treatment of choice now a days in patients with spinal deformity with large kidney stones. Objectives of our present study to compare in which position it is better to perform and costs minimum complications after surgery. METHODS: A total of 14 patients with spinal deformity having nephrolithiasis were selected randomly. No preferences for age, gender, size, location, and laterality of stone or BMI. All the patients were fit according to AUA guideline criteria for management by PCNL. Preoperative and postoperative data were collected in all operated patients. Descriptive statistics were performed as means, standard deviations, and ranges using Microsoft excel. For categorical variables percentage were used. RESULTS: A total of 14 patients with spinal deformity having nephrolithiasis underwent PCNL. Seven patients operated in prone position and seven patients operated in modified supine position within approximately 2 years. As compared to prone position in supine position there were reduced operative time, little or no change in Hb concentration, shorter hospital stay, little intraoperative blood loss, and higher significant stone free rate were detected. CONCLUSIONS: Supine PCNL in spinal deformity patients with nephrolithiasis is an alternative to the standard prone PCNL. It provides an additional benefit of large operative field performing the procedure in a single position, reduces total operating time, less anesthesia related complications, less neuromusculoskeletal injury, and reduce physical strain on operating surgeon.

Acellular Tissue Engineered Pericardial Patch Urethroplasty: A New Horizon of Substitution Urethroplasty.

OBJECTIVE: Buccal mucosal graft is the best autologous material for substitution urethroplasty. However, in cases where buccal mucosa is unavailable, a non-autologous tissue like acellular tissue-engineered pericar- dial patch can be very helpful. Our study is a small approach regarding the success and durability of acellular tissue-engineered pericardial patch as a substitution tissue in urethroplasty. MATERIAL AND METHODS: A total of 22 patients underwent acellular tissue-engineered pericardial patch substi- tution urethroplasty using dorsolateral onlay technique for long segment urethral stricture, for a period of twoyears. Observations and comparison were made in terms of postoperative change in maximum urinary flowrate (Qmax), resolution of obstructive lower urinary tract symptoms, improvement in retrograde urethrogram and complications encountered, with buccal mucosal graft urethroplasty as a historical control. RESULTS: Out of these 22 patients, 18 patients had successful outcomes considering maximum flow rate (Qmax)> 10 mL/s on uroflowmetry, resolved obstructive lower urinary tract symptoms, and normal postoperativeretrograde urethrogram, whereas four patients were considered a failure because of Qmax <10 mL/s, unre- solved obstructed lower urinary tract symptoms and recurrence of urethral stricture on retrograde urethro-gram and development of urethrocutaneous fistula. CONCLUSION: Acellular tissue-engineered pericardial patch substitution urethroplasty can be a useful alternative to autologous tissue substitution, especially where the buccal mucosal graft is unavailable for urethroplasty.

Interposing layer of fibrin glue: A new horizon in vesico-vaginal fistula repair.

AIM: In this study our idea is to compare the effectiveness of using interposing layer of fibrin glue to omental flap in reducing the failure of laparoscopic vesicovaginal fistula repair. METHODS: Forty patients with fairly large vesicovaginal fistula were enrolled and divided in two groups of 20 each. We have used fibrin glue in one group and omental flap in the other group. RESULT: Of 20 patients in fibrin glue group no failure was seen, while 5 patients out of 20 in omental flap group had failure. CONCLUSION: This result is statistically significant and hence use of fibrin glue to be considered during laparoscopic repair of vesicovaginal fistulas.

Supine versus prone PCNL in lower calyceal stone: Comparative study in a tertiary care center.

INTRODUCTION: Renal calculus disease is an age old disease of human being. PCNL (Percutaneous nephrolithotomy) stands as a gold standard treatment for large renal calculus which is traditionally being done in prone position. OBJECTIVE: To evaluate the safety and efficacy of supine PCNL versus prone PCNL comparing intraoperative time, requirement of relook PCNL, post op hemoglobin drop, post operative hospital stay, post operative complication, SFR ( stone free rate). METHODS AND MATERIALS: It is a prospective study done in Urology department in a tertiary care center in Eastern India between October 2017 and October 2018. A total of 84 patients with lower calyceal renal stones underwent PCNL, 42 of them in supine and 42 in prone position. Lower calyceal stone, size measuring 1 to 2 cm were included in the study. RESULTS: The mean intra operative time was 91.76 min in supine group and 85.43 min in prone group with a p value of 0.115. The mean hemoglobin drop was 1.11 g/dl and 1.18 g/dl in supine and prone position, respectively (p value 0.75). The mean post operative hospital stay was 4.1 and 3.86 days in supine and prone group (p value 0.58), respectively. Two patients in each group require relook PCNL. Stone free rate at 1 month was 95.23% and 90.47% (p value 0.9), respectively in case of supine and prone group. CONCLUSION: Supine PCNL is feasible, comparable to prone PCNL in respect to operative parameters with relatively higher stone free rate though statistically insignificant.

Role of Preoperative Ureteric Stenting in Optimization of Patients with Retroperitoneal Tumors Associated with Obstructive Uropathy.

Retroperitoneal tumors can cause ureteric obstruction leading to obstructive uropathy. Early preoperative ureteric stenting helps to improve renal function and also helps in identifying ureters and prevent ureteric injury during surgery. This study was aimed at assessing the outcome of preoperative stenting in optimizing such patients. A total of 24 cases were enrolled. Of these, 15 patients who had obstructive uropathy were taken for ureteric stenting preoperatively and other 9 patients have undergone surgery without stenting. Twelve patients were stented successfully but 3 patients could not be stented (underwent percutaneous nephrostomy). All 24 patients underwent laparotomy, and of the 12 stented patients, 11 underwent successful resection and one had unresectable tumor. The patient's serum creatinine was assessed initially and then twice after stenting (48 h and 5 days). Serum creatinine was also estimated 24 h after excision of the tumor. In the successfully stented and operated patients, mean initial creatinine was 7.85. The mean creatinine at 48 h and 5 days after stenting was 4.29 and 1.19 respectively. The mean creatinine 24 h after resection of the tumor was 1.04. Of the non-stented patients, 3 had ureteric injury during surgery. We conclude that preoperative ureteric stenting is helpful for optimization of patients with retroperitoneal tumors with obstructive uropathy.

Tissue engineered indigenous pericardial patch urethroplasty: A promising solution to a nagging problem.

OBJECTIVE: Urethral stricture is a highly prevalent disease and has a continued rising incidence. The global burden of disease keeps rising as there are significant rates of recurrence with the existing management options with the need for additional repeat procedures. Moreover, the existing treatment options are associated with significant morbidity in the patient. Long segment urethral strictures are most commonly managed by augmentation urethroplasty. We explored the potential for the application of an acellular tissue engineered bovine pericardial patch in augmentation urethroplasty in a series of our patients suffering from urethral stricture disease. The decreased morbidity due to the avoidance of harvest of buccal mucosa, decreased operative time and satisfactory postoperative results make it a promising option for augmentation urethroplasty. METHODS: Nine patients with long segment anterior urethral strictures (involving penile and/or bulbar urethra and stricture length >4 cm) were included in the study after proper informed consent was obtained. Acellular tissue engineered indigenous bovine pericardial patch was used for urethroplasty using dorsal onlay technique. RESULTS: A total of nine patients underwent tissue engineered indigenous pericardial patch urethroplasty for long segment urethral strictures, mostly catheter injury induced or associated with balanitis xerotica obliterans. Median follow-up was 8 months (range: 2-12 months). Out of nine patients, eight (88.9%) were classified as success and one (11.1%) was classified as failure. CONCLUSION: Our study brings a product of tissue engineering, already being used in the cardiovascular surgery domain, into the urological surgery operating room with satisfactory results achieved using standard operating techniques of one stage urethroplasty.

Is urodynamic study is a necessity for evaluation of lower urinary tract symptoms in postmenopausal female patients? Result of a prospective observational study.

AIM: The aim of this study is to evaluate the causes of lower urinary tract symptoms (LUTS) in postmenopausal female patients (PMFP) and correlate their symptoms with their urodynamic study (UDS) findings. MATERIALS AND METHODS: A prospective observational study analyzing the clinical and UDS findings of PMFP presenting with LUTS. A detailed history including history of diabetes, neurological disease, drug history, and pelvic surgeries was taken, followed by physical examination and urodynamic assessment. RESULTS: A total of 100 patients were classified according to their predominant symptoms into three categories: (1) voiding dysfunction (45 patients), (2) storage symptoms (30 patients), and (3) urinary incontinence (25 patients). The patients with voiding LUTS could be categorized urodynamically into three grades of bladder outlet obstruction (BOO): (a) early (37.8%) (maximal flow [Qmax] >15 mL/s and detrusor pressure at maximal flow [PdetQmax] >30 cm of water), (b) compensated (31.1%) (Qmax <15 mL/s and PdetQmax >30 cm of water), and (c) late (31.1%) (Qmax <15 mL/s and PdetQmax <30 cm of water). The patients with storage symptoms could be categorized into two with either the presence of demonstrable idiopathic detrusor contractions (53.3%) or not (46.7%). The patients with incontinence were of three types: (a) stress incontinence (44%), (b) urge incontinence (28%), and (c) mixed incontinence (28%). UDS showed no demonstrable leak in nine patients (36%) and the rest had UDS findings corroborative to their symptoms. CONCLUSIONS: Thus, the major LUTS in PMFP were BOO, storage symptoms, and incontinence. Proper evaluation of LUTS necessitates UDS and along with good physical examination can help us in reaching a correct diagnosis and plan respective treatment.

Renal lymphangiectasia treated with percutaneous drainage and sclerotherapy.

Renal lymphangiectasia is a rare benign condition of the lymphatic system. Primarily, the diagnosis is based upon characteristic imaging findings along with biochemical analysis of aspirated fluid. No definitive algorithm exists for treating this condition owing to its rarity. The literature describes various modes of management ranging from conservative management to nephrectomies. We present a case of bilateral renal lymphangiectasia managed with percutaneous drainage along with sclerotherapy. Our initial findings show a favorable outcome with this approach.

Acute leukemia masquerading as xanthogranulomatous pyelonephritis.

An 82-year-old man presented with high-grade fever, left flank pain with dysuria. Urine culture revealed the growth of Escherichia coli. Contrast-enhanced computed tomography features were suggestive of xanthogranulomatous pyelonephritis (XPN) of the left kidney. Serial hemogram studies revealed markedly raised white cell count with the presence of blast cells. On further evaluation by peripheral blood smears and bone marrow biopsy studies, a background disease setting of acute prolymphocytic leukemia was diagnosed. This is a very rare case report of acute leukemia masquerading as a case of XPN, and the optimum treatment protocol is yet to be established in such a scenario.

Rationalization of interpretation of uroflowmetry for a non-caucasian (Indian) population: conceptual development and validation of volume-normalized flow rate index.

AIMS: We intended to define volume-normalized flow rates (cQ; VQI) and to construct and validate uroflow (Q)-volume (V) nomograms in our Indian (non-Caucasian) population. METHODS: Prospective observational study. PARTICIPANTS: Group A, male healthy volunteers 18-45 years without LUTS. Group B, men >18 years with LUTS (IPSS > 7; global QOL > 2). The participants voided in standing on normal-to-strong desire into digital gravimetric uroflowmeter. Data of <50 ml void and intermittent flow was discarded. Reference cQ calculated using (i) Von Garrelts equations (=Q/VV(2)), (ii) cubic equations (=Q/VV(3)). Bladder volume (BV) rather than voided volume (VV) was considered for Q-V relation (BV = VV + PVR). VQI derived from present data were compared with the reference-VQI in terms of differences in area-under-curve of receiver operating characteristics. For comparing sensitivity, specificity and predictive values of study nomograms with Caucasian nomograms (Liverpool and Siroky), data of group-A and -B were plotted on each nomogram and no. of observations above and below the cutoffs (defined as equivalent to -1 SD) manually counted. RESULTS: Total 542 voids of group-A and 465 of group-B included for final analysis. Q-V relation was best described as [Q ∝ BV(2.4) ≅ BV(2)]. The derived VQI (=Q/BV(2.4) ≅ Q/BV(2)) fared significantly superior to reference VQI with VV as denominator. Nomograms, constructed on Q ∝ BV(2) , were less sensitive but had higher specificity and positive predictive values compared to Caucasian nomograms. CONCLUSIONS: Volume-normalized flow-rate index with BV as denominator (Q/BV(2)) is has highly discriminative value in screening for voiding dysfunction. Population-specific Q-BV nomograms are more specific and predictive than Caucasian Q-VV nomograms.

Are urine flow-volume nomograms developed on Caucasian men optimally applicable for Indian men? Need for appraisal of flow-volume relations in local population.

INTRODUCTION: Flow-volume nomograms and volume-corrected flow-rates (cQ) are tools to correct uroflow rates (Q) with varied voided volumes (VV) of urine. We investigated the applicability of the available nomograms in our local population. MATERIALS AND METHODS: Raw data of our previous study on variation in Q with voiding position (standing, sitting, and squatting) in healthy adult men was reanalyzed. Additionally, the departmental urodynamic database of the last four years was searched for uroflow data of men with voiding symptoms (International Prostatic Symptom Score (IPSS) > 7 and global quality of life score >2). These results were projected on the Liverpool and Siroky nomograms for men. The Q-VV relations were statistically analyzed using curve-estimation regression method to examine the current definition of corrected maximum flow rate (Qmax). RESULTS: We found a cubic relation between Q and VV; based on this we developed novel equation for cQ [cQ=Q/(VV)(1/3)] and novel confidence-limit flow-volume nomograms. The imaginary 16(th) percentile line of Liverpool nomogram, -1 standard-deviation line of Siroky nomogram and lower 68% confidence-limit line of our nomogram had sensitivity of 96.2%, 100% and 89.3%, and specificity of 75.3% 69.3% and 86.0%, respectively for Qmax-VV relations. Corresponding values for average flow rate (Qave)-volume relations were 96.2%, 100% and 94.6%, and 75.2%, 50.4% and 86.0%, respectively. The area under curve of the receiver operating characteristics (ROC) curve for cQmax and cQave was 0.954 and 0.965, respectively, suggesting significantly higher discriminatory power than chance (P = 0.0001). CONCLUSION: Flow-volume nomograms developed on Caucasian population may not be optimally applicable to the Indian population. We introduce flow-volume nomograms and cQ, which have high sensitivity and specificity.