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.

Chyluria with massive proteinuria: Do not reach for the biopsy gun!

We report on a patient presenting with persistent chyluria due to filariasis, whose clinical course was complicated by massive proteinuria and severe hypoalbuminemia. Treatment with dietary manipulation, antifilarials, and sclerotherapy resulted in successful reversal of the above abnormalities. It has been reported that chyluria is not associated with massive proteinuria, or that even in cases of massive proteinuria, hypoalbuminemia is not seen and implies a glomerular pathology. We argue that chyluria is always associated with proteinuria, which may be massive, and does not warrant a kidney biopsy unless proteinuria persists despite resolution of chyluria.

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.

Can kidneys be saved in patients with urinary tuberculosis? A study in the era of modern chemotherapy and surgical armamentarium.

OBJECTIVE: To assess renal unit survival and factors affecting renal salvageability in a cohort of patients receiving modern medical and surgical therapy for urinary tuberculosis. METHODS: This was a retrospective single-center study including all patients diagnosed and treated as urinary tuberculosis between 2005 and 2015 at Christian Medical College, Vellore, Tamil Nadu, India. The primary outcome was time to renal unit non-salvageability (estimated glomerular filtration rate of <15 mL/min). RESULTS: A total of 128 patients were included in the study. The mean age was 37.7 ± 11.3 years, 33% had microbiological and 73% had histopathological confirmation in addition to radiological diagnosis. The estimated median survival of the involved renal units (n = 187) on Kaplan-Meier estimate was 75 months (95% CI 39-99). On multivariate analysis, renal units with initial split function >15 mL/min had fivefold the survival estimate as compared with those ≤15 mL/min (P < 0.001); the presence of one, two and three infundibular strictures had a 2.2-, 2.9- and fivefold higher hazard of renal unit loss respectively, and lower ureteric strictures had fivefold longer estimated survival (P = 0.015) after treatment. Renal units in the reconstruction group had 5.44-fold (95% CI 2.71-10.88, P < 0.001) longer survival than the permanent diversion group, with a mean change in split function of +0.76 (±16.11) mL/min, versus -5.61 (±10.87) mL/min respectively. CONCLUSIONS: Loss of renal units is a function of time despite modern treatment. Baseline renal unit function, site of ureteric involvement and extent of infundibular involvement on imaging are helpful in predicting the duration of renal salvageability. When feasible, reconstruction is better at renal function preservation.

The effect of phosphodiesterase-5 inhibitor, tadalafil, on in vitro potassium chloride-induced contractions of isolated human ureteral tissue.

INTRODUCTION: Drugs causing ureteral relaxation are used for medical expulsive therapy (MET) for stones. We investigated the in vitro ability of tadalafil to cause relaxation of potassium chloride (KCl)-induced contractions of isolated human ureteral tissue. MATERIALS AND METHODS: Eight grossly normal proximal ureteral tissues were collected from the radical and donor nephrectomy specimen. The standard organ bath protocol was followed. Ureteral contractions were induced with 80 mM KCl before and after exposure to tadalafil. RESULTS: The median amplitude and frequency of KCl-induced contractions and the median area under the contractility curve (AUCC) after exposure to 20 µM tadalafil showed significant reductions compared to that of before exposure to tadalafil (7.87 cm, 3.79/min, and 2.98 cm2, respectively, versus 9.37 cm, 4.48/min, and 4.50 cm2, respectively; P = 0,026, 0.008, and 0.008, respectively). After exposure to 40 µM tadalafil, the median amplitude and frequency of KCl-induced contractions and AUCC (4.50 cm, 2.56/min, and 0.92 cm2, respectively) showed significant reductions compared to that of before exposure to tadalafil (7.62 cm, 3.88/min, and 3.32 cm2, respectively; P = 0.008, 0.016, and 0.008, respectively). However, reductions in the parameters after exposure to 20 µM and 40 µM tadalafil were similar (P = 0.065, 0.195, and 0.130, respectively, for median amplitude, frequency, and AUCC). CONCLUSION: Tadalafil reduces KCl-induced contractions of isolated human ureteral tissue in vitro. No incremental relaxations in contractions occurred by increasing the dose of tadalafil from 20 µM to 40 µM.

Urodynamic outcomes of tamsulosin in the treatment of primary bladder neck obstruction in men.

INTRODUCTION: Alpha blockers are widely used in the treatment of primary bladder neck obstruction; however, evidence for objective urodynamic efficacy is scarce. We studied the effect of the uroselective α1-blocker tamsulosin on urodynamic parameters in male patients with type I primary bladder neck obstruction. METHODS: A single center prospective observational study was carried out from July 2013 to February 2015. Male patients (18-50 years) with type 1 primary bladder neck obstruction were recruited. Selected patients were started on tablet tamsulosin 0.4 mg once daily for 3 months. International prostate symptom score (IPSS), uroflow and urodynamic studies were done pre- and post-treatment. Primary outcome was decreased in minimum detrusor pressure at maximum flow rate by 15%. Wilcoxon-matched pair signed-rank test was used. RESULTS: Of 39 patients recruited, 21 patients completed the follow-up as per protocol and were analyzed. Mean age was 41 years. 57% patients achieved the primary outcome (median detrusor pressure pre- and post-treatment were 71 and 56 cm of water, P < 0.001). Similarly, median values for bladder outlet obstruction index (BOOI) and IPSS decreased from 59 to 38 (P < 0.001) and 22 to 12 (P < 0.001), respectively. Median maximum flow rate increased from 8 to 10 ml (P = 0.05). Pretreatment BOOI of >60 was associated with poor outcomes. CONCLUSIONS: Tamsulosin 0.4 mg once a day is effective in reducing bladder outlet obstruction on pressure flow studies in patients with primary bladder neck obstruction type 1.

A prospective randomised double-blind placebo-controlled trial to assess the effect of diuretics on shockwave lithotripsy of calculi.

OBJECTIVE: To assess the effect of diuretics with shockwave lithotripsy (SWL) on the treatment of renal and upper ureteric calculi. PATIENTS AND METHODS: Adult patients with a solitary non-obstructive radio-opaque renal or upper ureteric calculus with normal renal function were included. They were prospectively randomised to receive either SWL with placebo or SWL with diuretics (40 mg parenteral furosemide) in a double-blind manner with a sample size of 48 patients in each arm. The primary outcomes were the SWL success and failure rates. The secondary outcomes were the number of shocks and sessions. RESULTS: Complete fragmentation was achieved in 89.6% of the patients in the furosemide arm as compared to 81.3% in the placebo arm. Clearance was achieved in 77.1% of the patients in the furosemide arm as compared to 70.8% in the placebo arm. The number of shocks and the number of sessions were higher in the placebo arm. These differences were not statistically significant. CONCLUSION: The use of diuretics along with SWL treatment of renal and upper ureteric calculi does not show a statistically significant improvement in fragmentation or clearance.

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.

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).

A rare cause of anuria: Bilateral synchronous isolated mid-ureteric tubercular lesions.

A young female presenting with right flank pain, fever, raised creatinine and bilateral hydronephrosis was treated with antibiotics elsewhere, with presumptive diagnosis of bilateral pyelonephritis. She had partial relief in symptoms and her creatinine level showed an improvement. Three months later during evaluation at our center she had anuria, hypertensive crisis and pulmonary edema which were managed with emergency bilateral percutaneous nephrostomies. Cross-sectional imaging and ureteroscopy suggested bilateral synchronous intramural mid-ureteric lesions as underlying pathology. Histopathology of the ureteric segments during laparotomy revealed caseating granulomas suggestive of tuberculosis. This clinical presentation has not been previously described in urinary tuberculosis.

Nanobacteria in the pathogenesis of urolithiasis: Myth or reality?

Stone formation in the urinary tract is a common phenomenon with associated morbidity. The exact physicochemical factors responsible for stone formation are not clearly known. Over the past decade considerable interest has been generated in defining the role of nanobacteria in urinary stone formation. A review of the available literature has been carried out to give insights into their nature and outline their role in stone formation. The two aspects of nanobacteria that need to be considered include its biological nature and the other merely as mineralo-protein complexes. Though the current literature favors the concept of mineralo-protein particles, further research is needed to clearly define their nature. Whether living or nonliving, these apatite forming nanoparticles appear to play role in kidney stone formation.

Management of urological malignancies: Has positron emission tomography/computed tomography made a difference?

Positron emission tomography/computed tomography (PET/CT) technology has been a significant, but expensive addition to the oncologist's armamentarium. The aim of this review was to determine the clinical utility of PET/CT in urological oncology, its impact on disease outcome and cost-effectiveness. We searched MedLine and peer reviewed journals for all relevant literature available online from the year 2000 until January 2014 regarding the use of PET/CT in the management of urological malignancies. (11)C-choline PET/CT has emerged as a powerful tool for assessment of biochemical relapse in prostate cancer. Use of novel radiotracers like (124)I-girentuximab has shown promise in the diagnosis of clear cell renal carcinoma. Fluorodeoxyglucose PET has a proven role in seminoma for the evaluation of postchemotherapy residual masses and has shown encouraging results when used for detection of metastasis in renal, bladder, and penile cancer. Introduction of novel radiotracers and advanced technology has led to a wider application of PET/CT in urological oncology. However, testicular seminoma aside, its impact on disease outcome and cost-effectiveness still needs to be established.

Focused ultrasound guided relocation of kidney stones.

PURPOSE: Complete removal of all fragments is the goal of any intervention for urinary stones. This is more important in lower pole stones where gravity and spatial orientation of lower pole infundibulum may hinder spontaneous passage of fragments. Various adjuvant therapies (inversion, diuresis, percussion, oral citrate, etc.) are described to enhance stone-free rate but are not widely accepted. Focused ultrasound-guided relocation of fragments is a recently described technique aimed at improving results of intervention for stone disease. Purpose of this review is to discuss development of this technology and its potential clinical applications. MATERIALS AND METHODS: Pubmed search was made using key words "Focused ultrasound" and "kidney stone". All English language articles were reviewed by title. Relevant studies describing development and application of focused ultrasound in renal stones were selected for review. RESULTS: Focused ultrasound has proven its efficacy in successfully relocating up to 8 mm stone fragments in vitro and in pigs. Relocation is independent of stone composition. The latest model allows imaging and therapy with a single handheld probe facilitating its use by single operator. The acoustic energy delivered by the new prototype is even less than that used for extracorporeal shock wave lithotripsy. Therapeutic exposure has not caused thermal injury in pig kidneys. CONCLUSION: Focused ultrasound-guided relocation of stones is feasible. Though it is safe in application in pigs, technology is awaiting approval for clinical testing in human beings. This technology has many potential clinical applications in the management of stone disease.

Is thrombocytosis a useful prognostic marker in renal cell carcinoma? Results of a single-center retrospective analysis.

INTRODUCTION: Our aim was to determine the correlation of platelet count with stage and grade of renal cell carcinoma (RCC) and to determine whether progression of disease was more likely in those with thrombocytosis. MATERIALS AND METHODS: A retrospective review of patients with RCC from January 2004 to December 2011 was undertaken. Patients with no preoperative platelet count and those with multiple tumors were excluded. Disease progression was defined as appearance of local recurrence or distant metastasis on follow-up. Thrombocytosis was defined as a platelet count of >400,000/cumm. Standard tests of significance and multivariate analysis using logistic regression were performed. RESULTS: A total of 322 cases were identified. The median follow-up was 7 months (range, 2-84 months). The platelet count correlated significantly with higher Fuhrmann grade, as well as increasing TNM stage at diagnosis. Patients with a platelet count of >400,000/cumm (n = 35) had a significantly higher mean tumor size and worse grade at diagnosis than those with a normal platelet count (n = 287). Patients with thrombocytosis also had a significantly worse stage at presentation. Progression of disease was seen more often in patients with thrombocytosis (28.6% vs 11.9%, P = 0.07). The median time to progression was significantly faster in patients with thrombocytosis (9 vs 18 months, P = 0.018). However, on multivariate analysis TNM stage was the only significant predictor of time to progression. CONCLUSION: Rising platelet count correlated significantly with advancing stage and grade of disease. Patients with thrombocytosis were significantly more likely to have advanced tumors at presentation, poorer histological features, and rapid disease progression.

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.

Painful varicoceles: Role of varicocelectomy.

The incidence of varicocele in the general population is up to 15%. It is estimated that the prevalence of pain with varicoceles is around 2-10%. Till the year 2000, only two studies evaluated efficacy of varicocelectomy in painful varicoceles with conflicting results. Over the past decade many other studies have addressed this issue and reported on the treatment outcome and predictors of success. We critically appraised studies published from March 2000 to May 2013 evaluating surgical management in painful varicoceles to provide an evidence based review of effectiveness of varicocelectomy in relieving pain in patients with symptomatic painful varicoceles. The association between varicoceles and pain is not clearly established. Conservative treatment is warranted as the first line of treatment in men with painful clinical varicoceles. In carefully selected men with clinically palpable varicoceles and associated characteristic chronic dull ache, dragging or throbbing pain who do not respond to conservative therapy, varicocelectomy is warranted and is associated with approximately 80% success. However, surgical success does not always translate into resolution of pain and pain might persist even when no varicoceles are detected postoperatively.

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.

Renal arteriovenous malformation with inferior vena caval extension mimicking renal cell carcinoma.

A young lady presented with complaints of right flank pain and a palpable mass. On contrast-enhanced tomography (CECT), a renal mass with extension into the inferior vena cava (IVC) - suggestive of renal cell carcinoma - was diagnosed and she underwent radical nephrectomy with en bloc excision of the IVC thrombus. Histopathology revealed a benign arteriovenous malformation that had extended into the IVC. Arteriovenous malformation should therefore be kept in the list of differentials for a renal mass with IVC extension.