Discrepancies in Gleason score between needle core biopsy and radical prostatectomy specimens with correlation between clinical and pathological staging.

BACKGROUND: The studies have shown that GS given after assessment of the entire prostate gland on the radical prostatectomy specimen may differ from GS given after examination of a small sample from needle core biopsy. We conducted this study to assess discrepancies in the Gleason score between NCB and RP specimens and to find out the correlation between the clinical stage and pathological stage. METHODS: The study included 174 patients with carcinoma prostate which underwent robotic-assisted radical prostatectomy (RARP). Pre-operative Gleason score was determined on 12-core biopsy samples under trans-rectal ultrasound (TRUS) guidance. The Gleason score obtained from the radical prostatectomy specimen was compared with that of the NCB Gleason score to find out differences. RESULTS: The preoperative Gleason score (GS) ranges from 6 to 9 with a mean GS of 6.97 ± 1.02. The post-operative GS ranges between 6 and 10 with mean and GS of 7.5 ± 1.10. On the pre-operative assessment of biopsy specimens, 70 (43.2%) patients had a GS of 6, while 44 patients had a GS of 7 (27.1%) and 48 (29.8%) patients had a GS of more than 7. On the postoperative assessment of specimens, 31 (19.1%) patients had post-operative GS of 6, while 66 (41%) patients had GS of 7 and 74 (41.1%) patients had GS of more than 7. When pre-operative GS and post-operative GS were compared, no changes were observed in the GS of 79 patients, whereas 83 patients showed the difference in GS, with 75 patients showing up-gradation and eight patients marked as down-graded. CONCLUSION: concordance between biopsy and the pathology results directly affects the prognosis of the patient. The results of our study demonstrated the rate of discordance between Gleason scores obtained from transrectal prostate biopsy and RP surgical specimens. This rate brings into question the accuracy of the chosen treatment.

Robot-assisted ureteric reconstructive surgeries for benign diseases: Initial single-center experience with point of technique.

INTRODUCTION: We present our initial experience with robot-assisted reconstructive surgeries with the Da Vinci Xi robotic system for benign ureteric pathologies. MATERIALS AND METHODS: This is a retrospective review of prospectively collected data of patients who underwent robot-assisted reconstructive procedures for benign diseases of the ureter at our department from April 2018 to November 2022. Demographic and perioperative details were recorded. Patients were followed up and surgical success was evaluated on the basis of symptomatic, functional, and radiological improvement. RESULTS: A total of 34 patients underwent robot-assisted reconstructions for benign ureteric pathologies by various techniques. Mean age, body mass index (BMI), hospital stay and follow-up duration were 36 years, 24.1 kg/m2, 5.29 days, and 7.08 months respectively. Procedures included pyeloplasty in eight, primary ureteroneocystostomy (UNC) in seven, Psoas hitch UNC in five, Boari flap UNC in six, Ureteroureterostomy in four, ureterocalicostomy in two and ileal ureteral transposition in two patients. Mean docking time, total operative time, and estimated blood loss were 31.5 min, 178 min, and 64.3 ml, respectively. All patients had radiologic or functional improvement on follow-up after 6 months. CONCLUSION: Robot-assisted reconstructive surgery for benign ureteric and bladder pathologies imparted excellent short-term outcomes without major complications with all the advantages of a minimally invasive approach.

Early port site and peritoneal metastasis following robot-assisted radical cystectomy: a rare case report.

Radical cystectomy with pelvic lymph node dissection is the recommended treatment for managing muscle-invasive carcinoma of the urinary bladder. Early recurrence is observed in only about 4.1% of cases. Port-site metastasis following robot-assisted radical cystectomy is extremely rare. We encountered a challenging and a rare case of bladder cancer that manifested with port-site and peritoneal metastasis within 6 weeks of surgery.

Assessing pentafecta outcomes post radical cystectomy: A tertiary care center study.

INTRODUCTION: Bladder cancer is a common and serious disease globally, often requiring radical cystectomy as the preferred treatment. However, this procedure carries substantial risks and complications. To evaluate its success, pentafecta, a five-component measure, was introduced. This study investigates the attainment of pentafecta following radical cystectomy and examines factors that influence its achievement. METHODOLOGY: This retrospective, single-group study was conducted at AIIMS Jodhpur. The study population included 42 patients who underwent radical cystectomy for bladder cancer. Various data, including demographic characteristics, clinical features, surgical techniques, and postoperative outcomes, were collected from medical records. The primary outcome measure was the rate of achieving pentafecta, which comprises five parameters. RESULTS: Out of 42 patients, 26 (61.9%) achieved pentafecta. Age, gender, comorbidities and surgical approach did not significantly affect the attainment of pentafecta. Negative surgical margins were achieved in 95.2% of cases, and adequate lymph node dissection (>16 lymph nodes) was performed in 85.7% of cases. The absence of Clavien-Dindo grade 3-5 complications and recurrence was observed in 80.9% and 90.47% of cases, respectively. Uretero-enteric stricture was absent in 95.2% of cases. CONCLUSION: The study emphasizes the significance of negative surgical margins, thorough lymph node dissection, absence of complications, recurrence, and uretero-enteric strictures in evaluating the success of radical cystectomy as pentafacta outcomes. Patients with higher drain output and wound infections are less likely to achieve pentafacta outcome and indicates poorer outcome. By considering these factors, clinicians can assess patient outcomes and identify areas for improvement.

Correlation of urinary continence recovery with various factors after Robot assisted radical prostatectomy.

BACKGROUND: In addition to ensuring cancer control, prevention of incontinence which significantly impact patients' quality of life, is also an important issue in robot-assisted radical prostatectomy (RARP) operations. In this study, we aimed to find the correlation of urinary continence recovery with various factors after Robot assisted radical prostatectomy. METHODS: This study included 162 patients treated with RARP with perioperative data and at least 1 year of follow-up. Also, the preoperative, intraoperative, and postoperative parameters of the patients were analyzed. The continence recovery rate in our study was assessed at 6th week, 3rd month, 6th month, 9th month, and 12th month, post-surgery. Logistic regression analysis evaluated the association between the predictive factors and urinary continence recovery in the early and late stages. RESULTS: The majority of patients with prostate cancer present in sixth decade of life. The majority of our patients (56.7%) were categorized as high risk using D'Amico classification. The continence rate in our study at 6th week, 3rd month, 6th month, 9th month, and 12th month were 40.1%, 72.2%, 85.2%, 89.5%, and 91.4%, respectively. No improvement in continence status was observed after 1 year in our study. There was significant correlation of age with continence status at 6th week, 3rd month, and 6th month. The young age is associated with early recovery of continence. At 3 and 9 months, the non-diabetics cases achieved significantly higher continence rates than diabetics (p < 0.05) which shows that diabetes causes delay in attainment of continence. CONCLUSION: The young age may be associated with early recovery of continence, but further validation requires large number of cases. We attributed good continence recovery rate to meticulous dissection and preservation of good urethral length.

Post-operative chyle leak following nephrectomy: Inference from tertiary care center and review of literature.

OBJECTIVES: Lymphatic channels (LC) are not as prominent as blood vessels, so they tend to get damaged during surgical procedures. It can present with chyle leak in the postoperative period. We aimed to study the occurrence of chyle leak in patients undergoing nephrectomy and its management. METHODS: During the period of January 2021 and January 2023, 158 adult patients underwent nephrectomy for various reasons like non-functioning kidney, donor nephrectomy, and malignancy. We retrospectively analyzed data of patients who had chyle leak after nephrectomies. RESULTS: Eight patients out of the 158 patients (5.06%) undergoing nephrectomy developed chyle leak. One out of these eight patients underwent nephrectomy by open approach while seven underwent laparoscopic approach. All eight patients who had chyle leak undergone left sided nephrectomy. Six patients of chyle leak could be managed with dietary modification while two patients needed octreotide therapy for treatment. Higher Body Mass Index (BMI; p-value = 0.012), left sides nephrectomy (p-value = 0.013), h/o pyelonephritis (p-value = 0.005) were associated with higher incidence of chyle leak on univariate analysis. While on multivariate analysis no factor was found to be independently associated with chyle leak. Hospital stay was significantly prolonged in patients with chyle leak (p-value = 0.007). CONCLUSION: Chyle leak is not a very rare complication after nephrectomy. Patients with higher BMI, who undergo left sided nephrectomies and patients who had history of pyelonephritis or infectious complications had higher incidence of chyle leak. Most cases can be managed with conservative management (CM). Chyle leak is associated with a prolonged hospital stay.

Primary amelanotic malignant melanoma masquerading as adenocarcinoma prostate - A pathological dilemma.

A rare disease at an aberrant location can mimic a usual presentation of another disease. We report a case of primary amelanotic malignant melanoma of the prostate with clinical and histological characteristics that closely mimic poorly differentiated adenocarcinoma prostate.

18F-fluoro-2-deoxy-2-d-glucose PET-CT (FDG PET-CT) in staging of high-risk renal and urothelial bladder cancers (COPPER-T) trial protocol.

Background and Study Design: Role of 18F-fluoro-2-deoxy-2-d-glucose positron emission tomography-computed tomography (FDG PET-CT) in evaluation of renal cell cancers (RCC) and urinary bladder cancers is not standardized, and the COPPER-T trial, which is a single centre prospective randomized study, was designed to compare it with conventional imaging for staging of clinically localized high risk RCC and urinary bladder carcinoma (Stage T2 and above). Patients and Methods: There will be two subgroups of patients: RCC and urinary bladder carcinoma. In each of these, the patients will be randomized to either Arm A or Arm B. In each of the arms, each patient will be subjected to diagnostic imaging by FDG PET-CT. The CT scan will be a contrast-enhanced scan like that in conventional staging. A radiologist and nuclear medicine specialist will report the scan independently. The radiologist will not have access to the PET scan sequences and will only review the contrast-enhanced computed tomography (CECT) images. In Arm A, the report of the conventional imaging modality, that is, CECT and bone scan if done, will be reviewed first by the clinician, and based on this report, a management plan will be made. Then, the PET-CT report will be reviewed, and change in the management plan will be noted. New findings or equivocal findings if any in the PET-CT report would be noted. In Arm B, the report of the PET-CT report will be reviewed first by the clinicians, and a management plan will be made. Then, the CECT and/or bone scan reports will be reviewed, and any change in the management plan will be noted. Outcome and Significance: Final analysis of the data after completion of the trial will help in clarifying the role of FDG PET-CT in high risk RCC and transitional cell carcinoma (TCC) of the bladder, its diagnostic accuracy compared with conventional imaging and the impact of using it on patient management.

Correlation between androgen and estrogen receptor expression and clinicopathologic features in carcinoma urinary bladder.

INTRODUCTION: The molecular mapping of cancers by the Cancer Genome Atlas Project has accelerated the quest for new therapeutic targets for urinary bladder cancer, including sex steroid receptors. Previous studies have demonstrated conflicting results on their relationship with bladder cancer, and there is sparse data on their expression in the Indian population. The aim of our study is to examine the expression of androgen receptors (AR) and estrogen receptors (ERα and ERß) in patients with bladder cancer and their correlation with clinicopathologic features. MATERIALS AND METHODS: In this retrospective cohort study, a total of 132 patients, who were surgically managed for urinary bladder mass by transurethral resection or radical cystectomy in our institute, with transitional cell carcinoma on histopathology and with at least two years of follow-up were included. Their demographic and treatment details were obtained, histopathology blocks were retrieved and immunohistochemical staining for androgen and estrogen receptors was performed. Then, the relationship between their expression and clinicopathologic features was studied. RESULTS: A total of 3.79% of patients showed estrogen receptor alpha positivity, 51.52% estrogen receptor beta positivity and 63.64% androgen receptor positivity. No statistically significant correlation was found between age of patients (p = 0.75/0.52/0.87), tumour stage and grade (0.71/0.3/0.21), pathological variant (p = 1/0.58/0.38) and overall survival (p = 0.70/0.052/0.45 for NMIBC and p = 0.82/0.36/0.22) and estrogen receptor alpha, estrogen receptor beta and androgen receptor-positive status, respectively. Estrogen receptor beta positivity was significantly higher in patients with unifocal (p = 0.015) and small tumours (< 5 cm) (p = 0.03), and its expression was associated with better disease-free survival (DFS) (p = 0.046) in patients of non-muscle invasive bladder cancer (NMIBC). CONCLUSION: Our study has the largest sample size conducted on Indian population with results differing from previous studies conducted on western population. Estrogen receptor beta expression was significantly associated with small unifocal tumours and better DFS. Estrogen receptor alpha and androgen receptor expression were not found to be associated with the clinicopathologic features of the study population.

Extrarenal calyces in a pelvic kidney with ureteropelvic junction obstruction in an adult male - A rare case report.

Extrarenal calyces (ERC) is a rare renal anomaly. First described in 1925, and till now, >60 cases have been reported worldwide. The association of ERC in ectopic kidneys with ureteropelvic junction obstruction (UPJO) is a very rare presentation. We encountered a case of an adult male with ERC in a pelvic kidney with UPJO, in which the dilated ERC mimicked the ureter and created intraoperative confusion.

A rare case of air cysto-uretero-pyelogram due to emphysematous cystitis.

Emphysematous infection of the urinary tract is a hazardous condition and is life-threatening if not managed quickly. We report an 82-year-old woman with uncontrolled diabetes mellitus and urethral stricture who presented with emphysematous cystitis with the gas reaching up to the pelvicalyceal system on the left side (emphysematous pyelonephritis) and appearing in X-ray as air pyelogram. The patient was managed with drainage and intravenous antibiotics and she recovered.

To determine correlation between VIRADS scoring and pathological staging in bladder cancer: A prospective study and review of literature.

The development of standardized reporting systems is of paramount importance in medical-imaging. Based on the "RADS" methodology, PIRADS and BI-RADS have been successfully used. The management of bladder cancer (BC) depends on the stage at the time of identification. Accurate assessment of the muscle-invasive stage can alter therapies that are radically different. MRI can accurately diagnose this in a standardized manner (Vesical Imaging-Reporting and Data System: VIRADS) and spare additional procedures. The aim of the study is to determine diagnostic accuracy of VIRADS scoring in evaluation of muscle invasiveness in patients with BC. This study was conducted in a single center over a period of 2 years from April 2020. A total of 76 patients with bladder SOL/diagnosed BC were included. Final VIRADS scoring was calculated and compared with histopathological report.76 patients were evaluated which included 64 males and 12 females. Most of the cases came under the VIRADS-II category (23, 30.26%) followed by VIRADS-V (17, 22.36%). VIRADS-I was reported in 14 cases (18.42%). A total of 8 cases (10.52 %) were reported as VIRADS III and 14 cases (18.42%) as VIRADS IV. VIRADS-III was taken as cut off and found to have a sensitivity of 94.44%, a specificity of 87.50%, a positive predictive value of 87.17% and a negative predictive value of 94.59%. Though number of cases are still less to accurately predict test characteristics of VIRADS, our results are consistent with previously done retrospective studies and VIRADS has got good correlation with pathological staging.

Arteriovenous fistula in functional motor disability.

Arteriovenous fistula (AVF) is the preferred route for vascular access in patients with chronic kidney disease on maintenance haemodialysis. Many studies have demonstrated the positive effects of perioperative hand exercise on fistula maturation. Here, we present our experience of radio cephalic AVF creation in patients with neuromuscular disorders who had difficulty performing isometric hand exercises. We created AVF in three patients with neurological disorders. First patient had essential tremor, which created difficulty during hand exercises and surgery while the other two patients had right hemiparesis. Perioperative isometric exercises have been shown to help in maturation of AVF. Due to neurological involvement, our patients had difficulty performing hand exercises. All had successful AVF despite taking longer than usual time to mature. Creation of AVF in neuromuscular diseases is feasible. A preoperative Doppler ultrasound to assess the vessels might help in making an informed decision. This might spare such patients the only functional arm.

Renal mucormycosis presenting during the COVID-19 pandemic: A series of 11 cases from a tertiary care center in India.

Introduction: Renal mucormycosis has been documented to occur even in apparently immunocompetent individuals. Owing to the rarity of this disease, literature on its management is small. We present our experience of diagnosing and managing 11 cases of primary renal mucormycosis who presented during the second wave of the COVID-19 pandemic in India. Methods: We reviewed the records of all patients presenting to our institute with a diagnosis of acute pyelonephritis from March 2021 to September 2021. All patients with a radiological, microbiological, or histopathological diagnosis of renal mucormycosis were included in the analysis and all demographic and clinical details, including a history of COVID-19 disease and its treatment, were noted. All patients were treated by a combination of intravenous antifungal therapy and aggressive surgical debridement including nephrectomy and multivisceral resection as required. Predictors of mortality were evaluated by statistical analysis. Results: A total of 93 patients presented to our hospital with features of acute pyelonephritis of which 11 patients were suspected to have primary renal mucormycosis based on characteristic imaging features and confirmed on microbiological and histopathological examination. Of these, four patients had a history of COVID-19 infection. Only one patient had diabetes mellitus. Ten patients underwent nephrectomy and seven needed resections of surrounding organs. The colon was the most commonly involved organ. Five patients (45.5%) died of progressive sepsis. None of the predictors of mortality that were analyzed showed statistical significance. Conclusion: A high index of suspicion, early cross-sectional imaging, prompt institution of antifungal therapy, and aggressive surgical extirpation are very important for achieving good outcomes in patients of primary renal mucormycosis.

Mesh erosion into urinary bladder following laparoscopic inguinal hernia repair.

Along with advantages, evolving surgical techniques bring unique complications. A young male developed urinary symptoms a few months after undergoing laparoscopic inguinal hernia repair. On evaluation, mesh erosion into the urinary bladder was found. Removal of mesh with repair of bladder was done. A vesico-cutaneous fistula resulted which was managed with repeat surgery. We review all such cases reported in literature; discuss the etiopathogenesis, presentation, management and possible preventive measures. To the best of our knowledge, this is only the 12th case being reported.

An adolescent with prolapsed omentum per rectum: Spontaneous rectal perforation managed laparoscopically.

Spontaneous rupture of the rectum is a rare occurrence. A total laparoscopic approach to rectal perforation has only occasionally been reported. We report an unusual case of a young boy who developed a spontaneous rupture of the rectum following a trivial fall. A magnetic resonance imaging revealed a tear in the rectum at the peritoneal reflection with the omentum plugging it. He denied any history of rectal instrumentation or abnormal sexual activity. He had no history of constipation or rectal prolapse. The tear was repaired laparoscopically and a covering loop sigmoid colostomy was added. He made an uneventful post-operative recovery. Spontaneous rupture of the rectum can occur in younger age groups and even in the absence of significant trauma. One needs to diligently bring out a history of rectal trauma. Equally important is to rule out any underlying pathological condition. A laparoscopic approach is feasible, especially in early cases.

Severe intraperitoneal injuries due to self introduced rectal foreign body.

Rectal foreign body insertion is an increasingly common surgical dilemma that requires thorough history, physical examination, radiographs and inventiveness to treat. Additionally the surgeon should demonstrate a sympathetic and caring attitude. This case report highlights the successful surgical management of a rare and bizarre case of extensive intraperitoneal injuries due to a wire inserted by the patient to retrieve a rectal foreign body introduced for sexual gratification.

Ureteroscopy: savior to the gynecologist? Ureteroscopic management of post laparoscopic-assisted vaginal hysterectomy ureterovaginal fistulas.

Iatrogenic ureteral injuries are among the most serious complications in gynecologic surgery. With the increasing popularity of laparoscopic gynecologic surgery, the incidence of ureteral injuries is on the rise. We report 2 cases of post laparoscopic-assisted vaginal hysterectomy (post LAVH) ureterovaginal fistulas, which were managed successfully with retrograde stenting using ureteroscopy. Three middle-aged women who underwent LAVH for symptomatic myomas of the uterus presented with ureterovaginal fistulas in the late postoperative period. Excretory urography revealed ureterovaginal fistulas involving the distal ureter. Retrograde stenting was possible in 2 patients, using a 7.5F rigid ureteroscope. Both patients became continent 2 days after surgery. Urography at 6 weeks revealed normal renal function without obstruction or extravasation of urine, and the stents were removed. Stenting failed in the third patient; the patient underwent a ureteric reimplantation successfully. Post LAVH ureterovaginal fistulas are amenable to ureteroscopic retrograde double-J stenting, which enables spontaneous recovery of the injured ureter. An attempt of ureteroscopic stenting should be considered in all patients with post LAVH ureterovaginal fistulas before subjecting them to other modalities.