Intratumoral Heterogeneity, Chemoresistance and Lymph Node Landing Zone Prognosis in Testicular Tumors Based on Histopathological Characteristics.

BACKGROUND: Existing data on the histopathological correlation of testicular tumors with lymph node prognosis have been poorly explored. We aimed to investigate the relationship of the histopathological properties of testicular tumors with lymph nodes and their involvement with chemoresistance and heterogeneity of testicular tumors. METHODS: Patients with non-seminomatous germ cell tumor (NSGCT) were selected for histopathological correlation of testicular tumor with lymph nodes and its relationship with chemoresistance and heterogeneity. Histopathological and radiological parameters associated with the risk of chemoresistance and tumor progression were measured pre- and post-chemotherapy. Binomial logistic regression and Kaplan-Meier analysis were implemented to determine the predictors of progression and adverse overall patient survival. All categorical variables were analyzed using the Chi-square test, while Pearson's R coefficient determined the correlation. RESULTS: Male patients who were diagnosed with NSGCT from March 2017 to December 2018 at Guwahati Medical College, Guwahati, India, were included in this study. Lymph node groups were predominantly incriminated with the EYST or EYS groups and minimally linked with the pure E and YCS groups. Furthermore, the highest number of lymph node stations was associated with pre-chemotherapy. In salvage chemotherapy in the form of VIP, we found exciting outcomes, as approximately 41% of cases responded positively, especially in the EYS group. CONCLUSION: Our study classifies NSGCT according to the most favorable histopathological grouping and explores the tumoral response in different intrinsic and extrinsic variables. Our analysis can serve as a triumphant histopathological nomogram for a sublime management protocol to deal with the onerous histological pairing in NSGCT.

Comparison of Risk Factors for Erectile Dysfunction (ED) in Type 2 Diabetics and Nondiabetics: A Retrospective Observational Study.

BACKGROUND AND AIMS: We aim to compare the various risk factors for erectile dysfunction (ED) in type 2 diabetes mellitus (DM) and nondiabetic patients. MATERIALS AND METHODS: We retrospectively collected and evaluated the data of 175 OPD patients with ED. We included 138 patients of ED from endocrinology and urology OPD after exclusion. ED was assessed by using a questionnaire adapted from the abridged five-item version of the International Index of Erectile Function (IIEF-5) score. RESULTS: A total of 96 (69.56%) were diabetic, and 42 (30.43%) were nondiabetic. The majority of patients (62.31 %) were in the age group of 40-60 years. Thirty-nine (28.26%) were alcoholics, and 55 (40%) were smokers. The average duration of diabetes was 6.6±1.5 years. Hypertension was present in 49 (35.5%). Diabetic patients were significantly older (47.9±8.2 vs. 40.2±7.6 years, p=0.0001) and obese (BMI (kg/m2), 27.3±5.4 vs. 24.6±3.9, p=0.004). Waist circumference in diabetics was 95.3±10.9, as compared to nondiabetics, which was 89.6±9.2 cm (p=0.0037). The IIEF-5 score was significantly lower in diabetic subjects in comparison to nondiabetics (9.4±3.2 vs. 12.1±3.6 p=0.0001). Moderate-to-severe ED was more common in diabetic patients (76%) in comparison to nondiabetics (59.5%). The prevalence of mild and mild-to-moderate ED was 11.45 % and 12.5 % in diabetic patients in comparison to 16.7% and 23.5% in nondiabetics, respectively. The prevalence of hypertension and coronary artery was higher in diabetics in comparison with nondiabetics. Hypertension was significantly higher in diabetic patients with ED (42.7% vs. 19.04%, p=0.0075), but coronary artery disease was not statistically significant (8.3% vs. 2.3%, p=0.1925). LH (2.6±0.7 vs. 3.5±0, p=0.0001) and testosterone (312.1±110.7 vs. 367.8±115.1, p=0.0081) were significantly lower in diabetics in comparison to nondiabetics. CONCLUSIONS: The IIEF-5 score was lower in diabetic cases as compared to those without diabetes. The factors that significantly contributed to ED in type 2 DM patients, as compared to nondiabetic patients, were age, BMI, waist circumference, hypertension, poor glycemic control, LH, and testosterone levels.

Skeletal-Related Events in Renal Cell Carcinoma: Prediction With Alkaline Phosphatase (ALP), C-reactive Protein (CRP), Haemoglobin (Hb) and Erythrocyte Sedimentation Rate (ESR) (A.C.H.E.) Score for Risk Stratification.

Introduction  Skeletal metastasis is catastrophic in patients with renal cell carcinoma (RCC), leading to skeletal-related events (SRE) such as nerve entrapment, hypercalcemia and even pathological fractures, which may require surgical intervention. The nature of the bone metastasis in advanced RCC is large, destructive, hyper-vascular and mostly lytic. The present retrospective analysis aims to identify potential risk factors for predicting SREs in advanced RCC with bone metastasis. Methods The clinical data of 42 patients with RCC and bone metastasis and at least one episode of SRE were reviewed, and the correlations between erythrocyte sedimentation rate (ESR), alkaline phosphatase (ALP), C-reactive protein (CRP), haemoglobin (Hb), carcinoembryonic antigen (CEA) and bone metastases were analysed. Risk factors were identified by multivariate logistic regression analysis. Bone metastasis was diagnosed on a bone scan. The receiver operating characteristic (ROC) curve calculated the cut-off value of the independent correlation factors. Results The areas under the ROC curve for ALP, Hb, CRP, and ESR were 0.84, 0.76, 0.86 and 0.88, respectively, suggesting excellent discriminatory capability of ALP, CRP, ESR and sufficient discriminative ability of Hb in predicting bone metastasis. Multivariate logistic regression analysis showed ALP, CRP, Hb and ESR associated with SRE and skeletal metastasis. Conclusion We propose that an A.C.H.E. score encompassing ALP, CRP, Hb, and ESR are potential risk factors for developing SRE and concomitant bone metastasis in advanced RCC patients. For new RCC patients, if values of ALP >128 U/L, CRP ≥74 mg/L, Hb <11.5 g/L, and ESR ≥55 mm/hr are detected, intensive monitoring and bone scanning are warranted as these cases are at a higher risk of skeletal events.

Electronic medical records-based retrospective, longitudinal, observational study to understand the patient management of benign prostatic hyperplasia with alpha-blockers monotherapy in Indian population.

Objective: The present retrospective study evaluates the effectiveness and tolerability of alpha-blockers as monotherapy in patients with benign prostatic hyperplasia associated with lower urinary tract symptoms (LUTS). Materials and Methods: A total of 335 male patients >50 years were categorized into four groups (Alfuzosin: 166, Silodosin: 67, Tamsulosin: 70, Prazosin: 32). The efficacy evaluated as a change in International Prostate Symptom Score (IPSS), peak flow rate (Qmax), residual urine volume, and relief from LUTS, and tolerability of the various alpha-blockers was assessed across the study group. Results: At baseline, most of the patients in alfuzosin (60%), silodosin (77%), and tamsulosin (90%) groups presented with severe IPSS (20-35), whereas patients in the prazosin group (69%) presented with a moderate score. At the end of the study, the mean IPSS gradually improved to moderate (41%, 62%, 66%, and 28%) and mild (59%, 38%, 28%, and 72%) in the alfuzosin, silodosin, tamsulosin, and prazosin groups, respectively (P = 0.004), with improvement in mean change in residual urine volume and complete relief from LUTS symptoms with no surgical or radiological interventions. Overall, 194 adverse events (AEs) were observed in 38.8% of patients. Of the total AEs, patients in the alfuzosin, silodosin, tamsulosin, and prazosin groups experienced 21%, 22%, 39%, and 18% of AEs, respectively. Conclusion: The nonselective alpha-adrenergic receptor antagonist, alfuzosin, emerged as noninferior in effectiveness and superior in tolerability than other selective alpha-blockers, silodosin, tamsulosin, and prazosin.

SPATA16 promoter hypermethylation and downregulation in male infertility.

Spermatogenesis associated 16 (SPATA16) gene plays an important role in acrosome formation. In this study, we analysed SPATA16 promoter methylation in 29 oligozoospermic infertile and 16 normozoospermic fertile sperm samples and in testicular biopsy from 16 non-obstructive azoospermic and 2 obstructive azoospermic individuals. Next, we analysed SPATA16 level in sperm from 8 oligozoospermic infertile, 6 normozoospermic fertile, 9 IVF failed normozoospermic and 10 IVF successful normozoospermic samples by immunoblotting. This was followed by the analysis of SPATA16 expression in testicular biopsy from azoospermic individuals (n = 8) in comparison to normozoospermic individuals (n = 2). Oligozoospermic infertile sperm samples showed significantly higher methylation in the SPATA16 promoter region. Similarly, testicular biopsy from azoospermic men also showed significantly higher level of DNA methylation. Sub-group analysis of infertile sperm and testicular biopsy samples showed a direct correlation between DNA methylation and the degree of spermatogenic impairment. Oligozoospermic infertile samples and IVF failed samples showed reduced SPATA16 expression in comparison to normozoospermic fertile and IVF successful samples, respectively. Human biopsy analysis showed a significant decrease in SPATA16 expression in hypospermatogenesis, maturation arrest and Sertoli cell only syndrome. In conclusion, hypermethylation in SPATA16 promoter shows a highly significant correlation with infertility, which is consistent with its down-regulation in infertility.

Expert survey on management of prostate cancer in India: Real-world insights into practice patterns.

To gain insights on the diverse practice patterns and treatment pathways for prostate cancer (PC) in India, the Urological Cancer Foundation convened the first Indian survey to discuss all aspects of PC, with the objective of guiding clinicians on optimizing management in PC. A modified Delphi method was used, wherein a multidisciplinary panel of oncologists treating PC across India developed a questionnaire related to screening, diagnosis and management of early, locally advanced and metastatic PC and participated in a web-based survey (WBS) (n = 62). An expert committee meeting (CM) (n = 48, subset from WBS) reviewed the ambiguous questions for better comprehension and reanalyzed the evidence to establish a revote for specific questions. The threshold for strong agreement and agreement was ≥90% and ≥75% agreement, respectively. Sixty-two questions were answered in the WBS; in the CM 31 questions were revoted and 4 questions were added. The panelists selected answers based on their best opinion and closest to their practice strategy, not considering financial constraints and access challenges. Of the 66 questions, strong agreement was reached for 17 questions and agreement was achieved for 22 questions. There were heterogeneous responses for 27 questions indicative of variegated management approaches. This is one of the first Indian survey, documenting the diverse clinical practice patterns in the management of PC in India. It aims to provide guidance in the face of technological advances, resource constraints and sparse high-level evidence.

Results of bladder neck reconstruction using bladder flaps in complex female urethral defects.

INTRODUCTION AND HYPOTHESIS: Female urethral defects are rare, congenital defects being more uncommon than acquired, and difficult to manage. Most female urethral defects are associated with incontinence or acute urinary retention. There is a lack of standard protocol-based management of female urethral defects because of limited experience. In this study, we describe our results of using anterior or posterior bladder wall flaps in the management of a variety of female urethral defects. METHODS: We reviewed the case records of 22 patients who had undergone either anterior or posterior bladder wall-based flap procedures for complex urethral defects at our institute. Patients were assessed by taking a comprehensive history including aetiological factors and details of prior surgical intervention, thorough physical and pelvic examination, cysto-urethroscopy and relevant imaging. These factors, along with availability and status of tissue available for reconstruction affected the selection of procedure for reconstruction. RESULTS: Out of 22 patients, anterior and posterior bladder flaps were used in 16 and 6 patients respectively. A total of 18 patients became socially dry and 15 achieved complete continence after removal of the catheter and were voiding satisfactorily, whereas the remaining 4 patients had incontinence postoperatively. An additional 3 out of 18 patients had minimal stress incontinence requiring conservative treatment and 2 patients developed voiding difficulty requiring self-calibration. CONCLUSIONS: Female urethral defects with bladder neck involvement are complex and challenging to manage. Bladder wall-based flaps offer a good chance of successful repair of these complex urethral defects.

AZF deletions in Indian populations: original study and meta-analyses.

PURPOSE: To identify the frequency of Y chromosome microdeletions in Indian populations and to quantitatively estimate the significance of association between these deletions and male infertility. METHODS: A total of 379 infertile males (302 azoospermic and 77 oligozoospermic infertile males) and 265 normozoospermic fertile males were evaluated for Y chromosome microdeletions (YCD) using PCR amplification and gel electrophoresis. Meta-analyses were performed on AZFa (2079 cases and 1217 controls), AZFb (2212 cases and 1267 controls), AZFc (4131 cases and 2008 controls), and AZFb+c (1573 cases and 942 controls) deletions data to quantitatively estimate the significance of association between these deletions and male infertility in Indian populations. RESULTS: The results revealed that out of 379 infertile azoospermic and oligozoospermic males, 38 (10.02%) had AZF deletions. No deletion was found in control samples. The highest percentage of deletions was observed in the AZFc region, followed by AZFa and AZFb. Qualitative analysis showed that AZF deletions were present in 0.59 to 32.62% (average 13.48%) of infertile cases in Indian populations. Meta-analysis revealed a significant association of AZFa (OR = 6.74, p value = 0.001), AZFb (OR = 4.694, p value = 0.004), AZFc (OR = 13.575, p value = 0.000), and AZFb+c (OR = 5.946, p value = 0.018) deletions with male infertility. CONCLUSION: AZF deletions were seen in 10.02% of azoospermic and oligozoospermic cases with the highest frequency of AZFc deletions. Pooled analysis for all studies showed deletion frequency from 0.59 to 32.62% (average = 13.48%). Meta-analysis showed significant association of AZFa, AZFb, and AZFb+c deletions with male infertility. Analysis of Y chromosome microdeletions should be reckoned as an essential testing for diagnostic and therapeutic purposes.

Increased DNA methylation in the spermatogenesis-associated (SPATA) genes correlates with infertility.

BACKGROUND: Spermatogenesis-associated (SPATA) family of genes plays important roles in spermatogenesis, sperm maturation or fertilization. The knockout studies in mice have demonstrated that SPATA genes are crucial for fertility. Gene expression and genetic polymorphism studies have further suggested their correlation with infertility; however, methylation analysis of SPATA genes in human male infertility has not yet been undertaken. OBJECTIVES: To analyze the methylation status of SPATA4, SPATA5 and SPATA6 genes in oligozoospermic male infertility. MATERIALS AND METHODS: In the present study, we have analyzed DNA methylation pattern in the promoter regions of SPATA4, SPATA5 and SPATA6 genes in oligozoospermic patients and compared it with normozoospermic fertile controls. Semen samples were obtained from 30 oligozoospermic infertile and 19 normozoospermic fertile controls, and DNA methylation levels of the target gene promoters were analyzed by amplicon based deep sequencing methylation analysis using MiSeq. RESULTS: SPATA4 (P < 0.0008), SPATA5 (P = 0.009) and SPATA6 (Promoter, P < 0.0005; Exon 1, P = 0.0128) genes were significantly hypermethylated in oligozoospermic patients in comparison to controls. This is the first study reporting a higher methylation in the promoters of SPATA4, SPATA5 and SPATA6 in oligozoospermic infertile individuals in comparison to the normozoospermic fertile controls. DISCUSSION: Altered methylation of SPATA genes would affect pathways involved in sperm production or affect various processes linked to sperm fertility. CONCLUSION: In conclusion, hypermethylation in the SPATA4, SPATA5 and SPATA6 genes correlates with oligozoospermic infertility.

Duplications in 19p13.3 are associated with male infertility.

PURPOSE: To identify genomic imbalances and candidate loci in idiopathic male infertility. METHODS: Affymetrix CytoScan 750K Array was used to analyze genomic imbalances and candidate loci in 34 idiopathic infertile cases of different phenotypes (hypo-spermatogenesis, n = 8; maturation arrest, n = 7; and Sertoli cell-only syndrome, n = 13, severe oligozoospermia, n = 6, and 10 normozoospermic fertile men). Ten ethnically matched controls were screened for comparison. RESULTS: The cytogenetic array analysis detected a genomic gain at the 19p13.3 region in 9 (26.47%) cases, with the highest frequency in patients with Sertoli cell-only syndrome (SCOS) (38%). Its complete absence in the control group suggests its likely pathogenic nature. In addition to Y-classical, micro, and partial deletions, the duplication in 19p13.3 could serve as a unique biomarker for evaluation of infertility risk. The common region across the individuals harboring the duplication identified STK11, ATP5D, MIDN, CIRBP, and EFNA2 genes which make them strong candidates for further investigations. The largest duplicated region identified in this study displayed a major network of 7 genes, viz., CIRBP, FSTL3, GPX4, GAMT, KISS1R, STK11, and PCSK4, associated with reproductive system development and function. The role of chance was ruled out by screening of ethnically matched controls. CONCLUSION: The result clearly indicates the significance of 19p13.3 duplication in infertile men with severe testicular phenotypes. The present study underlines the utility and significance of whole genomic analysis in the cases of male infertility which goes undiagnosed due to limitations in the conventional cytogenetic techniques and for identifying genes that are essential for spermatogenesis.

Array-based DNA methylation profiling reveals peripheral blood differential methylation in male infertility.

OBJECTIVE: To study peripheral blood DNA differential methylation in oligozoospermic infertile men in comparison with normozoospermic fertile controls. DESIGN: Case-control study. SETTING: Reproductive biology laboratory. PATIENTS(S): Azoospermic and oligozoospermic infertile patients (n = 6) and normozoospermic fertile controls (n = 6) in the discovery phase, and oligo/asthenozoospermic infertile men (n = 11) and normozoospermic fertile controls (n = 10) in the validation phase. INTERVENTION(S): Blood samples drawn from all participants, DNA isolation and methylation analysis. MAIN OUTCOME MEASURE(S): DNA methylation values analyzed using genomewide methylation 450K BeadChip array, followed by deep sequencing of selected regions for methylation analysis in the neighborhood regions of differentially methylated CpGs. RESULT(S): We found 329 differentially methylated CpG spots, out of which 245 referred to the genes, representing 170 genes. Deep-sequencing analysis confirmed the methylation pattern suggested by 450K array. A thorough literature search suggested that 38 genes play roles in spermatogenesis (PDHA2, PARP12, FHIT, RPTOR, GSTM1, GSTM5, MAGI2, BCAN, DDB2, KDM4C, AGPAT3, CAMTA1, CCR6, CUX1, DNAH17, ELMO1, FNDC3B, GNRHR, HDAC4, IRS2, LIF, SMAD3, SOD3, TALDO1, TRIM27, GAA, PAX8, RNF39, HLA-C, HLA-DRB6), are testis enriched (NFATC1, NMNAT3, PIAS2, SRPK2, WDR36, WWP2), or show methylation differences between infertile cases and controls (PTPRN2, RPH3AL). CONCLUSION(S): We found a statistically significant correlation between peripheral blood DNA methylation and male infertility, raising the hope that epigenome-based blood markers can be used for screening male infertility risk. The study also identified new candidates for spermatogenesis and fertility.

Azoospermic infertility is associated with altered expression of DNA repair genes.

Compelling evidence suggest that germs cells are predominantly sensitive to DNA damaging agents in comparison to other cells. High fidelity DNA repair in testicular cells thus becomes indispensable to preserve the genomic integrity for passing on to the progeny. Compromised DNA repair machinery in the testicular cells may result in impaired spermatogenesis and infertility. It remains unclear if the alterations in the expression of DNA repair genes correlate with azoospermia and male infertility. In the present study, 54 non-obstructive azoospermic infertile patients with hypospermatogenesis (HS, n = 26), maturation arrest (MA, n = 15), Sertoli cell only syndrome (SCOS, n = 13) and 14 controls with obstructive azoospermia, but normal spermatogenesis were recruited. Expression profiling of 84 DNA repair genes in testicular biopsy samples was performed using PCR array. Out of 84 genes, 27, 64 and 28 genes showed >5 fold down-regulation in the HS, MA and SCOS groups, respectively. On the basis of differential expression and their functional significance in spermatogenesis, ten genes (MSH2, BRIP1, CCNH, LIG4, MGMT, NTHL1, PMS1, DMC1, POLB and XPA) were selected for validation of transcript levels in a higher number of cases using RT-PCR, which corroborated the findings of array. Four genes (MSH2, LIG4, PMS1 and DMC1) were analyzed for protein levels using immunohistochemistry, which further validated the loss of DNA repair gene expression. Caspase-3 immunostaining showed that the loss of DNA repair correlated with increased testicular apoptosis in patients. Maturation arrest showed the highest apoptotic index with maximum number of downregulated genes. We conclude that the loss of DNA repair genes expression in testis correlates with increased apoptosis, azoospermia and infertility.

XRCC1 deficiency correlates with increased DNA damage and male infertility.

High fidelity DNA repair is critical to sustain the genomic integrity and quality of developing germ cells. Deficiencies in DNA repair machinery may result in increased DNA damage in germ cell leading to abnormal spermatogenesis and infertility. X-ray repair cross-complementing group 1 (XRCC1) is a testis enriched protein that plays a crucial role in the DNA base excision repair (BER) pathway. The aim of this study was to analyze the level of XRCC1 transcript and protein in infertile men and its association with DNA damage in sperm. A total of eighty infertile patients with different infertile phenotypes (Azoospermia, n = 30; Severe oligozoospermia, n = 25; Severe oligoasthenozoospermia, n = 25) and age-matched controls (normal spermatogenesis [NS], n = 15 and fertile controls, n = 10) were recruited. γ-H2 AX protein levels were analyzed to estimate the DNA damage in sperm. XRCC1 transcript levels in cases and controls were determined by qRT-PCR. XRCC1 and γ-H2 AX proteins were immunohistochemically analyzed in testicular biopsy sections obtained from NOA patients and OA controls. The determination of XRCC1 and γ-H2 AX protein levels was performed with Western blots. The results revealed reduced expression of XRCC1 mRNA and protein in infertile individuals as compared to controls (p < 0.001). γ-H2 AX levels were significantly increased in infertile cases as compared to controls, indicating increased DNA damage in infertile men. The results indicate decreased expression of the XRCC1 gene in infertile patients which may be one of the factors associated with impaired spermatogenesis and infertility.

SNPs in ERCC1, ERCC2, and XRCC1 genes of the DNA repair pathway and risk of male infertility in the Asian populations: association study, meta-analysis, and trial sequential analysis.

PURPOSE: We investigated if substitutions in the ERCC1, ERCC2, and XRCC1 genes of the DNA repair pathway correlate with non-obstructive azoospermia and male infertility. METHODS: A total of 548 azoospermic infertile males and 410 fertile controls were genotyped for XRCC1 399A > G, 280G > A, and ERCC1 C > A 3' UTR and 541 azoospermic infertile males and 416 fertile controls were genotyped for ERCC2 751A > C using iPLEX Gold Assay. Meta-analyses were performed on XRCC1 399A > G (1022 cases and 1004 controls), ERCC1 C > A 3' UTR (879 cases and 1059 controls), and ERCC2 751A > C (914 cases and 850 controls) polymorphisms to quantitatively estimate the significance of the association between these polymorphisms and the risk of infertility. RESULTS: Statistically significant association between ERCC2 751A > C SNP and male infertility was found using the codominant model (p = 0.03). Results of meta-analysis suggested a lack of correlation with male infertility risk, which could be due to pooling of studies from different ethnic populations. Due to limited the number of studies, a stratified analysis for different ethnic groups could not be performed. CONCLUSION (S): In conclusion, AA genotype of 751A > C SNP in ERCC2 correlated with a higher risk of male infertility and may contribute to an increased risk of azoospermia and male infertility in Indian men.

Genome-wide differential methylation analyses identifies methylation signatures of male infertility.

STUDY QUESTION: Do methylation changes in sperm DNA correlate with infertility? STUDY ANSWER: Loss of spermatogenesis and fertility was correlated with 1680 differentially-methylated CpGs (DMCs) across 1052 genes. WHAT IS KNOWN ALREADY: Methylation changes in a number of genes have been correlated with reduced sperm count and motility. STUDY DESIGN, SIZE, DURATION: This case-control study used spermatozoal DNA from 38 oligo-/oligoastheno-zoospermic infertile patients and 26 normozoospermic fertile men. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: Genome-wide methylation analysis was undertaken using 450 K BeadChip on spermatozoal DNA from six infertile and six fertile men to identify DMCs. This was followed by deep sequencing of spermatozoal DNA from 32 infertile patients and 20 fertile controls. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 1680 DMCs were identified, out of which 1436 were hypermethylated and 244 were hypomethylated. Classification of DMCs according to the genes identified BCAN, CTNNA3, DLGAP2, GATA3, MAGI2 and TP73 among imprinted genes, SPATA5, SPATA7, SPATA16 and SPATA22 among spermatogenesis-associated genes, KDM4C and JMJD1C, EZH2 and HDAC4 among genes which regulate methylation and gene expression, HLA-C, HLA-DRB6 and HLA-DQA1 among complementation and immune response genes, and CRISPLD1, LPHN3 and CPEB2 among other genes. Genes showing significant differential methylation in deep sequencing, i.e. HOXB1, GATA3, EBF3, BCAN and TCERG1L, are strong candidates for further investigations. The role of chance was ruled out by deep sequencing of select genes. LARGE-SCALE DATA: N/A. LIMITATIONS, REASON FOR CAUTION: Genome-wide analyses are fairly accurate, but may not be exactly validated in replication studies across all DMCs. We used the 't' test in the genome-wide methylation analysis, whereas other tests could provide a more robust and powerful analysis. WIDER IMPLICATIONS OF THE FINDINGS: DMCs can serve as markers for inclusion in infertility screening panels, particularly those in the genes showing differential methylation consistent with previous studies. The genes validated by deep sequencing are strong candidates for investigations of their roles in spermatogenesis. STUDY FUNDING/COMPETING INTEREST(S): The study was funded by the Council of Scientific and Industrial Research (CSIR), Govt. of India with grant number BSC0101 awarded to Rajender Singh. None of the authors has any competing interest to declare.

Using the Modified Clavien Grading System to Classify Complications of Percutaneous Nephrolithotomy.

PURPOSE: A modified Clavien classification system has been proposed to grade perioperative complications. We share our experience in grading the complications of percutaneous nephrolithotomy (PNL), according to this new classification. METHODS: A total of 809 PNLs performed between 2010 and 2014 were reviewed retrospectively. The modified Clavien classification system, which classifies the perioperative complications into 5 grades, was applied. Grade wise comparison of complications between the patients with simple and complex calculi was done. We also carried out a univariate analysis of different predictors of complications after surgery. RESULTS: A total of 253 perioperative complications were observed in 237 (29.29%) patients. Most complications were related to bleeding and urinary leakage. Patients with complex calculi had significantly more number of complications across all Clavien groups. In a univariate analysis, positive preoperative urine culture and multiple access for stone clearance were identified to be the independent predictors of complications. CONCLUSION: The modified Clavien system is a simplistic grading system for classification of postoperative complications. However, it suffers from various shortcomings. Therefore, till the proposition of a more comprehensive classification system, the modified Clavien system is useful for reporting the complications and short-term outcomes of PNL.

Non-Functional Paraganglioma of the Urinary Bladder Treated by Transurethral Resection: Report of Two Cases.

Paraganglioma of the urinary bladder is a rare tumour derived from chromaffin tissue of the sympathetic nervous system. Paraganglioma of the urinary bladder especially the non-functional type is often misdiagnosed as urothelial cancer. Two female patients aged 32 years and 45 years presented with painless haematuria without any symptoms of catecholamine excess. Radiological investigations revealed urinary bladder tumour. The tumour was removed by transurethral resection in both the patients. Histopathological diagnosis was paraganglioma, which was confirmed by immunohistochemistry. Complete resection of tumour by transurethral approach is curative in paraganglioma of the urinary bladder. We hereby, also discuss the salient features of nonfunctional paraganglioma of the urinary bladder.

Dysuria and fever in a young woman diagnosed as having inflammatory myofibroblastic tumour of the urinary bladder.

A 38-year-old woman presented with dysuria and fever. Her medical and family histories were unremarkable. CT scan of the abdomen revealed a polypoid mass of 4×2.6×2.2 cm. Her cystoscopy showed a 4×2 cm solid broad-based growth at trigone of the urinary bladder. She underwent transurethral resection of the urinary bladder tumour (TURBT). Histopathology revealed a poorly circumscribed proliferation of spindle cells arranged in a haphazard and fascicular manner along with many traversing blood vessels in a myxoid and hyalinised stroma. Immunohistochemistry was positive for anaplastic lymphoma kinase-1, smooth muscle actin, CD10, cytokeratin and desmin; and negative for CD34 and S-100 protein. Ki-67 proliferative index in the tumour was <1%. The patient was diagnosed as having inflammatory myofibroblastic tumour of the urinary bladder. After TURBT, her fever and urinary symptoms resolved. Her 1-month postoperative period was uneventful. She has been advised regular follow-up.

Emphysematous pyelonephritis in a domestic shorthair cat.

A 3-year-old male castrated domestic shorthair cat was presented with an acute history of lethargy and decreased appetite. Pertinent physical examination abnormalities included palpable irregularity of the right kidney and pain on palpation of the left kidney. Ultrasonographic imaging of the abdomen revealed gas present at the corticomedullary junction of the left kidney, consistent with emphysematous pyelonephritis, as well as emphysematous cystitis. While quantitative urine culture via pyelocentesis yielded a negative culture, a sample via cystocentesis was positive for Escherichia coli and emphysematous changes were presumed most likely secondary to an ascending infection. The purpose of this report is to describe the temporary management of ureteral obstruction secondary to emphysematous pyelonephritis using a ureteral stent in a cat.