Da Vinci Robotic Surgical System: Early Experience from Pakistan.

OBJECTIVE: To determine the outcomes of robotic surgeries using the Da Vinci robotic surgical system (DVSS) at Pakistan's largest urological tertiary healthcare system. STUDY DESIGN: Descriptive study. Place and Duration of the Study: Department of Minimally Invasive and Robotic Surgery, Division of Urology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan, from March 2017 to December 2021. METHODOLOGY: Hospital records of patients who underwent robotic urological surgeries were assessed for their outcomes in terms of blood loss, mortality, system malfunction, and conversion to open surgery. Descriptive statistics were determined. RESULTS: A total of 550 procedures were performed. The mean age recorded was 39.58±16.83 years. The mean blood loss recorded was 255.611±353.57 ml; there were 3 cases of malfunction. Forty cases were converted to open surgery, and the mortality rate was 1.1%. CONCLUSION: Minimally invasive surgical techniques have high precision, fewer complications, and lower morbidity rates. Using DVSS for surgical interventions is both effective and safe. KEY WORDS: Minimally invasive surgery, Da Vinci robotic surgical system, Robotic surgery.

Early post-operative outcomes of robot-assisted pyeloplasty in patients with unilateral ureteropelvic junction obstruction.

INTRODUCTION: Ureteropelvic junction obstruction (UPJO) is a commonly encountered abnormality and it can lead to serious consequences such as renal dysplasia eventually resulting in loss of kidney. Hence, early diagnosis and timely management remains the cornerstone of the treatment. The most anticipated technique amongst modern day urologist is the robot-assisted laparoscopic pyeloplasty (RALP). The study aims to determine early post-operative outcomes of robot-assisted laparoscopic transperitoneal pyeloplasty procedure in patients presenting with unilateral ureteropelvic junction obstruction to establish the local perspective. METHODOLOGY: This is a descriptive study involving patients with ureteropelvic junction obstruction in a tertiary care facility in Karachi; Sindh Institute of Urology and Transplant (SIUT). A total of 46 participants were recruited. Robot-assisted laparoscopic transperitoneal dismembered Hynes-Anderson pyeloplasty was performed by a single surgeon with over 3 years of experience in the presence of the researcher. Early postoperative outcome total operative time, length of hospital stay, console time and blood loss were noted by the researcher as per operational definition. Data were analyzed on SPSS Version 22. RESULTS: Mean age in our study was 46.51 years with the standard deviation of ± 10.87. Whereas, mean length of hospital stay, total operative time, total blood loss, console time, pre-hemoglobin, posthemoglobin, height, weight and BMI in our study was 1.19 ± 0.40 days, 64.58 ± 17.59 min, 9.56 ± 6.13 ml, 30.17 ± 4.99 min, 12.66 ± 1.47 ml, 11.79 ± 1.93 ml, 165.62 ± 8.23 cm, 68.34 ± 8.23 kg and 24.85 ± 3.34 kg/m2, respectively. CONCLUSION: Recent advancements in technology have yielded the latest RALP technique which has been proven significantly better than existing approaches and similar results are reported by this study demonstrating improvement in peri-operative and post-operative outcomes ultimately ameliorating the quality of life of patients with UPJO.

Incidental Prostate Cancer: A 23-Year Review Of A Tertiary Care Hospital.

Prostate cancer is the second most commonly diagnosed malignancy in men worldwide. The prevalence has been increasing with significant differences between regions. This study assesses the prevalence of incidental prostate cancer detected in specimens removed during bladder outlet obstruction operation. A retrospective analysis of the records of patients who had either endoscopic or open prostatectomy from January 1998 to December 2021 was conducted. The variables analysed were age, procedure, date of surgery, and Gleason score. A total of 2,842 patients underwent surgery on the prostate gland during the study period. Most of the patients, i.e. 2,733 (96.2%), were pathologically diagnosed with benign prostatic hyperplasia, while only 110 (3.9%) had prostate cancer. The frequency of incidental prostate cancer following surgery for bladder outlet obstruction has decreased over the last two decades at our centre, possibly because of an increase in PSA testing.

Squamous Cell Carcinoma of the Kidney: A Large Case Series.

OBJECTIVES: We present our experience with and data about a very rare neoplasm of the kidney, squamous cell carcinoma (SCC). METHODS: A total of 14 patients with a diagnosis of SCC were identified on the basis of a retrospective analysis of medical records of patients who underwent surgery for renal cancers between 2015 and 2021 at the Sindh Institute of Urology and Transplantation. IBM SPSS v25 was used to record and analyze data. RESULTS: Most patients found to have SCC of the kidney were male (71.4%). The mean (SD) patient age was 56 (13.7) years. Flank pain was the most common presenting symptom (n = 11; 78.6%) followed by fever (n = 6; 42.9%). Only 4 (28.5%) of the 14 patients had a preoperatively established diagnosis of SCC; the remaining 10 (71.4%) had an incidental finding of SCC on their histopathology specimen. The mean (SD) overall survival was 5 (4.5) months. CONCLUSIONS: SCC of the kidney is a rare upper urinary tract neoplasm reported in the literature. The gradual onset of vague symptoms, lack of pathognomonic signs, and inconclusive radiological features make the disease unsuspected in most cases, therefore delaying diagnosis and treatment. It usually presents at an advanced stage, and the prognosis is often poor. A high index of suspicion is warranted in patients with chronic kidney stone disease.

Excision of Postchemotherapy Residual Retroperitoneal Mass in Testicular Cancer.

In this study, patients, who underwent excision of retroperitoneal mass following chemotherapy for testicular cancers from 2006 to 2016, were studied and followed till 2021. The clinical and oncological outcomes were measured. Among 338 patients, who were treated for TC during the entire study period, 38 (11.2%) underwent excision of the residual retroperitoneal mass. The mean age of these patients was 26.9±6.3 years. The majority were stage 3 testicular cancer. Complete resection with negative microscopic margins was achieved in the majority of cases i.e. 31 (81.6%). Damage to the collateral structures was seen in 12 (31.6%) cases. On histopathological examination, teratoma was seen in 18 (47.4%) of the cases followed by necrosis in 10 (26.3%). Complications were recorded in 12 (31.5%) cases, most were low grades. At five years of follow-up, 19 (50%) were disease-free, 25 (65.8%) were alive, and 9 (23.6%) were lost to follow-up. Five-year survival rates are lower than standard template-based retroperitoneal dissection, however, complications rates are comparable. Such complex surgeries should only be performed in high-volume centres. Key Words: Testicular neoplasms, Lymph node excision, Seminoma, Germ cell and embryonal.

Outcomes of Nephron-sparing Surgery in T1 vs T2 Renal Tumours.

OBJECTIVE:  To compare the drop in eGFR after nephron-sparing surgery in T1 and T2 renal tumours. STUDY DESIGN:  Descriptive study. PLACE AND DURATION OF STUDY:  Department of Uro-oncology, Sindh Institute of Urology, and Transplantation Karachi, from March 2020 to March 2021. METHODOLOGY:  Retrospective data were collected for all patients who underwent nephron-sparing surgery between 2014 to 2019. Eighty-seven patients were divided into two groups based on the T stage of renal tumours (T1 ≤7 cm and T2 >7 cm). The outcomes of the two groups were compared such as eGFR, blood transfusion, hospital stay and complications. RESULTS:  There was a higher drop in eGFR in T2 tumours when compared to T1 tumours at 1 year of follow-up. There were more perioperative complications, higher blood transfusions and longer hospital stays for T2 tumours. CONCLUSION:  Nephron sparing surgery for T2 renal tumours carries lower eGFR preservation, higher blood transfusions and complications when compared to T1 tumours. The indication for such extensive surgery should be individualized to specific contexts only. KEY WORDS: Adenocarcinoma kidney, Nephrectomy, Glomerular filtration rate, Length of hospital stay, Blood transfusion.

E-learning in postgraduate urology training: A Covid-19 pandemic experience.

Since the declaration of the Covid-19 pandemic in March 2020, several teaching institutions started the process of adjusting to the new challenge. Medical education could not be imparted the way it used to be and some new methods had to be taken to adapt to the pandemic. At our institute, an online e-teaching approach was adopted to ensure the continuation of post-graduate medical training. Each week two lectures were recorded and uploaded on the YouTube Channel and shared with the students. This was followed by an MCQ based test using Google forms. Ten lectures were delivered in five weeks to 55 participants. The majority of residents agreed that this activity increased their knowledge of the subject and opted to continue it in future. With the help of short online lectures (< 30 minutes) and online tests (5 MCQs), the learning experience of residents can be enhanced. In future, more online resources can be used to incorporate this method of teaching.

Inflammatory myofibroblastic tumour of genitourinary system.

Two cases of inflammatory myofibroblastic tumour (IMT) involving the genitourinary system are presented. One patient with mass of urinary bladder came in with lower abdominal pain whereas the second patient complained of right flank pain and investigations showed a mass involving the right kidney. At present, no specific guidelines exist for the management of inflammatory myofibroblastic tumours. In this case report, we will discuss the work-up and the management stratégies adopted for each case.

Stricture of Urethra: Patterns and Outcomes of Management from a Single Centre in Pakistan Over 7 Years.

OBJECTIVE: To determine the outcomes of urethroplasty and its complications from a large cohort of patients managed in a single centre. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Urology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, from January 2010 to December 2016. METHODOLOGY: A total of 546 patients with stricture urethra at different locations underwent urethroplasty from January 2010 to December 2016 were included. All patients had an ascending urethrogram followed by retrograde ± antegrade urethroscopy to assess the location and length of the stricture. Technique of urethroplasty was chosen according to the site, length and etiology. Following appropriate procedure, patients were followed up in the dedicated urethral stricture clinic. Procedure was considered successful if either no further therapeutic intervention was required and the maximum flow rate (Qmax) was >20 ml/sec with a voided volume of at least 200 mls. The procedure was regarded as unsuccessful, if further treatment was required or Qmax was <10ml/sec. RESULTS: A total of 546 patients with mean age of 32.3 +13.1 years (range: 12-74) involving anterior (n=323, 59.2%) or posterior (n=223, 40.8%) urethra were treated. Mean follow-up was 43.6 months (range: 3-84). The success rates of bulbar urethral strictures after excision and primary anastomosis (EPA) was 93. 3%, non-transecting urethroplasty 84.6% and oral mucosal graft (OMG), 81.8%. In penile urethral strictures, OMG, Orandi procedure and Johanson's techniques yielded success rates of 88.4%, 66.6% and 57.1%, respectively. In posterior urethral strictures, after excision and bulboprostatic anastomosis, good results were seen in 88.3%. In pan-urethral strictures, abdominal skin graft repair, combined tissue transfer and OMG urethroplasty yielded success rates of 74%, 78.5% and 75%, respectively. The complications/ adverse events were encountered in 251 / 546 (45.9%) patients in this series. CONCLUSION: Anastomotic urethroplasty yielded best outcomes followed by OMG urethroplasty. In the long-term follow-up, erectile dysfunction (ED), infertility and recurrence of stricture are the main complications which need individualised management.

Chondrosarcoma of right big toe with metastases to left orbital and left infra temporal region.

To report a case of chondrosarcoma of right big toe with left orbital and left infra temporal metastases. Chondrosarcoma is the second most frequent primary malignant tumour of the bone. A 56 year old man had history of trauma on his right big toe, which was amputated and the biopsy in 2011 at Sindh Institute of Urology and Transplantation (SIUT) revealed chondrosarcoma with clear margins. Eventually the patient was presented with swelling of the left eye, pain and gradual loss of vision of that eye. Later a CT scan of his chest, brain and orbit showed pulmonary and pleural based nodule, with mediastinal and hilar lymphadenopathy representing metastatic deposit in left orbit, extending to left infra temporal region. A treatment of palliative chemotherapy was started with doxorubicin and ifosfamide, after which he was referred for radiotherapy. At that time he had loss of vision, pain and exopthalamus, and palliative radiotherapy was delivered to the left orbit with the prescribed dose of30 Gy/300cGy×10 fraction. Thereafter his case will be followed up at the oncology OPD after a 03 month interval.

Short- and Intermediate-Term Outcomes in Living-Related Renal Transplant Donors.

OBJECTIVES: The aim of the present study was to evaluate the short- and intermediate-term outcomes of living-related kidney donors in terms of renal function and postnephrectomy complications at a single center in Pakistan. MATERIALS AND METHODS: Our study included healthy donors who underwent unilateral nephroureterectomy for living-related renal transplant procedures at the Sindh Institute of Urology and Transplantation (Karachi, Pakistan) between January 2005 and January 2006. All patients were evaluated for early postoperative complications and renal functions at last follow-up. The mean follow-up duration was 1.7 ± 1.3 years. RESULTS: A total of 256 living-related donors underwent nephroureterectomy during the study period, which included 142 men (55.5%) and 114 women (44.5%). The mean age of donors was 33.7 ± 10.0 years. Most donors were between 21 and 40 years old. Of total donors, most were siblings (n = 143, 55.8%), followed by offspring, parents, and spouses. Left nephrectomy was performed in 206 donors (80.4%) and right in 50 donors (19.5%). There were no deaths during transplant. The mean postoperative hospital stay was 6.37 ± 0.95 days. A total of 38 donors (14.8%) had one or more surgical complication. Hypertension developed in 25 (9.7%) and diabetes mellitus in 9 donors (5%). Creatinine clearance was > 90 mL/min in 96 (41%), 60 to 90 mL/min in 120 (51%), and ≤ 60 mL/min in 18 donors (8%). CONCLUSIONS: Living-related donor nephrectomy remains a valuable source of kidneys for transplant procedures and carries a small risk. With careful donor selection and good surgical management, operative complications can be minimized.

Laparoscopic Donor Nephrectomy: Early Experience at a Single Center in Pakistan.

OBJECTIVES: Laparoscopic donor nephrectomy has become the criterion standard for kidney retrieval from living donors. There is no information on the experience and outcomes of laparoscopic donor nephrectomy in Pakistan. The objective of the study was to identify benefits and harms of using laparoscopic compared with open nephrectomy techniques for renal allograft retrieval. MATERIALS AND METHODS: In this a retrospective study, patient files from May 2014 to September 2015 were analyzed. Patients were divided into 2 groups: those with open donor nephrectomy and those with laparoscopic donor nephrectomy. Donor case files and operative notes were analyzed for age, sex, laterality, body mass index, warm ischemia time, perioperative and postoperative complications, surgery time, and length of hospital stay. Finally, serum creatinine patterns of both donors and recipients were analyzed. Data were analyzed using SPSS version 10 (SPSS: An IBM Company, IBM Corporation, Armonk, NY, USA). RESULTS: Of 388 total donors, 190 (49%) had open donor nephrectomy and 198 (51%) had laparoscopic donor nephrectomy. For both groups, most donors were older than 25 years with male preponderance. Left-to-right kidney donation ratio was markedly higher in the laparoscopic group than in the open donor nephrectomy group, with 6 cases of double renal artery also included in this study. There were no significant differences in surgery times between the 2 groups, whereas the laparoscopic donor nephrectomy group had shorter hospital stay. Analgesic requirements were markedly shorter in the laparoscopic donor nephrectomy group. The 1-year graft function was not significantly different between the 2 groups. CONCLUSIONS: The results for laparoscopic donor nephrectomy were comparable to those for open donor nephrectomy, and its acceptability was high. Laparoscopic donor nephrectomy should be the preferred approach for procuring the kidney graft.

Surgical outcomes of percutaneous nephrolithotomy in 3402 patients and results of stone analysis in 1559 patients.

OBJECTIVE: To report our experience of a series of percutaneous nephrolithotomy (PCNL) procedures in a single centre over 18 years in terms of patient and stone characteristics, indications, stone clearance and complications, along with the results of chemical analysis of stones in a subgroup. PATIENTS AND METHODS: We retrospectively analysed the outcomes of PCNL in 3402 patients, who underwent the procedure between 1997 and 2014, obtained from a prospectively maintained database. Data analysis included patients' age and sex, laboratory investigations, imaging, punctured calyx, duration of operation, volume of irrigation fluid, radiation exposure time, blood transfusion, complications and stone-free status at 1-month follow-up. For the present analysis, outcomes in relation to complications and success were divided in two eras, 1997-2005 and 2006-2014, to study the differences. RESULTS: Of the 3402 patients, 2501 (73.5%) were male and 901 (26.5%) were female, giving a male:female ratio of 2.8:1. Staghorn (partial or complete) calculi were found in 27.5% of patients, while 72.5% had non-staghorn calculi. Intracorporeal energy sources used for stone fragmentation included ultrasonography in 917 patients (26.9%), pneumatic lithoclast in 1820 (53.5%), holmium laser in 141 (4.1%) and Lithoclast® master in 524 (15.4%). In the majority of patients (97.4%) a 18-22-F nephrostomy tube was placed after the procedure, while 69 patients (2.03%) underwent tubeless PCNL. The volume of the irrigation fluid used ranged from 7 to 37 L, with a mean of 28.4 L. The stone-free rate after PCNL in the first era studied was 78%, vs 83.2% in the second era, as assessed by combination of ultrasonography and plain abdominal film of the kidney, ureter and bladder. The complication rate in the first era was 21.3% as compared with 10.3% in the second era, and this difference was statistically significant. Stone analysis showed pure stones in 41% and mixed stones in 58% of patients. The majority of stones consisted of calcium oxalate. CONCLUSIONS: This is the largest series of PCNL reported from any single centre in Pakistan, where there is a high prevalence of stone disease associated with infective and obstructive complications, including renal failure. PCNL as a treatment method offers an economic and effective option in the management of renal stone disease with acceptable stone clearance rates in a resource-constrained healthcare system.

Analysis of the glutathione S-transferase genes polymorphisms in the risk and prognosis of renal cell carcinomas. Case-control and meta-analysis.

BACKGROUND: The Glutathione S-transferases (GSTs) genes deletion polymorphisms have been associated with the progression of several cancers. The association studies between the 2 GSTs (GSTM1 and GSTT1) null polymorphisms with the susceptibility to renal cell carcinoma (RCC) have been inconclusive. Therefore, with the inclusion of our own data, we performed a comprehensive meta-analysis to assess the association between these 2 polymorphisms and the risk of RCC. METHODS: A systematic literature search was carried out for studies published in the PubMed, EMBASE, Cochrane library, and Google Scholar from 1997 to December 2014. Results were stated as pooled odds ratios (ORs) for nonparametric data after heterogeneity analysis with 95% CI using fixed effect or random effect model. RESULTS: We systematically selected 13 relevant studies after thorough searches from the databases. Data showed no association between the GSTM1 and the GSTT1 null genotypes and the risk of RCC (OR = 1.01; CI: 0.92-1.11; P = 0.89 for GSTM1 and OR = 1.14; CI: 0.91-1.42; P = 0.25 for GSTT1). No association was found when the data were stratified according to the geographical/ethnic basis, source of control, and the risk factor evaluation. Subgroup analysis of occupational exposure to pesticides showed an inverse association of the active genotypes of both GSTM1 and GSTT1 polymorphisms with the exposed group of RCC (P<0.00001 and P<0.00001, respectively). The combined null genotype of the GSTM1/GSTT1 significantly increased the susceptibility to RCC by 1.4-fold (P = 0.001). This association remained significant for the Asian populations in subgroup analysis (OR = 1.8; CI: 1.30-2.49; P = 0.0004). CONCLUSION: In conclusion, this meta-analysis suggests that the 2 GSTs deletion polymorphisms independently have no association with the risk of RCC. However, combination of both deletions increases the risk of developing the RCC.

Long-term Safety of Living Kidney Donation in an Emerging Economy.

BACKGROUND: Long-term follow-up and management of donors was undertaken in a specialist kidney transplant unit in Pakistan to identify risk and prevent adverse outcomes in living related kidney donors. METHODS: In an observation cohort study between 1985 and 2012, 3748 donors were offered free medical follow-up and treatment 6 to 12 months after donation and annually thereafter. Each visit included history, physical examination, blood tests for renal, lipid, glucose profiles, and 24-hour urine for proteinuria and creatinine clearance. Preventive intervention was undertaken for new onset clinical conditions. Donor outcomes were compared with 90 nondonor healthy siblings matched for age, sex, and body mass index. RESULTS: Of the 3748 donors, 2696 (72%) were in regular yearly follow-up for up to 27 years (median, 5.6; interquartile range, 7.9). Eleven (0.4%) died 4 to 22 years after donation with all-cause mortality of 4.0/10 000 person years. Six (0.2%) developed end-stage renal disease 5 to 17 years after donation, (2.7/10 000 person years). Proteinuria greater than 1000 mg/24 hours developed in 28 patients (1%), hypertension in 371 patients (13.7%), and diabetes in 95 patients (3.6%). Therapeutic intervention-controlled protein was less than 1000 mg/24 hours, blood pressure was below 140/90 mm Hg, and glycemic control in 85% up to 15 years after onset. Creatinine clearance fell from 109.8 ± 22.3 mL/min per 1.73 m predonation to 78 ± 17 at 1 year, 84 ± 19 at 5 years, and 70 ± 20 at 25 years. Comparison of 90 nondonor sibling and donor pairs showed significantly higher fasting glucose and hypertension in nondonors. CONCLUSIONS: Long-term follow-up of donors has demonstrated end-stage renal disease in 0.6% at 25 years. Regular follow-up identified new onset of disease and allowed interventions that may have prevented adverse outcomes.

Utility of digital rectal examination, serum prostate specific antigen, and transrectal ultrasound in the detection of prostate cancer: a developing country perspective.

PURPOSE: To determine the utility of digital rectal examination (DRE), serum total prostate specific antigen (tPSA) estimation, and transrectal ultrasound (TRUS) for the detection of prostate cancer (PCa) in men with lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: All patients with abnormal DRE, TRUS, or serum tPSA >4ng/ml, in any combination, underwent TRUS-guided needle biopsy. Eight cores of prostatic tissue were obtained from different areas of the peripheral prostate and examined histopathologically for the nature of the pathology. RESULTS: PCa was detected in 151 (50.3%) patients, remaining 149 (49.7%) showed benign changes with or without active prostatitis. PCa was detected in 13 (56.5%), 9 (19.1%), 26 (28.3%), and 103 (74.6%) of patients with tPSA <4 ng/ml, 4-10 ng/ml, 10-20 ng/ml and >20 ng/ml respectively. Only 13 patients with PCa had abnormal DRE and TRUS with serum PSA <4 ng/ml. The detection rate was highest in patients with tPSA >20 ng/ml. The association between tPSA level and cancer detection was statistically significant (p<0.01). Among 209 patients with abnormal DRE and raised serum PSA, PCa was detected in 128 (61.2%). CONCLUSIONS: The incidence of PCa increases with increasing serum level of tPSA. The overall screening and detection rate can be further improved by using DRE, TRUS and TRUS-guided prostate needle biopsies.

Unique molecular alteration patterns in von Hippel-Lindau (VHL) gene in a cohort of sporadic renal cell carcinoma patients from Pakistan.

BACKGROUND: Renal cell carcinoma (RCC) is the most frequent form of kidney cancer in adults. Somatic mutations that inactivate the von Hippel-Lindau (VHL) gene are the most common cause of RCC. The frequencies of molecular changes in the VHL gene in RCCs vary among different populations. So far, a single chromosomal-based study has been reported from a South Asian population. This report presents, for the first time, the somatic changes and promoter hypermethylation in VHL in a cohort of 300 RCC patients from Pakistan. METHODS: To identify mutations in the VHL gene, direct DNA sequencing was carried out. Epigenetic silencing was investigated by using methylation-specific polymerase chain reaction. RESULTS: Our data showed molecular alterations in the VHL gene in 163 (54%) renal cell carcinoma patients. Somatic mutations were found in 87 (29%) patients and 35 novel mutations were identified. VHL promoter hyper-methylation analysis showed epigenetic changes in 106 (35%) out of 300 patients. Patients who had no evidence of molecular alterations in the VHL gene were significantly younger than patients who carried some molecular change. Molecular alterations in the VHL gene were not restricted to clear-cell RCCs (ccRCCs). CONCLUSIONS: This is the first report that identifies molecular aberrations in the VHL gene from a South Asian population. The frequency of somatic mutation is lower and that of promoter hypermethylation is higher when compared with data from other parts of the world. The data has important implications in the population-specific application of tailored preventive and therapeutic regimens in non-familial RCCs.

Primary Non-Hodgkin's Lymphoma of Penis Masquerading as a Non-Healing Ulcer in the Penile Shaft.

Primary malignant lymphoma of the male external genitalia is extremely rare and it is even rarer in the penis. Because of its rarity, the possibility of delay in diagnosis and mismanagement is always there. It can present as a nodule, non-healing ulcer, stricture urethra or periurethral abscess. We report a case presenting first a nodule and later on as a non-healing ulcer which was diagnosed by corporal biopsy and managed successfully with chemotherapy.

Extracorporeal shock wave lithotripsy (ESWL) vs. ureterorenoscopic (URS) manipulation in proximal ureteric stone.

OBJECTIVE: To compare the stone free rate at one week after extracorporeal shock wave lithotripsy (ESWL) and ureterorenoscopic (URS) manipulation for proximal ureteric stone (10 - 15 mm size). STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Sindh Institute of Urology and Transplantation (SIUT), Karachi, from August 2010 to February 2011. METHODOLOGY: One hundred and ninety patients with 10 - 15 mm proximal urteric stone, in each group were treated with ESWL and ureterorenoscopic manipulation by using an 8.0 or 8.5 Fr semi rigid ureteroscope. Intracorporeal lithotripsy was performed by using pneumatic lithoclast. The stone free rate were compared between groups by considering size of stone at one week after procedure. The success rate, retreatment rate, auxiliary procedure and complication rate were compared in each group. RESULTS: Success rate was 49.2% for ESWL and 57.8% for URS (p = 0.008). The re-treatment rate was significantly higher in ESWL group than in URS group (40% vs. 11 and 18% in URS group). CONCLUSION: Although ESWL is regarded as the preferred choice of treatment for proximal ureteric stone, the present results suggest that ureterorenoscopic manipulation with intracorporeal lithotripsy is a safe alternative, with an advantage of obtaining an earlier or immediate stone-free status. Laparoscopic approaches are reasonable alternatives in cases, where ESWL and URS have failed.

Problems and prospects of neglected renal calculi in Pakistan: can this tragedy be averted?

PURPOSE: To report our recent experience of treating patients with stones associated with renal failure, some of the factors underlying this problem, and few suggestions to avert this tragedy. MATERIALS AND METHODS: From January 2010 to December 2010, a total of 2838 new patients with stone disease were treated at a tertiary care center. The medical files of 278 patients presenting with stone disease and renal failure were reviewed and compared with a cohort of 878 patients with normal renal functions. Their demographic and clinicopathological parameters were noted and analyzed. RESULTS: Of 2838 patients, 278 (9.7%) presented with acute and chronic renal failure, 40 (1.4%) with unilateral non-functioning kidneys, and 25 (0.8%) with pyonephrosis and perinephric abscess. Management in 278 subjects was divided into initial relief of obstruction by percutaneous nephrolithotomy and double-J stents followed by definitive management in the form of open surgery, percutaneous nephrolithotomy, extracorporeal shockwave lithotripsy, and ureterorenoscopy to make these patients stone-free. Results of treatment showed that 72% of patients either recovered their renal functions or became dialysis-free at the end of the follow-up period. CONCLUSION: Complications of renal calculi in the era of modern treatment can be prevented by public education and organizing courses for family physicians as well as opening new stone clinics in the rural areas of the country equipped with modern treatment facilities and strategies for prevention of renal calculi.