Early urinary diversion with ileal conduit and vesicovaginostomy in the treatment of radiation cystitis due to carcinoma cervix: a study from a tertiary care hospital in South India.

BACKGROUND: To study the magnitude of radiation cystitis following radiation therapy for carcinoma cervix, and propose an algorithm to decide on early diversion, with or without vesicovaginostomy. METHODS: Women who developed radiation cystitis following radiotherapy for carcinoma cervix from January 1998 to December 2011 were included in this retrospective study. Electronic hospital records were analysed to document the presence of radiation cystitis. All women who developed evidence of radiation-induced cystitis, according to the common toxicity and Radiation Therapy Oncology Group criteria, were included in the study. We looked at transfusion requirements, number of hospital admissions, quality of life and cost involved. Chi-square tests were done where applicable. SPSS version 16 was used for analysis. RESULTS: Of the 902 patients who received radiation for carcinoma cervix in the 13-year period, 62 (6.87%) developed grade 3/4 cystitis. Twenty-eight of them underwent ileal conduit diversion, with 18 undergoing concomitant vesicovaginostomy. When compared with the patients who did not have diversion, the transfusion requirements, number of hospital admissions and quality of life had a statistically significant difference. Cost analysis of early diversion too showed a marginal benefit with early diversion. The limitation of the study was that it was retrospective in nature. CONCLUSION: In radiation cystitis, multiple hospital admissions and consequential increase in cost is the norm. In severe disease, early diversion is a prudent, cost-effective approach with good quality of life and early return to normal activity.

Warty carcinoma of the penis: A clinicopathological study from South India.

AIMS: There are few studies on the pathology of warty carcinoma (WC) of the penis and these have been from South America. Penile cancers are not uncommon in India. We reviewed the frequency of subtypes of penile squamous carcinoma (SC) and the pathological features and outcome of WC when compared to squamous carcinoma-not otherwise specified (SC-NOS). We also compared the clinicopathological features of WC in our series with those published earlier. MATERIALS AND METHODS: We studied 103 cases of penile cancers over 6 years. Cases were classified into different subtypes according to established histologic criteria. Clinicopathologic features were studied in detail and compared among the different subtypes, especially between WC and SC-NOS. The patients were followed-up and disease free survival in months was noted. RESULTS: SC-NOS constituted 75.7% of all penile cancer cases in our series. The frequency of other subtypes was WC: 9.7%, verrucous: 3.9%, basaloid type and papillary type: 0.97% each, and mixed types 8.7%. The average tumor size and depth of invasion did not differ significantly between the two subtypes. Frequency of lymphovascular emboli and percentage of lymph node metastasis in WC (30 and 10%) were lesser than in SC-NOS (49.37 and 26.58%), respectively. There were no recurrences after partial penectomy in the WC subtype. In the SC-NOS type, three cases had recurrence after partial/total penectomy. CONCLUSION: Warty carcinoma constitutes nearly 10% of all penile squamous cell cancers. These patients seem to have a less aggressive behavior than SC-NOS.

Symptomatic lymphocoeles post renal transplant.

The aim of this study was to evaluate the outcome of various treatment modalities of symptomatic lymphoceles and suggest an optimal management protocol. Case records of 744 renal transplant recipients who underwent surgery between January 2000 and December 2007 were retrospectively reviewed. There were a total of 36 (4.38%) lymphoceles detected in the postoperative period, of which 14 (1.88%) were symptomatic. A total of 32 procedures for the treatment of lymphocele were performed in 14 of these patients. Aspiration or percutaneous catheter drainage was performed as a primary procedure in all cases. Open marsupialization and laparoscopic marsupialization procedures were performed as secondary treatments. Percutaneous nephrostomy was required in one case before definitive treatment. Primary aspiration was successful in (n = 2) 28.5% and percutaneous drainage in (n = 3) 42.8%. Sclerotherapy was definitive in (n = 2 of 3) 66.6%. Seven of 14 patients required secondary procedure. Laparoscopic marsupialization was successful in (n = 4 of 5) 80% and open technique (n = 3) was curative in all cases. In our opinion, the first step in the management of symptomatic lymphocele in post-renal transplant recipients should be percutaneous drainage with or without drug instillation. This can stabilize renal function and optimize patients who may require surgery. Surgical marsupialization offers superior definitive treatment of lymphoceles with the least recurrence rates.

Does urinary metabolic assessment in idiopathic calcium nephrolithiasis matter? A matched case control study among Indian siblings.

OBJECTIVE: To identify the differences in urinary profile of a stone former and the matched member of the family. PATIENTS AND METHODS: This prospective case-control study was conducted from April 2006 to January 2008. Forty-one matched pairs from one geographic region were recruited. Renal/ureteric idiopathic calcium nephrolithiasis in patients of 18 years and above were included as cases. Controls were of the same gender and first-degree relative with no urolithiasis or history. They were living together at least for the last 5 years and consuming minimum of two out of three major meals together per day. For cases and controls besides fluid intake, ambulatory serum analysis for calcium, phosphorus, uric acid, albumin-globulin ratio, sodium, potassium and bicarbonate was done. Ambulatory 24-hour urinalysis was done for urinary volume, calcium, phosphorus, oxalate, uric acid, citrate, magnesium, creatinine and urinary pH was measured. For controls X-ray and USG-Kidney-Ureter-Bladder was done to rule out stone disease. The statistical analysis was done using Mc-Nemar test. RESULTS: Of the 41, 31 cases (76%) were first-time stone formers. No statistical difference was found for 24-hour urinary calcium (P = 0.68), oxalate (P = 0.68), citrate (P = 0.45) and urinary volume (P = 0.14). All pairs had normal 24-hour urinary magnesium, uric acid and urinary pH. CONCLUSIONS: The urinary biochemical profile of idiopathic calcium nephrolithiasis was similar to the appropriately matched family member. It appears that an independent intrinsic factor may possibly be present and responsible for stone disease. The usefulness of urinary metabolic evaluation is seems to be of doubtful significance.

Second transurethral resection in T1G3 bladder tumors - Selectively avoidable?

AIM: To assess the need of a second transurethral resection (TUR) in select T1G3 bladder tumor patients. MATERIALS AND METHODS: All the pT1G3 bladder tumors diagnosed during the period between January 2005 and December 2008 were included. Second TUR was routinely performed in all the pT1G3 bladder tumors within 4-6 weeks. Fifty out of the 68 patients with T1G3 underwent a second TUR and were retrospectively reviewed. The primary bladder lesions were grouped as solitary papillary, multiple papillary and sessile lesions. Statistical analysis was performed using STATA version 11 (STATA Corp., Texas, USA). RESULTS: Forty percent (n = 20) of the lesions were solitary papillary, 48% (n = 24) were multiple papillary and 12% (n = 6) were sessile lesions. All our resections had muscularis propria sampled at the end of the resection and separately sent for histopathological examination (HPE), which showed them to be tumor free. Thirty-six percent of patients had residual disease at the second resection and 4% were upstaged. Ninety-five percent of the patients (n = 19) with solitary papillary lesions did not have any residual disease and 50% (n = 12) of the multiple papillary and 83.3% (n = 5) of the sessile group had residual disease at the second TUR. CONCLUSIONS: Patients with T1G3 tumors do not represent a homogenous group. Second TUR is recommended in patients with high-grade T1 urothelial bladder carcinoma as it identifies residual disease and invasive disease. Solitary papillary lesions may be the only group where the need for the second TUR is questionable.

Tensor fascia lata flap reconstruction following groin dissection: is it worthwhile?

OBJECTIVE: To compare the morbidity of primary skin closure with elective Tensor Fascia Lata (TFL) flap cover in groin dissections. MATERIALS AND METHODS: This was a retrospective study between January 2007 and December 2009. All patients undergoing groin dissections without skin involvement were included. RESULTS: Of the twenty-five patients, who underwent groin dissections, 14 had primary skin closure (28 groin dissections)-group I. Eleven had TFL flap cover as a means of primary reconstruction (20 groin dissections)-group II. In group I, there were 16 (57%) inguinal dissections and 12 (43%) ilioinguinal block dissections, whereas 82% in group II underwent ilioinguinal dissections (p = 0.09). Wound infection requiring treatment with a culture specific antibiotic was required in 4 (14%) in group I (n = 28) and only 1 (5%) in group II (n = 20) (p = 0.38). In group I, 7 (25%) had major flap necrosis and minor necrosis was seen in another 7 (25%). Only three (15%) in group II developed minor flap necrosis (p = 0.01). Following an ilioinguinal dissection, flap necrosis occurred in 75% of groins that underwent primary closure and in 17% of those which were reconstructed with TFL (p = 0.001). Seroma formation was seen in 5 (18%) in group I and 3 (15%) in group II (p = 1.0). Lymphoedema occurred in equal numbers in both groups. The duration of hospital stay was 20 ± 14 days in the primary closure group and 16 ± 3 days in the TFL group. CONCLUSION: The TFL flap can reduce postoperative morbidity and decrease hospital stay. Prophylactic TFL flap reconstruction following ilioinguinal dissections is advisable.

Outcome of shock wave lithotripsy as monotherapy for large solitary renal stones (>2 cm in size) without stenting.

PURPOSE: To evaluate the outcome of shock wave lithotripsy (SWL) as monotherapy for solitary renal stones larger than 2 cm without ureteral stenting. MATERIALS AND METHODS: Our retrospective study included patients with solitary renal radio opaque stones larger than 2 cm treated with SWL using electromagnetic Dornier Compact S lithotripter device (Wessling, Germany) for a period of 3 years (September 2002-2005). Stone clearance was assessed at 1 week, 1 month, and 3 months with plain X-rays of kidney, ureter, and bladder region, ultrasonography, and tomograms. Stone-free status, morbidity of the procedure, and fate of clinically insignificant residual fragments (CIRF) were studied. A stone-free state was defined as no radiologic evidence of stone. Success was defined as complete clearance + CIRF. RESULTS: Fifty-five patients, aged 11-65 years (mean 49.8) underwent SWL. Of them, only two were children. Male-to-female ratio was 3:1. The stone size was 21-28 mm (average 24 mm). The mean number of shocks were 3732 (range 724-12,100) and average energy level was 14 kV (range 11-16 kV). The mean follow-up was 18 months (range 3-22 months). Over all, stone-free status was achieved in 50% and success in 81% at 3 months. Stone clearance was not affected by stone location. Stones <25 mm had better stone-free rate (54.16% vs. 28.5%) and lesser CIRF (14.6% vs. 28.5%) when compared to larger stones (>26 mm) (P = -0.10). Of 54 patients, 39 developed steinstrasse with mean length of 3.2 cm (range 1.4-6.2 cm) and only four required intervention. Effectiveness quotient (EQ) for SWL monotherapy for solitary renal stones more than 2 cm was 25.3%. The EQ for stones <25 mm and those more than 25 mm were 28.4% and 10% (P = -0.12), respectively. There was a lesser trend of difference between stones with size <25 and more than 25 mm. During the last review, the overall stone-free rate was 67.2%. CONCLUSIONS: SWL monotherapy was safe but significantly less effective for solitary renal stones larger than 2 cm. It can only be suggested to those who refuse surgical intervention. Pretreatment DJ stenting is not mandatory when closer follow-up is ensured.

Factors predicting inguinal node metastasis in squamous cell cancer of penis.

PURPOSE: To identify factors predicting the risk of inguinal metastasis in squamous cell carcinoma of the penis. The therapeutic advantages of early lymphadenectomy in squamous cell carcinoma of the penis must be counterbalanced against its post-operative morbidity. Loss to follow up is a major problem in developing countries. Generating a nomogram based on clinical lymph node status and histopathological findings in the primary tumor could facilitate clinical decision making in the management of penile cancer. METHODS: We prospectively studied 106 patients with penile squamous cell cancer treated from September 2001 to August 2007 at our institution. All patients were offered lymphadenectomy (LAD). A multivariate logistic regression model was used to develop a nomogram. We highlight the problems of loss to follow up in these patients. RESULTS: Of 53 who opted for LAD, 22 had nodal metastasis. The presence of high grade (P = 0.004), lymphovascular invasion (LVI) (P = 0.01) and palpable inguinal lymph nodes (P = 0.05) were the strongest predictors of metastasis. Of 51 who refused LAD, 22 were lost to follow up. Out of these, 16 were at high risk and 9 of them came back with inoperable fungating nodes. A nomogram predicting the risk of lymph node metastasis showed a bias corrected good concordance index (0.74) and good calibration. CONCLUSIONS: High grade and LVI in the tumor along with clinical stage of the inguinal nodes were the strongest predictors of metastasis. These features helped us to develop a nomogram to predict and to identify patients at risk of nodal metastasis.

Detection and treatment of transplant renal artery stenosis.

PURPOSE: To assess the effects of transplant renal artery stenosis (TRAS) on blood pressure, renal function, and graft survival. To assess the usefulness of Doppler in predicting the clinical significance of TRAS and also to identify the predictive factors in Doppler that correlated with clinical features of TRAS. MATERIALS AND METHODS: A prospective study was done on consecutive renal allograft recipients at Christian Medical College, over a period of 66 months from January 2002. All recipients underwent Doppler ultrasound (DUS) evaluation on the fifth post-operative day. Subsequent evaluation was done if the patients had any clinical or biochemical suspicion of TRAS. Angiogram was done in case of a high index of suspicion of significant stenosis or before angioplasty and stenting. The clinical and radiological outcomes of the patients with symptomatic or asymptomatic TRAS were analyzed. RESULTS: Five hundred and forty three consecutive renal allograft recipients were analyzed, of whom, 43 were found to have TRAS. Nine recipients (21%) were detected to have TRAS on first evaluation. All had a high peak systolic velocities (PSV) recorded while 25 of them had other associated features. Patients with only high PSV required no further intervention and were followed up. They had a pretransplant mean arterial pressure (MAP) of 107.83 mmHg (SD = 13.32), ranging from 90 to 133 mm Hg and a posttransplant MAP of 106.56 mmHg (SD =16.51), ranging from 83 to 150 mm Hg. Their mean nadir serum creatinine was 1.16 mg% (SD = 0.24), at detection was 1.6 mg% (SD = 1.84) and at 6 months follow-up was 1.26 mg% (SD=0.52). Of the remaining 25 patients with other associated Doppler abnormalities, 11 required further intervention in the form of re-exploration in 2, angioplasty in 3 and stenting in 6 patients. One patient in the group of patients intervened, expired in the immediate post-operative period due to overwhelming urosepsis and consumption coagulopathy. The mean creatinine clearance (Cockroft-Gault method) in this group of remaining 10 patients, before and after intervention was 44.75 ml/min (SD=17.85) and 68.96 ml/min (SD = 10.56), respectively, with a mean increase by 24.21 ml/min (P=0.000). The mean arterial pressure before and after intervention in this group were 132.80 mm Hg (SD = 13.22) and 102 mm Hg (SD = 10.55), with a decline in the MAP by 30.80 mmHg (P=0.017). The haemoglobin levels also increased from 11.72 (SD=2.13) to 12.48 gm% (SD = 1.75), with a mean increase by 0.76 gm% (P=0.05). CONCLUSIONS: Patients with isolated high PSV do not have a significant alteration of blood pressure or allograft function and required no intervention. Although high PSV with associated Doppler anomalies are more suggestive of significant TRAS, the decision regarding surgical intervention is largely based on clinical assessment.

Emphysematous pyelonephritis: outcome of conservative management.

OBJECTIVES: To identify the prognostic factors, assess the outcome of conservative management, and modify the existing radiologic classification of emphysematous pyelonephritis. METHODS: Forty-one consecutive patients diagnosed with emphysematous pyelonephritis between January 2001 and February 2007 were studied retrospectively. On the basis of computerized tomographic scan they were grouped into four classes (1 to 4). The management was conservative with antibiotics alone or with a combination of percutaneous drainage and antibiotics. RESULTS: Thirty-eight (93%) of a total of 41 patients were diabetic. Escherichia coli (in 97%) was the predominant pathogen identified in pus culture. With antibiotics alone treatment was successful in 40%, and with a combination of percutaneous drainage and antibiotics the success rate was 80%. None underwent nephrectomy as a primary procedure. The risk factors for mortality were thrombocytopenia, shock, altered sensorium, and hemodialysis. In the absence of risk factors the success rate with conservative management was 100%. The mortality rate was 27%, 75%, and 100% in the presence of one, two, and three risk factors, respectively. The mortality rate in class 1, 2, 3, and 4 was 9%, 13%, 50%, and 33% respectively. The overall success rate was 78%. CONCLUSIONS: A combination of percutaneous drainage with antibiotics offers an effective therapy for emphysematous pyelonephritis.

Histopathological analysis of T1 renal cell carcinoma: Does presentation matter?

OBJECTIVES: To study the differences in the clinico-pathological features of incidental and symptomatic T1 renal cell carcinoma (RCC) and to see, particularly in T1b RCC, if symptomatic presentation has adverse pathological features concerning the oncological safety of elective nephron-sparing surgery (NSS) in this subgroup. MATERIALS AND METHODS: Of 278 patients who underwent radical nephrectomy for RCC from January 1995 to January 2005, 70 had tumor size up to 7 cm (T1). They were categorized as incidental or symptomatic and as T1a or T1b tumors. Clinico-pathological features were compared between incidental (IRCC) and symptomatic (SRCC) groups. Tumors were analyzed using the 1997 TNM staging and Fuhrman's grade. RESULTS: Of the 70 with T1 tumors, 24 had T1a (IRCC, 12 and SRCC, 12) and 46 had T1b tumors (IRCC, 27 and SRCC, 19). Clear cell was the commonest histology. In T1a cancers, though no significant difference in histopathological pattern and grade was seen between the incidental and symptomatic groups, symptomatic tumors had more papillary, mixed histopathological pattern and higher nuclear grade. Among T1b tumors, 14 had papillary and mixed histology, 12 (86%) of which were symptomatic (P= <0.0001). In T1b, 15 (79%) symptomatic had higher nuclear grade (G2-3) while 22 (81%) incidental had lower Fuhrman's grade (P= <0.0001). CONCLUSION: Symptomatic T1b RCCs had higher nuclear grade and papillary histology. This difference was statistically significant. This may be relevant when considering elective NSS in symptomatic T1b disease.

Is there a role for tamsulosin in shock wave lithotripsy for renal and ureteral calculi?

PURPOSE: We evaluated the effect of the alpha-blocker tamsulosin on stone clearance, analgesic requirements and steinstrasse in shock wave lithotripsy for solitary renal and ureteral calculus. MATERIALS AND METHODS: A prospective, double-blind, randomized placebo controlled study was performed during 1 year involving 60 patients with a solitary renal or ureteral calculus undergoing shock wave lithotripsy. The control group (30) received 0.4 mg tamsulosin and the study group (30) received placebo daily until stone clearance or for a maximum of 30 days. An oral preparation of dextropropoxyphene hydrochloride and acetaminophen was the analgesic used on an on-demand basis. The parameters assessed were stone size, position, clearance time, effect on steinstrasse and analgesic requirement. RESULTS: The overall clearance rate was 96.6% (28 of 29) in the study group and 79.3% (23 of 29) in the control group (p = 0.04). With larger stones 11 to 24 mm the difference in the clearance rate was significant (p = 0.03) but not so with the smaller stones 6 to 10 mm (p = 0.35). The average dose of analgesic used was lower with tamsulosin than with controls, without statistical significance. Steinstrasse resolved spontaneously in the tamsulosin group whereas 25% (2 of 8) required intervention in the placebo group. There was no difference between the 2 groups with regard to age, stone size or location. CONCLUSIONS: The alpha-blocker tamsulosin seemed to facilitate stone clearance, particularly with larger stones during shock wave lithotripsy for renal and ureteral calculus. It also appeared to improve the outcome of steinstrasse. Tamsulosin may have a potential role in routine shock wave lithotripsy.

Fine-needle aspiration cytology versus open biopsy for evaluation of chronic epididymal lesions: a prospective study.

OBJECTIVE: To compare the efficacy of fine-needle aspiration cytology (FNAC) with that of open biopsy in the evaluation of chronic epididymal lesions. MATERIAL AND METHODS: Forty men evaluated for chronic epididymal lesions were studied. Men aged >25 years who did not intend to father any more children and had had local symptoms for >6 weeks were included. Of these 40 men, 23 who satisfied the above criteria were subjected to FNAC and open biopsy. The slides were reviewed by two independent pathologists. The sensitivity, specificity and positive predictive value of FNAC were compared with the results of open biopsy. RESULTS: Tuberculous epididymitis was the commonest cause of chronic epididymal lesions, followed by non-specific epididymitis, sperm granuloma, epdidymal cyst and normal epididymis. The sensitivity and specificity of FNAC for the diagnosis of tuberculous epididymitis were 87% and 93%, respectively. For the diagnosis of non-specific epididymitis, FNAC was 100% sensitive and 100% specific. The positive predictive value was 87% for the diagnosis of both tuberculous and non-specific epididymitis. CONCLUSIONS: FNAC has an overall sensitivity and specificity of 90% for diagnosing chronic epididymal lesions, with a positive predictive value of 87.5%. It is a valuable tool for evaluating chronic epididymal lesions. We suggest that FNAC should be the first-choice investigation for establishing the histopathological diagnosis of epididymal lesions.

Radiographic anatomical factors do not predict clearance of lower caliceal calculus by shock-wave lithotripsy.

OBJECTIVE: Use of shock-wave lithotripsy (SWL) for lower caliceal calculus is associated with a relatively high rate of residual fragments. Various radiographic anatomical factors of the lower calix predicting the outcome of lithotripsy have been described and have generated considerable discussion. We aimed to reassess the role of these factors in predicting clearance of lower caliceal stones by SWL. MATERIAL AND METHODS: Between January 1998 and December 2001, 148 patients underwent SWL for solitary lower caliceal stones using a Dornier Compact S lithotripter. The infundibular length, infundibular width, caliceopelvic height and infundibulopelvic angle were measured. Success was defined as either complete clearance or clearance with insignificant residual fragments <4 mm in size at 3 months follow-up. The results were analysed using the chi2 test and logistic regression analysis. RESULTS: Complete clearance was seen in 69% of cases and clearance with residual fragments <4 mm in size at 3 months was seen in 5%. The overall clearance rate at 3 months was 74%. Infundibular length, infundibular width, caliceopelvic height and stone size were not found to be statistically significant in predicting clearance. None of the patients had an infundibulopelvic angle of >90 degrees. Contrary to most previous studies, univariate and multivariate analysis revealed that an infundibulopelvic angle of <70 degrees was statistically significant in predicting clearance in the stone-free group. CONCLUSIONS: The use of radiographic anatomical factors to predict clearance of lower caliceal stones following SWL is an attractive concept. However, based on this study, we feel that these factors do not merit the attention they have attracted. In routine practice, regardless of the radiological anatomy, SWL continues to be the initial treatment option, given its non-invasive nature and ease of administration.

Stone-bearing live-donor kidneys for transplantation.

OBJECTIVE: To evaluate potential donor kidneys with asymptomatic calculi detected during screening, and the management of the calculus before, during and after transplantation, as with fewer live donors, marginal kidneys and donors are a significant subgroup in renal transplantation. PATIENTS AND METHODS: Five live-related donors, with one incidentally detected calculus during their routine evaluation, were accepted for transplantation. Of these, three were detected only on spiral computed angiography. There was no biochemical evidence of a metabolic abnormality or history of stone disease. One donor had elective lithotripsy and another nephrolithotomy under ultrasonographic control immediately after perfusion. The others were transplanted with the calculus in situ. Ureteric reimplantation was by the Leadbetter-Politano technique over a JJ stent. RESULTS: One recipient patient passed the calculus within 4 h of stent removal. The follow-up ultrasonogram at 3 months showed a stone in only one recipient. In the others, the calculus could not be seen after stent removal. The maximum follow-up was 2 years and graft function has remained normal in all. CONCLUSIONS: Voluntary kidney donors with one calculus incidentally detected on routine evaluation form a unique group and can be accepted for transplantation in selected cases. Careful follow-up of the donor and recipient is essential, with early intervention if necessary.