Incidence of Ureteric strictures Following Ureteroscopic Laser Lithotripsy: Holmium:YAG Versus Thulium Fiber Laser.

OBJECTIVE: We aimed to compare the incidence of ureteric strictures between holmium:yttrium aluminum garnet and thulium fiber laser following ureteroscopic laser lithotripsy. In the present era of miniaturization of endourologic armamentarium and better optics, how safe are lasers to fire inside ureter? MATERIALS AND METHODS: It is a prospective comparative study over a period of 2 years that included patients who underwent ureteroscopic laser lithotripsy for ureteric stones. Patients were randomly divided into 2 groups: group A underwent holmium:yttrium aluminum garnet laser lithotripsy and group B underwent thulium fiber laser lithotripsy. RESULTS: A total of 478 patients were analyzed after excluding patients not willing to participate and patients lost to follow-up. Two hundred forty patients underwent holmium:yttrium aluminum garnet laser lithotripsy (group A) and 238 patients underwent thulium fiber laser lithotripsy (group B). The demographic data of 2 groups were comparable. The mean age of patients in group A and group B was 36.5 ± 12.52 years and 38.62 ± 10.71 years, respectively. The mean operative time in group A and group B was 47 ± 15 and 36 ± 13 minutes, respectively, while the mean laser time in group A and group B was 13.5 ± 45 minutes and 9.25 ± 3.2 minutes, respectively. Four (1.67%) patients in group A and 11 (4.62%) patients in group B developed ureteric strictures during follow-up, and the difference was statistically significant (P <.001). The mean length of stricture was 2.67 ± 1.27 cm in group A and 4.42 ± 2.2 cm in group B, and the difference was statistically significant. CONCLUSION: Thulium fiber laser, projected as safe laser previously, has a higher incidence of ureteric strictures compared to holmium:yttrium aluminum garnet laser when used for ureteroscopic laser lithotripsy.

"Collaterals a savior" in superior mesenteric artery injury post radical nephrectomy and retroperitoneal lymph node dissection.

Superior Mesenteric Artery (SMA) during renal surgery is rarely reported but potentially devastating complication. It can rarely occur in patients with distorted vascular anatomy like in large left renal tumors with vascular infiltration and bulky lymphadenopathy, or in the setting of re-do surgery with extensive scarring. Failure to recognize and repair an SMA injury may result in ischemic bowel and consequently high mortality. Herein, we present a case scenario of injury to the SMA during radical nephrectomy missed intraoperatively and managed conservatively in the post-operative period in view of collateral circulation to the gut.

Massive perinephric hematoma - A rare complication of extracorporeal shock wave lithotripsy.

Extracorporeal shock wave lithotripsy is commonly used to fragment renal calculi. This treatment modality is considered safe with minimal complications. We report a case of massive retroperitoneal hematoma following extracorporeal shock wave lithotripsy in a patient with no comorbidity and normal coagulation parameters. Patient was managed conservatively and had excellent recovery with normal renal function.

Etiopathogenic Models of Psychosis Spectrum Illnesses Must Resolve Four Key Features.

Etiopathogenic models for psychosis spectrum illnesses are converging on a number of key processes, such as the influence of specific genes on the synthesis of proteins important in synaptic functioning, alterations in how neurons respond to synaptic inputs and engage in synaptic pruning, and microcircuit dysfunction that leads to more global cortical information processing vulnerabilities. Disruptions in prefrontal operations then accumulate and propagate over time, interacting with environmental factors, developmental processes, and homeostatic mechanisms, eventually resulting in symptoms of psychosis and disability. However, there are 4 key features of psychosis spectrum illnesses that are of primary clinical relevance but have been difficult to assimilate into a single model and have thus far received little direct attention: 1) the bidirectionality of the causal influences for the emergence of psychosis, 2) the catastrophic clinical threshold seen in first episodes of psychosis and why it is irreversible in some individuals, 3) observed biotypes that are neurophysiologically distinct but clinically both convergent and divergent, and 4) a reconciliation of the role of striatal dopaminergic dysfunction with models of prefrontal cortical state instability. In this selective review, we briefly describe these 4 hallmark features and we argue that theoretically driven computational perspectives making use of both algorithmic and neurophysiologic models are needed to reduce this complexity and variability of psychosis spectrum illnesses in a principled manner.

A childhood blast victim presenting with bladder stone in adulthood-A rare case report of retained blast fragment with secondary stone.

Secondary bladder stones in young adults are usually a result of bladder outlet obstruction secondary to urethral stricture disease or neurogenic bladder. Foreign body inside bladder is a perfect nidus for the development of secondary bladder stone. We report a rare case of bladder stone in a young adult developing on the retained blast fragment inside bladder.

Comparison of percutaneous nephrolithotomy under epidural anesthesia versus general anesthesia: A randomized prospective study.

INTRODUCTION: PCNL has revolutionized the treatment of renal calculi putting almost an end to the era of open stone surgery. The procedure can safely be carried out under general anesthesia (GA) or regional anesthesia viz. spinal anesthesia (SA), epidural anesthesia (EA) or combined spinal and epidural anesthesia (CSE). AIMS AND OBJECTIVES: We evaluated the surgical outcome after PCNL in two groups of patients randomly divided to undergo procedure under GA or EA. PATIENTS AND METHODS: Two hundred and thirty patients with American Society of Anesthesiologists (ASA) score <3 were randomly divided into two groups according to the type of anesthesia: i.e. GA (n=110) or EA (n=120). All patients underwent PCNL in prone position. Puncture was done using Bulls eye technique under fluoroscopic guidance and tract dilated using serial dilators up to 24Fr-28 Fr. Demographics, perioperative and postoperative parameters were noted and data analysed. RESULTS: The two groups were comparable in terms of mean age, distribution of stone location, and stone burden. The stone free rate was 90.9% in GA group and 89.2% in EA group and the difference was statistically insignificant (P= 0.659). The requirement for auxiliary procedures was similar between the two groups. A significant difference in pain score was seen in favor of EA group during early post-operative period (P< 0.05). CONCLUSION: It seems that PCNL can be performed safely and effectively under regional epidural anesthesia with results comparable to general anesthesia with the added advantage of less immediate postoperative pain and analgesic requirement.

Significant Implications of APOA1 Gene Sequence Variations and Its Protein Expression in Bladder Cancer.

Apolipoprotein A1 (APOA1) is a potential biomarker because of its variable concentration in different types of cancers. The current study is the first of its kind to evaluate the association between the APOA1 genotypes of -75 G/A and +83 C/T in tandem with the APOA1 protein expression in urine samples to find out the risk and potential relationship for differentially expressed urinary proteins and APOA1 genotypes. The study included 108 cases of bladder tumors and 150 healthy controls that were frequency matched to cases with respect to age, sex, and smoking status. Genotyping was performed using PCR-RFLP and the urinary expression of the APOA1 protein was done using ELISA. Bladder tumor cases were significantly associated with the APOA1 -75 AA genotype (p < 0.05), while the APOA1 +83 C/T heterozygotes showed an association with cases (p < 0.05). The overall distribution of the different haplotypes showed a marked difference between the cases and controls in GT when compared with the wild type GC (p < 0.03). Bladder tumor cases that carried the variant genotype APOA1 -75AA were found more (70.0%) with a higher expression (≥20 ng/mL)of the APOA1 urinary protein and differed significantly against wild type GG (p = 0.03). Again, in low grade bladder tumors, urinary APOA1 protein was exhibited significantly more (52.4% vs. 15.4% high grade) with a higher expression (≥20 ng), while high grade tumor cases (84.6% vs. 47.5% low grade) showed a lower APOA1 expression (<20 ng/mL) (O.R = 6.08, p = 0.002). A strong association was observed between APOA1 -75G/A and risk for bladder tumor and its relation to urinary protein expression, which substantiates its possible role as a marker for the risk assessment of the disease and as a promising diagnostic marker for different grades of malignant bladder tumors.

Wave-like dopamine dynamics as a mechanism for spatiotemporal credit assignment.

Significant evidence supports the view that dopamine shapes learning by encoding reward prediction errors. However, it is unknown whether striatal targets receive tailored dopamine dynamics based on regional functional specialization. Here, we report wave-like spatiotemporal activity patterns in dopamine axons and release across the dorsal striatum. These waves switch between activational motifs and organize dopamine transients into localized clusters within functionally related striatal subregions. Notably, wave trajectories were tailored to task demands, propagating from dorsomedial to dorsolateral striatum when rewards are contingent on animal behavior and in the opponent direction when rewards are independent of behavioral responses. We propose a computational architecture in which striatal dopamine waves are sculpted by inference about agency and provide a mechanism to direct credit assignment to specialized striatal subregions. Supporting model predictions, dorsomedial dopamine activity during reward-pursuit signaled the extent of instrumental control and interacted with reward waves to predict future behavioral adjustments.

The Description of Urodynamic Study for Bladder Dysfunction in Compressive Myelo- or Radiculo-pathy: A Prospective Study in an Institutional Setup.

PURPOSE: To study the significance of filling cystometry with pressure flow studies and bladder electromyography (EMG) in assessment and management of neurogenic bladder with myelopathies and evaluated neurological recovery in the follow-up period. METHODS: The study was a 3-year prospective urodynamic study in 63 patients, with traumatic and nontraumatic myelopathy. Bladder management was advised based on the cystometric findings. Neurological recovery and mode of bladder management were evaluated during follow-up after a minimum of 6 months. RESULTS: Mean age was 44.6 years (range 10-80 years). Thoracolumbar area was most commonly involved. Cystometry revealed overactive detrusor in 46 patients, (17 had detrusor sphincter dyssynergia [DSD], 29 without DSD) and areflexic/underactive detrusor in 9 patients. Postvoid residual (>15% of voided urine) was significant in 27 patients. Neurological recovery was seen in 60.3%, whereas 22.2% showed no improvement (partial improvement in 4.8%) and 12.6% had normal bladder function both initially and at follow-up. Correlation between neurological recovery and bladder management was found to be insignificant (P > 0.05) using spearman's correlation coefficient. CONCLUSION: Filling cystometry with pressure flow studies and EMG study is valuable for the assessment and management of neurogenic bladder in patients with myelopathy. In neurogenic bladder management and follow-up, pressure flow studies help to prevent complications and upper urinary tract complications.

Publisher Correction: Dissociable dopamine dynamics for learning and motivation.

Change history: In this Article, an extraneous label appeared in Fig. 4b, and has been removed in the online version.

Dissociable dopamine dynamics for learning and motivation.

The dopamine projection from ventral tegmental area (VTA) to nucleus accumbens (NAc) is critical for motivation to work for rewards and reward-driven learning. How dopamine supports both functions is unclear. Dopamine cell spiking can encode prediction errors, which are vital learning signals in computational theories of adaptive behaviour. By contrast, dopamine release ramps up as animals approach rewards, mirroring reward expectation. This mismatch might reflect differences in behavioural tasks, slower changes in dopamine cell spiking or spike-independent modulation of dopamine release. Here we compare spiking of identified VTA dopamine cells with NAc dopamine release in the same decision-making task. Cues that indicate an upcoming reward increased both spiking and release. However, NAc core dopamine release also covaried with dynamically evolving reward expectations, without corresponding changes in VTA dopamine cell spiking. Our results suggest a fundamental difference in how dopamine release is regulated to achieve distinct functions: broadcast burst signals promote learning, whereas local control drives motivation.

Mesolimbic dopamine signals the value of work.

Dopamine cell firing can encode errors in reward prediction, providing a learning signal to guide future behavior. Yet dopamine is also a key modulator of motivation, invigorating current behavior. Existing theories propose that fast (phasic) dopamine fluctuations support learning, whereas much slower (tonic) dopamine changes are involved in motivation. We examined dopamine release in the nucleus accumbens across multiple time scales, using complementary microdialysis and voltammetric methods during adaptive decision-making. We found that minute-by-minute dopamine levels covaried with reward rate and motivational vigor. Second-by-second dopamine release encoded an estimate of temporally discounted future reward (a value function). Changing dopamine immediately altered willingness to work and reinforced preceding action choices by encoding temporal-difference reward prediction errors. Our results indicate that dopamine conveys a single, rapidly evolving decision variable, the available reward for investment of effort, which is employed for both learning and motivational functions.

An isolated renal hydatid cyst in a 6-year-old child: A rare case report.

Isolated involvement of the kidney is rare in hydatid disease and is even rarer in children. We present a case of primary right renal hydatid cyst in 6-year-old female child who presented with pain right flank of 4 months duration. The patient was managed by nephrectomy.

µ-Opioid receptors within subregions of the striatum mediate pair bond formation through parallel yet distinct reward mechanisms.

The prairie vole is a socially monogamous rodent that is an excellent animal model for studies of the neurobiology of social attachment. Such studies have demonstrated that activation of reward circuitry during social interactions facilitates pair bond formation. Within this circuitry, µ-opioid receptors (MORs) modulate naturally rewarding behavior in an anatomically segregated manner; MORs located throughout the striatum (dorsal striatum, NAc core, and the entire NAc shell) are implicated in general motivational processes, whereas those located specifically within the dorsomedial NAc shell mediate positive hedonics (and are referred to as a "hedonic hotspot"). The purpose of the present study was to determine whether MORs within these distinct subregions differentially mediate pair bond formation. We first used receptor autoradiography to compare MOR binding densities between these regions. MOR binding was significantly higher in the NAc core and dorsomedial NAc shell compared with the ventral NAc shell. We next used partner preference testing to determine whether MORs within these subregions differentially mediate pair bonding. Blockade of MORs using 1 or 3 µg of H-d-Phe-Cys-Tyr-d-Trp-Arg-Thr-Pen-Thr-NH2 within the dorsal striatum decreased mating during the cohabitation period and inhibited partner preference formation. In contrast, blockade of MORs within dorsomedial NAc shell inhibited partner preference formation without effecting mating behavior, whereas other regions were not involved. Thus, MORs within the dorsal striatum mediate partner preference formation via impairment of mating, whereas those in the dorsomedial NAc shell appear to mediate pair bond formation through the positive hedonics associated with mating.

Oxygen modulation of neurovascular coupling in the retina.

Neurovascular coupling is a process through which neuronal activity leads to local increases in blood flow in the central nervous system. In brain slices, 100% O(2) has been shown to alter neurovascular coupling, suppressing activity-dependent vasodilation. However, in vivo, hyperoxia reportedly has no effect on blood flow. Resolving these conflicting findings is important, given that hyperoxia is often used in the clinic in the treatment of both adults and neonates, and a reduction in neurovascular coupling could deprive active neurons of adequate nutrients. Here we address this issue by examining neurovascular coupling in both ex vivo and in vivo rat retina preparations. In the ex vivo retina, 100% O(2) reduced light-evoked arteriole vasodilations by 3.9-fold and increased vasoconstrictions by 2.6-fold. In vivo, however, hyperoxia had no effect on light-evoked arteriole dilations or blood velocity. Oxygen electrode measurements showed that 100% O(2) raised pO(2) in the ex vivo retina from 34 to 548 mm Hg, whereas hyperoxia has been reported to increase retinal pO(2) in vivo to only ~53 mm Hg [Yu DY, Cringle SJ, Alder VA, Su EN (1994) Am J Physiol 267:H2498-H2507]. Replicating the hyperoxic in vivo pO(2) of 53 mm Hg in the ex vivo retina did not alter vasomotor responses, indicating that although O(2) can modulate neurovascular coupling when raised sufficiently high, the hyperoxia-induced rise in retinal pO(2) in vivo is not sufficient to produce a modulatory effect. Our findings demonstrate that hyperoxia does not alter neurovascular coupling in vivo, ensuring that active neurons receive an adequate supply of nutrients.

Liposarcoma of the spermatic cord: a rare entity.

Primary malignant tumours of spermatic cord are rare. The liposarcoma of spermatic cord is a rare entity and only a few cases have been reported in the literature. We report a case of forty five-year-old male with huge left inguinoscrotal swelling. Fine needle aspiration cytology (FNAC) of swelling revealed the diagnosis of a liposarcoma. The patient was subjected to radical orchidectomy and wide excision. Histopathological examination (HPE) of the resected specimen reported a well-differentiated liposarcoma of the spermatic cord and confirmed the diagnosis.

Role of NMP22 Bladder Check Test in early detection of bladder cancer with recurrence.

AIM: To assess clinical utility of NMP22 Bladder Check Test and to compare it with voided urine cytology and cystoscopy in early detection of Bladder Cancer. MATERIAL AND METHODS: A total of 115 patients of follow up cases of bladder cancer were enrolled in this study. Urine samples were assayed for the presence of NMP22 using NMP22 Bladder Check Test and cytology was performed by a cytopathologist. The diagnosis, determined from the cystoscopic findings and biopsy findings of the suspicious lesion was considered as the gold standard. For positive biopsies, the results of the NMP22 Test and cytology were also correlated with tumour grade and stage. RESULTS: Mean age of the patients was 57.2 years for males and 55.3 years for females. A total of 59 cases of transitional cell carcinomas (TCCs) were diagnosed among which NMP22 test was positive in 48 cases and cytology in 26 cases. The sensitivity and specificities of NMP22 Test in recurrent bladder cases was 81.3% and 92% which was significantly greater than that of cytology 44% and 96.1% respectively. In non-invasive lesions of TCC, NMP22 Test and cytology was positive in 71.8% and 42.8% of cases respectively. In muscle-invasive lesions, NMP22 Test was positive in 82.2% and 44.4% cases were positive for cytology. The sensitivity of the NMP22 test was 81.3%, which was significantly greater than that of cytology at 44%. CONCLUSION: The NMP22 Bladder Check is a new point of care diagnostic test for urinary bladder cancer. The results of our study have shown that the NMP22 can be used as a substitute for urine cytology as we achieved high sensitivity and specificity with recurrent bladder cases.

Promoter methylation profile of GSTP1 and RASSF1A in benign hyperplasia and metastatic prostate cancer patients in a Kashmiri population.

Promoter hypermethylation is a marginal approach to inactivating tumor suppressor genes in cancer. DNA hypermethylation is a well-recognized epigenetic malfunction observed in several malignancies, most predominantly in prostate cancer. Aberrant DNA methylation patterns are considered to be the earliest somatic genome changes in prostate cancer. The function of promoter hypermethylation in malignant transformation of the prostate has been widely studied, from its presence in benign hyperplasia (BHP) to development and to the advanced stages of tumor formation. In the present study, we examined the promoter hypermethylation status of the glutathione S-transferase P1 (GSTP1) and RASSF1A genes in 45 BHP samples, 50 proven prostate tumor samples and 80 normal samples. Hypermethylated GSTP1 was found in 29/50 (58.0%) prostate carcinoma cases and 12/45 (26.6%) BHP cases. The RASSF1A gene was methylated in 17/50 (34.0%) prostate cancer samples and 7/45 (15.5%) BHP samples. On the basis of these findings, we propose that the epigenetic regulation of the GSTP1 and RASSF1A genes through promoter hypermethylation may play a crucial role in the progression of prostate cancer, and has probable involvement in BHP.

Comparative study of various forms of urinary diversion after radical cystectomy in muscle invasive carcinoma urinary bladder.

OBJECTIVE: To compare the three types of urinary diversion namely Ileal Conduit, MAINZ Pouch II and Ileal Neobladder in terms of patient preference, post-operative hospital stay, early and late complications, continence rates, quality of life and patient satisfaction. METHOD: From January 2003 to October 2007, 30 patients (28 males and 2 females) of muscle invasive carcinoma urinary bladder (mean age 57.7 years) were operated upon by radical cysto- prostatectomy or anterior pelvic exenteration and urinary diversion was performed by Ileal conduit, Mainz pouch II or Ileal neobladder. The patient preference for the type of diversion was determined pre-operatively after discussing all the three types of urinary diversions. Post-operative hospital stay, early and late complications, continence rates, quality of life and patient satisfaction with the type of diversion were evaluated on follow up. RESULTS: 60% of the patient's preferred Ileal neobladder, 10% preferred Ileal conduit and 10% preferred Mainz pouch II as their 1st choice diversion; 20% left the decision to the operating surgeon. The mean post-operative hospital stay was 15.0 days in Ileal conduit group, 17.8 days in Mainz pouch II group and 19.7 days in Ileal neobladder group. The mean follow up was 27.7 months. Early complications (within 1 month of surgery) were observed in 46.2% of patients in Ileal conduit group, 38.5% in Mainz pouch II group and 50.0% in Ileal neobladder group. Late complications (after 1 month of surgery) were seen in 61.5% of patients in Ileal conduit group, 46.2% in Mainz pouch II group and 50.0% in Ileal neobladder group. In Mainz pouch II group 92.3% of the patients achieved daytime continence and 84.6% achieved night time continence 3 to 6 months after surgery. In Ileal neobladder group, 75.0% patients achieved day time continence and 50.0% achieved night time continence 3 to 6 months after surgery. Patient satisfaction and overall quality of life was described 'Good' by majority of patients in Ileal conduit group and 'Very Good' by majority of patients in Mainz pouch II group and Ileal neobladder group. CONCLUSION: There are inherited advantages and disadvantages to each form of urinary diversion and patient selection is important to identify the most appropriate method of diversion for an individual.

An Evaluation of Use of Trans-Obturator Tape (TOT) Sling Procedure in the Current Surgical Management of Female Stress Urinary Incontinence.

OBJECTIVE: To assess the role of TOT sling procedure in current surgical management of female Stress Urinary Incontinence (SUI) in terms of post-operative results, cost effectivenss, pt acceptance and complications. METHOD: From June 2006 to September 2008, 30 patients of SUI were treated surgically by TOT-sling procedure. Pre-operatively the patients were evaluated by thorough history taking, clinical examination and different diagnostic test depending upon the individual clinical scenario. Patients were explained in their own language the nature of procedure and the principle behind it. Any complication(s) (intra/postoperative) were noted. After discharging the patients they were followed up by atleast 3 visits (follow-up visits) at 1, 3 & 6 month interval. Any complications of the procedure and patient acceptance were evaluated at each follow-up. RESULTS: The mean age of the total patients (n=30) was 39.5 yrs and 28 (93.33%) were multiparous. Involuntary loss of urine on straining was the most common complaint present in 25 (83.33%) patients and 22 (73.33) patients were having duration of symptoms less than 3 yrs. 9 (30%) patients were having mild cystocele pre-operatively which resolved after surgery. All the 30 (100%) patients were continent post-operatively while 7 (23.33%) were having lower urinary tract symptoms (LUTS). No major intra/post-operative complication was seen but, urgency, dysuria, fever and haematuria was seen post-operatively which resolved after few days. The operative time was 24 ± 3.8 months and catheter was removed on 2.7 ± 1.7 days post-operatively. Hospital stay was 6 ± 2.4 days (3 - 11) and app. Cost of the treatment was Rs3253 ± 360 (2700,3900). CONCLUSION: TOT Sling procedure is currently the Gold Standard for management of female SUI. It is very important to diagnose SUI and rule out other causes of incontinence because only the former one (Genuine SUI) is improved by TOT sling and other types may be even worsened by this procedure.