Safety and efficacy of bipolar versus monopolar transurethral resection of bladder tumor: a systematic review and meta-analysis.

PURPOSE: Transurethral resection of bladder tumor is the standard of care for the management of patients with bladder mass. Primary objective of this study was to compare safety and efficacy of the two energy modalities used for TURBT (monopolar and bipolar). MATERIALS AND METHODS: Systematic literature search of various electronic databases was conducted to include all the randomized studies comparing two groups. Standard PRISMA (Preferred reporting Items for Systematic reviews and Meta-analysis) guidelines were pursued for this review and study protocol was registered with PROSPERO (CRD42019139987). RESULTS: In the present review, eight RCTs including 1147 patients were included. Resection time, hospital stay and catheter duration were significantly shorter with bipolar group. There was no significant difference in incidence of obturator reflex (OR 0.65, CI [0.35, 1.2], p = 0.17), whereas incidence of bladder perforation was significantly higher in the monopolar group (6.4% versus 3.3%, p = 0.01. However, sensitivity analysis including 3 high quality studies revealed equal incidence of bladder perforations. Need for blood transfusion was similar in the two groups but fall in hemoglobin was significantly lower in bipolar group (MD - 0.45 CI [- 0.72, - 0.18], p = 0.0009). Bipolar group was found to have significantly lower incidence of tissue artifacts due to thermal energy on pathological examination (OR 0.27 CI [0.15, 0.47], p < 0.00001). CONCLUSIONS: Bipolar and monopolar devices are equally safe in terms of obturator jerk and bladder perforation. Bipolar group was significantly better as compared to monopolar for hospital stay, catheter duration and fall in hemoglobin; however, the clinical relevance of most of these parameters is little.

Development and validation of a novel prediction model for predicting renal function recovery after diversion in patients with obstructive uropathy.

OBJECTIVE: To develop and validate a novel prediction model predicting renal function recovery following diversion in patients with obstructive uropathy (OU) to the emergency department (ED). METHODS: After a systematic literature search, a novel prediction model called PGIMER Obstructive Uropathy Score (POUS) was constructed including five variables: age (<60 or >60 years), duration of symptoms (<4 or >4 weeks), presence of solitary functioning kidney, baseline hemoglobin levels and venous blood pH. This model was then validated in a prospective, observational single-center study of patients presenting with OU caused by various etiologies. Patients with OU and raised serum creatinine (>2 mg/dL) presenting to our ED were included. Renal function recovery was defined as creatinine value <1.5 mg/dL at 4 weeks following diversion. RESULTS: In this study, 174 consecutive patients with OU were recruited, and 74 (42.5%) patients had renal function recovery. All the variables included in the POUS were noted to be statistically significant on univariate analysis. On multivariate logistic regression analysis, only POUS was identified as an independent predictor of renal function recovery. On receiver operating curve analysis, the area under the curve for POUS was 0.832 for predicting recovery. A POUS of 5 or more had specificity and sensitivity of 83% and 73.6%, respectively, in predicting renal function recovery. The goodness of fit and calibration plots showed good concordance of the predicted values with the observed values. CONCLUSIONS: The POUS model is an accurate and simple-to-use tool for predicting renal function recovery. POUS model requires external validation prior to clinical use in different populations.

Comparison of efficacy of various drugs used for medical expulsive therapy for distal ureter stones: A systematic review and network meta-analysis.

OBJECTIVES: Medical expulsive therapy has been found to be effective for distal ureteric stones; however, which drug is most efficacious in terms of stone expulsion rate (SER) and stone expulsion time (SET) is not known. With this review we aimed to compare the efficacy of various drug treatments for distal ureter stones used as medical expulsive therapy in terms of SER and SET. METHODS: Systematic literature search was conducted to include all the randomised study comparing various drug interventions for lower ureter stones. Standard preferred reporting items for systematic review and meta-analysis for network meta-analysis (PRISMA-NMA) were pursued. RESULTS: In this review, 50 randomised studies with 12,382 patients were included. For stone expulsion rate (SER), compared with placebo all the treatment groups were more effective except nifedipine and sildenafil. According to the SUCRA values obtained, naftopidil plus steroid was the highest rank and nifedipine lowest. For stone expulsion time (SET), compared with placebo only tadalafil plus silodosin, nifedipine plus steroid, alfuzosin, silodosin, tadalafil and tamsulosin were more effective. SUCRA values were highest for tadalafil plus silodosin and least for naftopidil plus steroid. From subgroup analysis with individual drugs for SER, SUCRA values were highest for naftopidil followed by silodosin and SET was highest for silodosin and least for naftopidil. CONCLUSION: For lower ureter stone, tadalafil plus silodosin is the best combination and silodosin best individual drug considering the SET and SER. Nifedipine as monotherapy is no more effective than control group.

Safety and efficacy of "on-demand" tramadol in patients with premature ejaculation: an updated meta-analysis.

INTRODUCTION: Tramadol has been used for the treatment of premature ejaculation, however, the studies published for the same are not well designed. The primary objective of this study was to explore the literature pertaining to the use of tramadol in patients with PE to determine its safety and efficacy in this population. Materials ande methods: Systematic literature search of various electronic databases was conducted to include all the randomized studies and quasi-randomized studies. Standard PRISMA (Preferred reporting Items for Systematic reviews and Meta-analysis) guidelines were pursued for this review and study protocol was registered with PROSPERO (CRD42019123381). RESULTS: Out of 9 studies included in this review, 5 were randomized controlled trials, and rests of the 4 studies were quasi-randomized studies. Tramadol resulted in significantly higher improvement of IELT with the mean difference (MD) of 139.6 seconds and confidence interval (CI) 106.5-172.6 seconds with a p-value of p < 0.00001. All dosages except 25mg fared well as compared to placebo. Tramadol fared better than placebo at 1 month, 2 months, and 3 months after initiation of therapy as compared to the placebo. Tramadol group had reported a significantly higher number of adverse events with treatment as compared to placebo but none of them were serious. CONCLUSION: Tramadol appears to be an effective drug for the management of PE with a low propensity for serious adverse events. However, evidence obtained from this study is of low to moderate quality. Furthermore, effective dose and duration of therapy remain elusive.

Role of phosphodiesterase inhibitors in stent-related symptoms: a systematic review and meta-analysis.

PURPOSE: Stent-related symptoms are frequent following stent placement for various indications. Use of PDE inhibitors has expanded beyond their classical indication and has been tried in patients with stent-related symptoms. The systematic review was conducted to ascertain the efficacy of PDE inhibitors in ameliorating stent-related symptoms. METHODS: We performed systematic review and metanalysis on the use of PDE inhibitors for stent-related symptoms in patients who underwent stent placement for various reasons (postpercutaneous nephrolithotomy or ureterorenoscopy). We followed PRISMA guidelines while conducting this review and study protocol was registered with PROSPERO (CRD42019121781) RESULTS: Three studies with 280 participants were included in this review. There was considerable heterogeneity across all the outcome parameters assessed; thus, random-effect model was used for analysis. Comparison of PDE inhibitors with control arm revealed that PDE inhibitors were significantly more effective than placebo in all but one domain (Work performance) of the USSQ. On comparison with alfa blockers, PDE inhibitors were found to be equally effective for urinary symptoms, general health, and body pain parameters, but sexual health parameters improved significantly with PDE inhibitors. CONCLUSION: PDE inhibitors can be considered an option for patients with stent-related symptoms especially in patients with sexual dysfunction. Due to various limitations of the studies included in this review, we recommend conducting further high-quality studies.

A neglected reddish penile patch: A wolf in sheep's clothing.

Microinvasive squamous cell carcinoma (SCC) is a known premalignant lesion of carcinoma cervix. It is also reported from other sites such as the oral cavity, larynx, and vulva. Microinvasive SCC is very rarely reported from the penis. We report the occurrence of microinvasive SCC in a long-standing erythematous lesion of glans penis in a patient, with extensive metastasis. We emphasize the need for awareness among patients and urologists about the premalignant lesions of penis and prompt treatment of such lesions to prevent possible spread of the disease.

STAMPEDEing metastatic prostate cancer: CHAARTing the LATITUDEs.

With the emergence of recent landmark trials, the treatment for hormone-sensitive metastatic prostate cancer (hsMPC) is changing from androgen deprivation therapy (ADT) alone to combination therapy. Both, docetaxel chemotherapy and abiraterone in addition to ADT have been extensively studied in well-conducted randomized controlled trials and were shown to improve outcomes. However, this paradigm shift in the treatment has also raised some queries. This mini review reflects upon the four landmark trials and tries to provide some perspective about the decision-making process for the patients with hsMPC.

Comparison of RENAL, PADUA, and C-index scoring systems in predicting perioperative outcomes after nephron sparing surgery.

INTRODUCTION AND OBJECTIVE: The RENAL, PADUA and centrality index (C-index) nephrometry scoring systems (SS) have been individually evaluated for their role in predicting trifecta outcomes after nephron-sparing surgery (NSS). However, there is little data on their comparative superiority. The present study was designed to evaluate the predictive value of three SS and to assess interobserver reliability. MATERIALS AND METHODS: Fifty patients undergoing NSS at our center between January 2014 and April 2016 were included in the study. The demographic details were noted. Images (computed tomography [CT] scans or magnetic resonance imaging) were reviewed by a urologist and a radiologist independently and RENAL, PADUA, and C-index were calculated. The correlation between these scoring system and trifecta outcomes were calculated. RESULTS: The RENAL and PADUA score did not correlate with any of the perioperative parameters. However, C-index had a significant correlation with operative time (OT) (P = 0.02) and trifecta outcomes (P < 0.05). There was an excellent concordance between the two observers in scoring the RENAL score (α = 0.915; intraclass correlation coefficient [ICC] = 0.814) and PADUA score (α = 0.816; ICC = 0.689 [P < 0.001]). There was lesser although acceptable concordance in the calculation of C-index (ICC -0.552; α -0.711). CONCLUSIONS: There is good correlation among all the 3 SS. C-index has lower reproducibility due to difficult mathematical calculation but correlated best with trifecta outcomes.

Robot-assisted vesicovaginal fistula repair: a safe and feasible technique.

INTRODUCTION AND HYPOTHESIS: Open transabdominal repair of vesicovaginal fistula (VVF) requires a long cystotomy incision, suprapubic drainage and delayed recovery. Laparoscopic repair is limited by difficult suturing in pelvic procedures. Therefore, the utility of robotic assistance is being increasingly explored. We share our initial experience of robot-assisted laparoscopic VVF repair. METHODS: The data from patients who underwent robot-assisted VVF repair from December 2014 to August 2016 were recorded and analyzed. Patients underwent standard preoperative evaluation. After cystovaginoscopy and placement of an access catheter across the fistula, a four-port transperitoneal approach was used. Following adhesiolysis, limited posterior cystotomy was performed. The vaginal and bladder flaps were separated and repaired in the transverse and vertical directions, respectively. V-Loc sutures were used for bladder closure. Omental/sigmoid colon epiploicae or a peritoneal flap was interposed. A pelvic drain was placed. RESULTS: During the study period, 30 patients underwent surgery, of whom 11 (36.7 %) had complex VVF (9 with failure of a previous repair, 1 following radiotherapy, and 1 with a large defect following obstructed labor), and 27 had supratrigonal VVF. The mean age of the patients was 43.5 ± 8.6 years. The mean operative time was 133 ± 48 min. Median blood loss was 50 ml (IQR 50 ml). No suprapubic catheter was placed. The median durations of drain placement and hospital stay were 3 days (IQR 2 days) and 7.5 days (IQR 4.5 days), respectively. The median duration of follow up was 38 weeks (IQR 46 weeks). No recurrence was seen in 28 patients (93.3 %). CONCLUSIONS: Current data suggest that robot-assisted VVF repair is safe and feasible and probides the advantages of minimally invasive surgery.

Initial experience of robotic nephron sparing surgery in cases of high renal nephrometry scores.

INTRODUCTION: The renal nephrometry scoring (RNS) system enables prediction the feasibility of nephron-sparing surgery (NSS) in renal masses. There is insufficient data regarding the outcome of robot-assisted NSS in tumors with RNS ≥10. We reviewed the trifecta outcomes of patients undergoing robotic NSS with high RNS and compare it with tumors of low and intermediate RNS. MATERIALS AND METHODS: Our prospectively maintained data of all robot-assisted NSS were reviewed, and those with RNS of ≥10 were identified. Patient data, outcomes and postoperative estimated glomerular filtration rate were compared between high, intermediate and low RNS patients. RESULTS: In high RNS group, the mean age of the patients was 53 years (male:female = 15:3). Mean diameter of tumors was 6.28 cm (3.0-10.5 cm). Mean operative time was 173.61 ± 52.66 min and mean warm ischemia time was 27.85 ± 5.27 min. Mean estimated blood loss (EBL) was 363.89 ± 296.45 ml. Mean hospital length of stay was 5.39 ± 1.91 days (3-9 days). When compared with low and intermediate RNS, only EBL and need for pelvicalyceal system repair was significantly higher in high RNS group. Postoperative complications, renal function preservation and oncological outcomes at 3 months were comparable in all the three groups. CONCLUSION: Robot-assisted NSS is feasible with comparable outcomes in tumors with high RNS.

Successful management of renal mucormycosis with antifungal therapy and drainage.

We report a case of isolated extensive renal mucormycosis in an immunocompetent adult, who was successfully managed conservatively without surgical debridement. To the best of our knowledge, this is the first case where antifungal therapy alone was sufficient even with such an extensive involvement.

Adrenal Schwannoma: Case Description and Diagnostic Pointers of a Rare Disease.

Benign nerve sheath tumours such as schwannomas commonly involve the peripheral and cranial nerves. A schwannoma in the adrenal gland is a very rare occurrence, which arises from the adrenal medulla. Its most common presentation is a non-functional incidentaloma. It does not have any unique imaging characteristic distinguishing it from other adrenal masses; hence, its diagnosis is usually confirmed by final histopathology. In this report, we present two cases of an adrenal schwannoma for which we anticipated an unusual diagnosis, which was confirmed through adrenalectomy on histopathology.

External validation of SPARE nephrometery score in predicting overall complications, trifecta and pentafecta outcomes following robot-assisted partial nephrectomy.

BACKGROUND: There is an ongoing need and search for a simple yet accurate nephrometry scoring system for predicting the postoperative outcomes after partial nephrectomy (PN). Simplified PADUA Renal (SPARE) Nephrometry Scoring System, a simplified version of Preoperative Aspects and Dimensions Used for an Anatomical Classification (PADUA) has been proposed as a predictor of postoperative complications following PN recently. However, this score has never been externally validated and assessed as a predictor of trifecta and pentafecta outcomes of PN. In the current study, we applied the SPARE scoring system to our robot-assisted PN cohort (RAPN). METHODS: Prospectively maintained data of patients, who underwent RAPN from November 2014 to December 2018, was abstracted. Imaging was analyzed to calculate SPARE and RENAL nephrometry scores (RNS) by two urologists, independently. SPARE was compared with complications, trifecta outcomes, pentafecta outcomes, and RENAL nephrometry scoring (RNS). RESULTS: Data of 201 RAPN patients were analyzed. The mean SPARE score was 3 (range 0-11). One hundred thirteen patients were classified as low risk, 64 as intermediate risk, and 24 as high risks. On multivariate analysis SPARE score alone predicted complications (OR=1.37, P=0.014) and trifecta outcomes (OR=0.75, P=0.000) while age (OR=0.96, P=0.042), preoperative eGFR (OR=0.97, P=0.001) and SPARE scores (OR=0.81, P=0.016) were predictors for pentafecta outcomes. Receiver operated curve (ROC) analysis between SPARE and RNS in predicting the complications; trifecta and pentafecta outcomes had a comparable area under the curve. CONCLUSIONS: Our study validates the SPARE nephrometry scoring system in predicting postoperative complications, trifecta, and pentafecta outcomes in a RAPN cohort. The predictive accuracy of SPARE is similar to RNS.

Comparison of stent related symptoms in patients taking mirabegron, solifenacin, or tamsulosin: A double blinded randomized clinical trial.

BACKGROUND: The present study aims to assess the efficacy of mirabegron, a novel beta-3 agonist for ameliorating stent related symptoms (SRSs) as compared to tamsulosin and solifenacin. METHODS: Total of 150 patients undergoing ureteral stent placement following ureteroscopic lithotripsy, percutaneous nephrolithotomy, or laparoscopic/robotic pyeloplasty were randomized in 1:1:1 fashion to receive mirabegron 50 mg (group A), solifenacin 5 mg (group B), and tamsulosin 0.4 mg (group C) OD respectively. Patients were followed at POD10 (I visit), 4 weeks (II visit) after surgery, and 2 weeks post-stent removal. Validated vernacular version of ureteric stent symptoms questionnaire (USSQ) was administered to the patients at each visit. RESULTS: Out of 150 patients randomized, 123 patients (A; n = 41, B; n = 40, and C; n = 42) completed the study. The groups were comparable in terms of urinary index score of USSQ at I and II visits (p = 0.119 and 0.076, respectively). A lower proportion of patients in group B experiencing bodily pain at II visit (p = 0.039), however, pain scores were comparable. Significantly lower general health index scores were observed in group A at I visit and over 4 weeks (p = 0.007). No significant differences were observed in other domains of USSQ. Age, sex, and surgical procedure undertaken did not significantly impact the scores in various USSQ domains. CONCLUSION: Mirabegron demonstrates comparable benefit in alleviating SRSs with better general health indices and may be an effective alternative for SRSs, especially when tamsulosin or solifenacin are contra-indicated or poorly tolerated.