The Urological Association of Asia clinical guideline for urinary stone disease.

The Urological Association of Asia, consisting of 25 member associations and one affiliated member since its foundation in 1990, has planned to develop Asian guidelines for all urological fields. The field of stone diseases is the third of its guideline projects. Because of the different climates, and social, economic and ethnic environments, the clinical practice for urinary stone diseases widely varies among the Asian countries. The committee members of the Urological Association of Asia on the clinical guidelines for urinary stone disease carried out a surveillance study to better understand the diversity of the treatment strategy among different regions and subsequent systematic literature review through PubMed and MEDLINE database between 1966 and 2017. Levels of evidence and grades of recommendation for each management were decided according to the relevant strategy. Each clinical question and answer were thoroughly reviewed and discussed by all committee members and their colleagues, with suggestions from expert representatives of the American Urological Association and European Association of Urology. However, we focused on the pragmatic care of patients and our own evidence throughout Asia, which included recent surgical trends, such as miniaturized percutaneous nephrolithotomy and endoscopic combined intrarenal surgery. This guideline covers all fields of stone diseases, from etiology to recurrence prevention. Here, we present a short summary of the first version of the guideline - consisting 43 clinical questions - and overview its key practical issues.

Nocturia in patients with benign prostatic hyperplasia: evaluating the significance of ageing, co-morbid illnesses, lifestyle and medical therapy in treatment outcome in real life practice.

AIM: The aim of study was to evaluate the influence of ageing, lifestyle, and co morbid illnesses on treatment outcome of nocturia among men with BPH. METHODS: Patients with BPH on medical therapy of least 6 months and up to 48 months were interviewed. Nocturia episodes, co morbid illnesses, beverage intake frequency, medications and work history were documented. Body Mass Index (BMI), waist circumference (WC), prostate volume, and prostate specific antigen (PSA) were recorded. Treatment failure is defined as persistent nocturia despite on medical therapy for BPH. RESULTS: In 156 patients, the prevalence of nocturia was 96.7% while nocturia of 2 or more was 85.9%. Factors associated with treatment failure was older age (p < 0.01), usage of diuretics (p = 0.03), and antimuscarinics (p < 0.01), while active working status (p < 0.01), use of desmopression (p = 0.01), and increased coffee intake (p = 0.02) were associated with nocturia improvement. Co-morbid illnesses, obesity, WC, alcohol intake, PSA, prostate volume, and use of BPH medical therapy did not influence treatment outcome. CONCLUSION: Advancing age has a significance negative outcome on nocturia treatment, while standard BPH medical therapy and co morbid illnesses have an insignificant impact. However, alleviation of bothersome symptoms is possible with the understanding of its patho-physiology and individual-based approach to treatment and expected outcome.

Fournier's Gangrene: A Case of Neglected Symptoms with Devastating Physical Loss.

Fournier's gangrene is a severe life-threatening infection involving the perianal area, perineum, and external genitalia. It demands prompt recognition, critical care therapy, surgical therapy, and a combination of antibiotics. The infection commonly spreads via the fascial planes and causes superficial vascular thrombosis within the Colles' fascia around the external genitalia. It can extend cephalad to involve the Scarpa's fascia and Camper's fascia in the abdominal wall. The treatment would include multiple debridements, which would result in disfiguring scars of the perineum and might lead to significant physical and psychological complications. We describe a case of a 58-years-old man presenting with Fournier's gangrene resulting from an infection of an impacted urethral stone. The patient previously had obstructive voiding symptoms for 1 month but chose to neglect them. The resultant infection was severe and caused penile and right testicular gangrene. He underwent multiple wound debridements, which included a total penectomy and right orchiectomy. Psychological and rehabilitative support was necessary for him to overcome his loss and disfigurement.

Scrotal mass: a rare complication of ventriculoperitoneal shunt.

SUMMARY: Ventriculoperitoneal shunts are associated with multiple complications. Among them are disconnection and migration of the tubing into the peritoneal cavity. Here we describe a case of a fractured ventriculoperitoneal shunt which migrated and coiled in the scrotum, masquerading as a scrotal swelling. Removal of the shunt via a scrotal incision was performed concomitantly with repair of the hernia sac.

Prospective evaluation of using multiparametric magnetic resonance imaging in cognitive fusion prostate biopsy compared to the standard systematic 12-core biopsy in the detection of prostate cancer.

PURPOSE: There is mounting evidence to suggest that multiparametric magnetic resonance imaging (mpMRI)-guided biopsy is better than systematic biopsy for the diagnosis of prostate cancer (PCa). Cognitive fusion biopsy (CFB) involves targeted biopsies of areas of suspicious lesions noted on the mpMRI by transrectal ultrasound (TRUS) operator. This study was undertaken to determine the accuracy of mpMRI of the prostate with Prostate Imaging-Reporting and Data System (PI-RADS) version 2 in detecting PCa. We also compare the cancer detection rates between systematic 12-core TRUS biopsy and CFB. MATERIALS AND METHODS: Sixty-nine men underwent mpMRI of the prostate followed by TRUS biopsy. In addition to 12-core biopsy, CFB was performed on abnormal lesions detected on MRI. RESULTS: Abnormal lesions were identified in 98.6% of the patients, and 59.4% had the highest PI-RADS score of 3 or more. With the use of PI-RADS 3 as cutoff, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI for the detection of PCa were 91.7%, 57.8%, 53.7%, and 92.8%, respectively. With the use of PI-RADS 4 as cutoff, the sensitivity, specificity, PPV, and NPV of mpMRI were 66.7%, 91.1%, 80%, and 83.7%, respectively. Systematic biopsy detected more PCa compared to CFB (29% vs. 26.1%), but CFB detected more significant (Gleason grade ≥7) PCa (17.4% vs. 14.5%) (P < 0.01). CFB cores have a higher PCa detection rate as compared to systematic cores (P < 0.01). CONCLUSIONS: mpMRI has a good predictive ability for PCa. CFB is superior to systematic biopsy in the detection of the significant PCa.

Evaluation of genotoxicity by micronucleus assay in oral leukoplakia and oral squamous cell carcinoma with deleterious habits.

BACKGROUND: Oral cancer is the 12th most common cancer in women and the 6th in men. Of all oral malignancies, more than 92-95% is Oral Squamous Cell Carcinoma (OSCC). The high risk was due to Lifestyle-related habits such as smoking, alcohol consumption, chewing of areca nut related products which are considered as the major risk factors in OSCC. The exogenous carcinogens from tobacco smoke may induce a defective DNA damage response, which may alter the expression of genes that protect us against cancer that may result in genomic instability and this DNA damage can be assessed by studying the chromosomal aberrations, sister chromatid exchanges and the varied forms of the micronucleus. AIMS AND OBJECTIVES: The aim of this study was to evaluate the risk of development of oral leukoplakia (OLP) and OSCC due to DNA damage by studying micronuclei count in the east coast of Andhra Pradesh population with tobacco consumption habit and habit-free controls using Fluorescent microscopy. MATERIALS AND METHODS: A total of 60 subjects, 20 normal controls, 20 oral leukoplakia and 20 OSCC patients were selected from the outpatient patients of GITAM Dental College and Hospital, Rushikonda, Visakhapatnam and peripheral cancer hospitals in and around Visakhapatnam. Exfoliated cells were collected by giving 5-6 gentle strokes with spatula in a continuous unidirectional movement and then were uniformly spread on the previously cleaned microscopic slide. Fluorescent stain 4', 6'-diamidino-2 phenylindole (DAPI) was used for MN analysis. RESULTS: Mean of cells with MN in controls, leukoplakia and OSCC cases was observed to be 1, 5.1,10.1 (F = 112.396, P < 0.001) respectively. Mean of the cells with MN in different grades of leukoplakia. (F = 35.594, P < 0.001) Mean of the cells with MN in different grades of OSCC. (F = 39.752, P < 0.001). CONCLUSION: The present study revealed an increase in mean frequency of cells with micronucleus from healthy individuals however similar studies in larger sample has to be done. This study concludes that MN index can be used as a screening test among high risk groups.

Urethral strictures after bipolar transurethral resection of prostate may be linked to slow resection rate.

PURPOSE: This study aimed to determine the urethral stricture (US) rate and identify clinical and surgical risk factors associated with US occurrence after transurethral resection of the prostate using the bipolar Gyrus PlasmaKinetic Tissue Management System (PK-TURP). MATERIALS AND METHODS: This was an age-matched case-control study of US occurrence after PK-TURP. Retrospective data were collected from the hospital records of patients who had a minimum of 36 months of follow-up information. Among the data collected for analysis were prostate-specific antigen level, estimated prostate weight, the amount of prostate resected, operative time, history of urinary tract infection, previous transurethral resection of the prostate, and whether the PK-TURP was combined with other endourological procedures. The resection rate was calculated from the collected data. Univariate and multivariate analyses were performed to identify clinical and surgical risk factors related to US formation. RESULTS: A total of 373 patients underwent PK-TURP between 2003 and 2009. There were 13 cases of US (3.5%), and most of them (10 of 13, 76.9%) presented within 24 months of surgery. Most of the US cases (11 of 13, 84.6%) occurred at the bulbar urethra. Multivariable logistic regression analyses identified slow resection rate as the only risk factor significantly associated with US occurrence. CONCLUSIONS: The US rate of 3.5% after PK-TURP in this study is comparable to contemporary series. A slow resection rate seems to be related to US occurrence. This should be confirmed by further studies; meanwhile, we must be mindful of this possibility when operating with the PK-TURP system.

Malignant Peripheral Nerve Sheath Tumor -A Rare Malignancy in Mandible.

Malignant Peripheral Nerve Sheath Tumor (MPNST) is biologically an aggressive tumor that is usually found in the extremities, trunk and infrequently found in the head and neck area particularly in the jaws, arising from the cells allied with nerve sheath. Mandibular MPNST may either arise from a preexisting neurofibroma or develop de novo. Because of the greater variability from case to case in overall appearance both clinically and histologically, a case of MPNST of the mandible in a 25-year-old female patient is reported. The lesion was excised and immunohistological studies (S-100 & Neuron specific enolase) were conducted to confirm the neural origin.

Ureteral stricture formation after ureteroscope treatment of impacted calculi: a prospective study.

PURPOSE: Urinary calculi is a familiar disease. A well-known complication of endourological treatment for impacted ureteral stones is the formation of ureteral strictures, which has been reported to occur in 14.2% to 24% of cases. MATERIALS AND METHODS: This was a prospective study. Ureterotripsy treatment was used on patients with impacted ureteral stones. Then, after 3 months and 6 months, the condition of these patients was assessed by means of a kidney-ureter-bladder (KUB) ultrasound. If the KUB ultrasound indicated moderate to serious hydronephrosis, the patient was further assessed by means of a computed tomography intravenous urogram or retrograde pyelogram to confirm the occurrence of ureteral strictures. RESULTS: Of the 77 patients who participated in the study, 5 developed ureteral strictures. Thus, the stricture rate was 7.8%. An analysis of the intraoperative risk factors including perforation of the ureter, damage to the mucous membrane, and residual stone impacted within the ureter mucosa revealed that none of these factors contributed significantly to the formation of the ureteric strictures. The stone-related risk factors that were taken into consideration were stone size, stone impaction site, and duration of impaction. These stone factors also did not contribute significantly to the formation of the ureteral strictures. CONCLUSIONS: This prospective study failed to identify any predictable factors for ureteral stricture formation. It is proposed that all patients undergo a simple postoperative KUB ultrasound screening 3 months after undergoing endoscopic treatment for impacted ureteral stones.

Stratifying patients with haematuria into high or low risk groups for bladder cancer: a novel clinical scoring system.

Haematuria is a common presentation of bladder cancer and requires a full urologic evaluation. This study aimed to develop a scoring system capable of stratifying patients with haematuria into high or low risk groups for having bladder cancer to help clinicians decide which patients need more urgent assessment. This cross- sectional study included all adult patients referred for haematuria and subsequently undergoing full urological evaluation in the years 2001 to 2011. Risk factors with strong association with bladder cancer in the study population were used to design the scoring system. Accuracy was determined by the area under the receiver operating characteristic (ROC) curve. A total of 325 patients with haematuria were included, out of which 70 (21.5%) were diagnosed to have bladder cancer. Significant risk factors associated with bladder cancer were male gender, a history of cigarette smoking and the presence of gross haematuria. A scoring system using 4 clinical parameters as variables was created. The scores ranged between 6 to 14, and a score of 10 and above indicated high risk for having bladder cancer. It was found to have good accuracy with an area under the ROC curve of 80.4%, while the sensitivity and specificity were 90.0% and 55.7%, respectively. The scoring system designed in this study has the potential to help clinicians stratify patients who present with haematuria into high or low risk for having bladder cancer. This will enable high-risk patients to undergo urologic assessment earlier.

Outcomes and Safety of Retrograde Intra-Renal Surgery for Renal Stones Less Than 2 cm in Size.

BACKGROUND: Retrograde intra-renal surgery (RIRS) has been used to remove stones of less than 2 cm in the kidney. However, its role is not well defined. OBJECTIVES: The objective of this study was to evaluate the outcomes and safety of RIRS, used either as a primary or secondary procedure, and to analyze factors predicting the stonefree rate (SFR). PATIENTS AND METHODS: A retrospective analysis was performed on data from patients who underwent RIRS over a 10-year period (2002-2012). Stone size was measured as the surface area and was calculated according to the EAU guidelines. In cases of multiple stones, the total stone burden was calculated as the sum of each stone size. Stone burden was then classified as ≤ 80 mm(2) or > 80 mm(2). RIRS was classified as primary procedure or secondary procedure (after failed extracorporeal shockwave lithotripsy or percutaneous nephrolithotripsy).Stone clearance was defined as a complete absence of stones or stones < 4 mm, which were deemed insignificant on ultrasonography and plain radiography. RESULTS: The overall SFR for renal stones treated with RIRS in our center was 55.4%, and the complication rate was 1.5%, which consisted of one case of sepsis. The only factor affecting SFR in this study was the indication for RIRS. When performed as a primary operation, RIRS showed a significantly better SFR (64.3%). The SFR for lower pole stones was only 44.4%. There were no statistically significant effects of stone burden, radio-opacity, or combination with ureteral stones on SFR. CONCLUSIONS: RIRS should be used as the primary treatment for renal stones whenever possible.

Male sexual dysfunction in Asia.

Sex has always been a taboo subject in Asian society. However, over the past few years, awareness in the field of men's sexual health has improved, and interest in sexual health research has recently increased. The epidemiology and prevalence of erectile dysfunction, hypogonadism and premature ejaculation in Asia are similar in the West. However, several issues are specific to Asian males, including culture and beliefs, awareness, compliance and the availability of traditional/complementary medicine. In Asia, sexual medicine is still in its infancy, and a concerted effort from the government, relevant societies, physicians and the media is required to propel sexual medicine to the forefront of health care.

Primary sclerosing lipogranuloma: an unusual scrotal mass.

Sclerosing lipogranuloma (SLG) of the male external genitalia is a rare benign condition presenting as subcutaneous masses. The underlying pathological process is a granulomatous reaction of fatty tissue in this area. The cause of this is unclear but hypothesis stems around the pathogenesis of exogenous lipid degeneration from injection of foreign bodies such as paraffin for penile augmentation. However, endogenous lipid degeneration from other various causes such as infection, trauma, and allergic mechanisms has also been reported. We present the case of a 40-year-old man with primary SLG of the external genitalia. Literature review on the treatment strategies are addressed and discussed.

Clinical characteristics of renal cancer in Malaysia : a ten year review.

Renal cancer is rare and its incidence is 1.9 per 100,000 in the Malaysian population, which consists of three major ethnic groups (Malay, Chinese and Indians). A retrospective study was her conducted to identify clinical characteristics and ethnic background influences on presentation. The study included all renal cancer patients from a single medical institution over ten years, with a total of 75 cases. Seventy-three patients underwent surgery while 2 received only radiotherapy or chemotherapy. The male to female ratio was 2.75:1. Incidence was equal among the Malay (49.3%) and Chinese ethnic groups (45.3%). Mean age of patients were 57.1 (18-93) years old. There were 26 (37.4%) patients with Stage I disease, 14 (18.7%) at Stage II, 23 (30.7%) at Stage III and 12 (16%) at Stage IV. The Chinese race presented at mean older age (p= 0.02) and later stage of disease (p= 0.046). Patients above 40 years old had more advanced stage disease (p= 0.023). Tumour histology were clear cell (72%), urothelial cell (13.3%), sarcomatoid cell and nephroblastoma each contributed 2.7%. The mean tumour size was 8.1 (2-20) cm. There was substantial agreement between the pre and post operative staging (kappa 0.691). In conclusion we observed significant influences of age and race in the clinical presentation of renal cancer in our institution based population. There was larger male to female ratio and mean tumour size as compared to previous epidemiology studies.

Encrusted and incarcerated urinary bladder catheter: what are the options?

Urinary bladder catheter encrustations are known complications of long-term urinary catheterisation, which is commonly seen in clinical practice. These encrustations can impede deflation of the balloon and therefore cause problems in the removal of the catheter. The options in managing an encrusted and incarcerated urinary bladder catheter include extracorporeal shock wave lithotripsy and lithoclast. We describe here another technique of dealing with a stuck and encrustated catheter, via direct crushing of the encrustations with a rigid cystoscope inserted through a suprapubic cystostomy tract.

Clinicopathological features of bladder tumours in a single institution in Malaysia.

OBJECTIVE: To determine the clinicopathological features of bladder tumours encountered over a five year period in Universiti Kebangsaan Malaysia Medical Centre. METHODS: Medical records of bladder tumour cases from 2005 till 2009 were retrospectively reviewed and tabulated. RESULTS: A total of 83 cases were recorded. The incidence was highest among the Chinese (56.6%), followed by Malays (34.9%), Indians (6%) and other races (2.4%). The male-to-female ratio was 9.4:1. The median age was 65 years (range 30-91 years) and median duration of follow up was 17.2 months (range 2-60 months). The main histopathology was transitional cell carcinoma (TCC) (90.4%), followed by adenocarcinoma (6%), squamous cell carcinoma (1.2%), leiomyoma (1.2%) and myeloid sarcoma (1.2%). For the TCCs, 58.6% were superficial while 41.4% were muscle invasive, and 13.3% had nodal metastasis with distant metastasis in 8%. Of the total, 5.3% were papillary urothelial tumours of low malignant potential, 33.3% pTa, 20% pT1, 10.7% pT2, 12.0% pT3 and 18.7% pT4. Of the superficial tumours, 32.5% were high grade tumours. There were ten radical cystectomies performed for transitional cell carcinomas; two had neobladder reconstruction whereas the other eight had ileal conduits. All the adenocarcinomas and squamous cell carcinomas were treated by radiotherapy due to the advanced stage of the disease while the myeloid sarcoma received chemotherapy. Mean survival of patients with muscle invasive cancer was 33+/-5 months. By the end of the study, 18.1% of patients had died of their cancer. CONCLUSION: The incidence of bladder tumours is highest among the Chinese. When compared to other studies, the incidence of muscle invasive and high-grade superficial tumours was greater.

Seven-year review of prostate carcinomas diagnosed by TRUS biopsy in a single Malaysian institution.

INTRODUCTION: Analysis of epidemiological as well as survival differences among the multiethnic population of Malaysia with prostate cancer is important. METHODS: Patients confirmed by transrectal-ultrasonographic-guided-biopsy performed from 2002 to 2008 were enrolled and analysed according to ethnicity, age, PSA level, Gleason score, stage of disease and survival. RESULTS: Among 83 patients, there were 38 Malay, 40 Chinese, 3 Indians and 2 others. Median age at diagnosis was 69.9 (range: 59-93), 43 patients (51.8%) being diagnosed before the age of 70. The median PSA level upon diagnosis was 574 ng/ml (range: 1-8632) and the median Gleason score was 7 (range: 2-10). Over half were already in Stage 4 when diagnosed. The most common site of metastasis was the bone. As a result the commonest prescribed treatment was hormonal manipulation. Five patients underwent radical prostatectomy and a further thirteen patients had radical radiotherapy (stage I: 1 patient, stage II: 7 patients and stage III: 5 patients). Ten patients defaulted follow-up. The median disease-specific survival was 21.9 months (range: 1-53). CONCLUSIONS: Prostatic carcinoma is a disease of the elderly and it is frequently diagnosed late in Malaysia. Greater efforts should be made to educate Malaysians regarding prostate cancer.

Spontaneous bladder perforation: a rare complication of tuberculosis.

Spontaneous bladder perforation secondary to tuberculosis (TB) is very rare. Only three cases have been reported so far in the literature. Due to its rarity, the diagnosis of spontaneous bladder perforation is often missed. Confirmation of TB via culture takes a long time and starting empirical treatment for TB is necessary. We relate our experience with a young woman who presented with clinical features of a perforated appendix and was only diagnosed with bladder perforation during laparotomy. She also had distal right ureteral stricture and left infundibular stenosis. The provisional diagnosis of TB was attained via typical histopathological features and a positive Mantoux test. She was started empirically on anti-TB treatment and recovered without any complications. Urine culture after 6 weeks confirmed the diagnosis of TB.

Iatrogenic bladder injury: a single institution’s ten-year experience in treatment and outcome 1999-2009, Kuala Lumpur, Malaysia / Lesión vesical iatrogénica: experiencia de diez años, tratamiento y resultados entre 1999-2009, Kuala Lumpur, Malasia

Introduction: This case series is a retrospective review of iatrogenic bladder injuries treated at our institution Universiti Kebangsaan Malaysia, Medical Centre, over a ten-year period, from 1999 to 2009. Materials and methods: A retrospective review of the operating theater database yielded the names and registration numbers of patients who underwent operative repair of bladder injuries. Patients who sustained bladder injuries due to non-surgical reasons (such as traumatic bladder injuries due to pelvic fractures, blunt trauma or penetrating injuries to the pelvis) were excluded.Results: There were 12 cases of iatrogenic bladder injury treated during this time. A total of eight injuries occurred during gynaecological surgery. Five injuries occurred during lower segment caesarean section, two injuries during total abdominal hysterectomy and bilateral salpingo-oopherectomy, and a single injury during Burch colposuspension. Four out of the five injuries during caesarian section had a history of previous caesarian section. Of the four remaining non-gynaecological related injuries, two injuries occurred during hernioplasty, one during exploration of an enterocutaneous fistula and the other was during laparoscopic appendicectomy.Conclusion: Iatrogenic bladder injury should be anticipated in patients undergoing caesarean section who have had multiple previous caesarean sections. Iatrogenic injuries should be identified intra-operatively to enable early repair and the best outcome. These injuries were adequately assessed by ascending cystography. Continuous repair with absorbable sutures together with perivesicle drainage and bladder catheterization produces good outcome.

Introducción: Esta serie del casos es una revisión retrospectiva de heridas iatrogénicas de vejiga tratadas en la Universidad Nacional de Malasia entre 1999 y 2009. Métodos: Se hizo una revisión retrospectiva de la base de datos de la sala de cirugía del Centro Médico de la Universidad Nacional de Malasia, en individuos a quienes se les realizó cirugía de heridas de vejiga. Se excluyeron los pacientes que presentaron heridas de vejiga sin cirugía como heridas traumáticas debido a fracturas pélvicas, trauma cerrado o heridas penetrantes en la pelvis. Resultados: Se encontraron 12 casos de herida de vejiga iatrogénica tratados entre 1999 y 2009. Ocho heridas ocurrieron durante cirugía ginecológica, 5 durante cesárea segmentaria baja, 2 durante histerectomía abdominal total y salpingo-ooforectomía bilateral y 1 herida durante colposuspensión de Burch. Las 4 heridas restantes no ginecológicas fueron: 2 heridas por iatrogenia ocurrida durante una hernioplastia, una durante exploración de una fístula entero-cutánea y la otra se presentó durante una apendectomía laparoscópica. Conclusión: La herida iatrogénica de la vejiga debe ser anticipada en pacientes que experimentan cesárea que han tenido múltiples cesáreas previas. Las heridas iatrogénicas deben ser identificadas intra-operatoriamente para permitir reparación temprana y obtener el mejor resultado. Obtuvo mejores resultados la reparación continua con suturas absorbibles junto con drenaje vesical mediante catéter. La cistografía ascendente con 300 ml de contraste es la mejor opción para el diagnóstico de herida iatrogénica de vejiga y también para la evaluación de la reparación total.