Transrectal ultrasonography (TRUS)-guided pelvic plexus block to reduce pain during prostate biopsy: a randomised controlled trial.

OBJECTIVE: To assess the role of pelvic plexus block (PPB) in reducing pain during transrectal ultrasonography(TRUS)-guided prostate biopsy, compared with the conventional periprostatic nerve block (PNB). PATIENTS AND METHODS: A prospective, double-blind observational study was conducted with patients being randomised into three groups. Group-1 (47 patients) received intrarectal local anaesthesia (IRLA) with 10 mL 2% lignocaine jelly along with pelvic plexus block (PPB) with 2.5 mL 2% lignocaine injection bilaterally. Group-2 (46 patients) received IRLA with periprostatic nerve block (PNB). Group-3 (46 patients) received only IRLA without any type of nerve block. The patients were requested to rate the level of pain from 0 to 10 on a visual analogue scale (VAS) at two time points: VAS-1: during biopsy procedure and VAS-2: 30 min after the procedure. RESULTS: The mean age of the patients, mean volume of the prostates and mean serum PSA values were comparable among the three groups. The mean pain score during biopsy was significantly less in the PPB group [mean (range) sore of 2.91 (2-4)] compared with the PNB group [mean (range) score of 4 (3-5)], and both these groups were superior to the no nerve block group [mean score of 5.4 (3-7)]. There was no significant difference between the mean pain scores, 30 min after the procedure among the three groups with the mean (range) scores being 2.75 (2-4), 2.83 (2-4) and 2.85 (2-4), respectively. CONCLUSION: PPB is superior to conventional periprostatic nerve block (PNB) for pain control during TRUS-guided biopsy and both are in turn superior to no nerve block.

Misinterpretation of the international prostate symptom score questionnaire by Indian patients.

INTRODUCTION: The international prostate symptom score (IPSS) is commonly used in the evaluation of the severity of symptoms of patients with prostatic enlargement. It is a self-administered questionnaire. It has not been validated in any Indian language and an English version is used which can be difficult to interpret by our patients who do not have English as their primary language. In this study, we evaluate the patient's ability to understand the IPSS by comparing the scores when the IPSS questionnaire was self-administered versus when it was administered using the assistance of a clinician. MATERIALS AND METHODS: Patients who presented with lower urinary tract symptoms suggestive of benign prostatic hyperplasia, who had passed at least twelfth grade of school and had a reasonable command over English were included in the study. They were allowed to self-administer the IPSS questionnaire following which a clinician, blinded to these scores, assisted the patient in filling the questionnaire. For each question, the score in both the questionnaires was noted and kappa agreement statistical test was used to assess the agreement between the two scores. RESULTS: A total of 87 patients were included in the study. It was found that none of the questions had a perfect agreement of scores in the self-administered and the assisted administration. CONCLUSION: Our results show that our patients misinterpret the IPSS questionnaire. This problem can lead to significant errors in interpretation of the symptom severity.

Comparison of the efficacy and safety of topical diltiazem and nitroglycerine for pain relief during transrectal ultrasound guided biopsy of the prostate.

INTRODUCTION AND OBJECTIVE: Transrectal ultrasound biopsy of prostate is a painful procedure. The introduction of the rectal probe is one of the major contributors to the pain associated with this procedure. Drugs that relax the anal sphincter should theoretically decrease this pain. This study was done to compare the efficacy and safety of two topical medications that relax the anal sphincter, diltiazem and nitroglycerine, in decreasing the pain associated with transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS: 66 patients who were to undergo their first prostate biopsy were randomized to receive either 2 mL of 2 % topical diltiazem or 2 mL of 0.2 % topical nitroglycerine or placebo 20 minutes before prostate biopsy. All patients also received 15 mL of intrarectal lignocaine. A 10-point visual analogue score was used to record the pain immediately after the insertion of the probe, during biopsy and at the end of the procedure. RESULTS: The pain scores due to probe insertion, during biopsy and at the end of the procedure in patients who received topical diltiazem or nitroglycerine were significantly lower compared to the placebo group (p < 0.001). There were no significant differences in the pain scores between the patients receiving diltiazem compared to those receiving nitroglycerine. Higher incidence of headache and fall in blood pressure was noted in patients who received nitroglycerine compared to those receiving diltiazem. CONCLUSION: Topical diltiazem and nitroglycerine are equally effective in reducing the pain associated with transrectal prostatic biopsy. Diltiazem is safer compared to nitroglycerine.

Catheter-induced urethral erosion.

Indwelling bladder catheters are often placed when a patient requires voiding assistance. Long-term use of these catheters has been associated with significant morbidity This case presentation describes a complete erosion of the glans, urethra, and penile skin, up to the penoscrotal junction, as an outcome from long-term use of an indwelling bladder catheter. Appropriate nursing interventions can prevent this devastating health care outcome.

Evaluation of various nephrometric scoring system for nephrolithiasis to predict stone free status after percutaneous nephrolithotomy: A comparative study.

BACKGROUND: The CROES Nephrolithometry nomogram, S.T.O.N.E. Nephrolithometry Score and Guy's stone score were introduced for stratification of kidney stones disease on the basis of quantitative stone burden and its distribution. Till date there has been very limited data on head to head comparison of the existing scoring systems. Comparison and analyses among the scoring system helps in further refinement of these systems along with development of new more effective and broadly acceptable nomogram. OBJECTIVE: Predictability of the stone-free status (SFS) and post-operative complication after PCNL by various scoring systems (The CROES nomogram, S.T.O.N.E. nephrolithometry score and Guy's stone score). MATERIALS AND METHODS: Total 100 adult patients underwent PCNL after considering inclusion and exclusion criteria. All patients underwent Preoperative NCCT scan, investigations of blood (Hb%, PCV, bleeding and coagulation profile, urea, and creatinine), and urine (RE/ME and C/S), Postoperative X ray KUB/NCCT. RESULTS: ROC curves were developed for each scoring system to determine the accuracy to predict stone free status. We found CS had significantly higher AUC than other scoring systems [p-value for CS vs GSS = 0.0091 & CS vs SS = 0.000]. So CS has higher accuracy to predict stone free status. None of the scoring system had shown significantly higher AUC than other scoring system in predicting complication. CONCLUSION: CROES Nephrolithometry nomogram is most accurate to predict preoperative stone-free rate. All scoring systems can equally predict perioperative complications and other variables.

Evaluating the role of hsa-miR-200c in reversing the epithelial to mesenchymal transition in prostate cancer.

Deregulated epithelial-to-mesenchymal transition constitutes one of the major aspects of cancer progression. In this study, to identify key molecular principles of EMT pathway in prostate carcinogenesis, an elaborate gene expression profiling was conducted by qRT-PCR and Western blot analyses. A preponderance of mesenchymal trait was observed in the pathological samples of prostate cancer. To simulate an appropriate in vitro model, PC3 cell line was subjected to hypoxic stress, which resulted in elevated expression of vimentin along with EMT-mediating transcription factors Zeb1 and Slug. To conciliate this mesenchymal behavior of PC3 cells, hsa-miR-200c was deliberately overexpressed which led to a marked reduction of cell motility and expression of vimentin, N-cadherin, Zeb1 and Slug with concurrent increase in level of ß-catenin. hsa-miR-200c was demonstrated to appease hypoxia-aggravated changes in cellular morphology by coordinated repression of vimentin, Zeb1 and Slug. Mode of action for hsa-miR-200c was mediated through transcriptional repression of Zeb1 and Slug interacting with E-box sequences in the vimentin promoter as documented by promoter assay. This ability of hsa-miR-200c to reclaim epithelial traits leads to the anticipation that molecular reprogramming of Zeb1-Slug/vimentin axis may relieve aggressiveness of prostate cancer.

Short-term Alteration of Renal Function and Electrolytes after Percutaneous Nephrolithotomy.

PURPOSE: To analyse the changes in renal function and serum electrolytes in the early post-operative period ofpercutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: A total of 110 patients with normal renal function, who underwent PCNL in our institutewere evaluated prospectively. Haemoglobin percentage, packed cell volume, blood urea nitrogen, serum creatinineand serum electrolytes, namely sodium, potassium, chloride and ionized calcium were measured on the day beforesurgery and after 72 hours of the procedure. Renal function was assessed by Cockcroft-Gault formula and estimatedglomerular filtration rate was calculated by modification of diet in renal disease formula. RESULTS: Serum creatinine increased significantly from a mean value of 0.89 ± 0.199 mg/dL to 0.96 ± 0.252 mg/dL(P = 0.0002) and both creatinine clearance and estimated glomerular filtration rate experienced a significant fall -from a median value (interquartile ranges) of 82.99 (72.37 to 96.88) mL/min to 75.38 (63.89 to 94.05) mL/min incase of creatinine clearance (P = 0.0004) and from a mean value of 95.18 ± 19.87 mL/min/1.73 m2 to 89.30 ± 23.14mL/min/1.73 m2 in case of estimated glomerular filtration rate (P = 0.003). Furthermore, there were significantdrops in both haemoglobin percentage and packed cell volume. There were no significant alterations in serum electrolytes- sodium and potassium (mmol/L) [Median (IQR)] changed from a pre-operative figure of 137.5 (134.0 to140.0) and 3.85 (3.60 to 4.10) to a post-operative value of 138 (135.0 to 140.0) and 3.85 (3.50 to 4.10) respectively. CONCLUSION: Even though there is no significant variation in serum electrolytes, PCNL causes significant reductionin renal function in the early post-operative period.

Urinary incontinence following transurethral prostatectomy presenting as self inflicted penile gangrene.

An elderly diabetic man with a 67 g prostate developed a moderate degree of stress urinary incontinence along with urge urinary incontinence after transurethral resection of the prostate. Initially, he did not perform the recommended pelvic floor exercise and wrapped a rubber band around his penis to control the problem. He presented with late development of penile gangrene requiring partial amputation of his penis. The stress urinary incontinence subsided on subsequent follow-up. The patient is now doing well.

A study of molecular signals deregulating mismatch repair genes in prostate cancer compared to benign prostatic hyperplasia.

Prostate cancer is one of the leading causes of mortality among aging males. There is an unmet requirement of clinically useful biomarkers for early detection of prostate cancer to reduce the liabilities of overtreatment and accompanying morbidity. The present population-based study investigates the factors disrupting expression of multiple functionally related genes of DNA mismatch repair pathway in prostate cancer patients to identify molecular attributes distinguishing adenocarcinoma from benign hyperplasia of prostate. Gene expression was compared between tissue samples from prostate cancer and benign prostatic hyperplasia using real-time-PCR, western blot and immunohistochemistry. Assessment of genotypes of seven single-nucleotide-polymorphisms of three MMR genes was conducted using PCR-coupled RFLP and sequencing. Promoter methylation was interrogated by methylation-specific-PCR and bisulfite-sequencing. Interaction between microRNAs and MMR genes was verified by 3'UTR-based dual luciferase assays. Concurrent reduction of three MMR genes namely hMLH1, hMSH6 and hMSH2 (34-85%, P<0.05) was observed in prostate cancer tissues. hMSH6 polymorphism rs1800932(Pro92Pro) conferred a borderline protection in cancer patients (OR = 0.33, 95% CI = 0.15-0.75). Relative transcript level of hMLH1 was inversely related (r = -0.59, P<0.05) with methylation quotient of its promoter which showed a significantly higher methylation density (P = 0.008, Z = -2.649) in cancer patients. hsa-miR-155, hsa-miR-141 and hsa-miR-21 gene expressions were significantly elevated (66-85%, P<0.05) in tumor specimens and negatively correlated (r = -0.602 to -0.527, P<0.05) with that of MMR genes. hsa-miR-155 & hsa-miR-141 and hsa-miR-155 & hsa-miR-21 were demonstrated to bind to their putative seed sequences in hMLH1 and hMSH6 3'UTRs respectively. Relatively higher expression of DNA methyl-transferases (DNMT1 and DNMT3b) and HIF-1α genes (34-50%, P<0.05) were also detected in tumor tissues. This study provides statistical evidence that MMR deficiency is correlated with hypermethylation of hMLH1 promoter and upregulation of hsa-miR-155, hsa-miR-141 and hsa-miR-21 in prostate cancer. This comparative study reflects that microRNA expression level, particularly hsa-miR-155, exhibits predictive signature of prostate adenocarcinoma.

Evaluation of stone-free rate using Guy's Stone Score and assessment of complications using modified Clavien grading system for percutaneous nephro-lithotomy.

To prospectively evaluate the ability of Guy's Stone Score (GSS) in predicting stone clearance rate and complication rate (by modified Clavien grade) for renal stones treated by percutaneous nephrolithotomy (PNL). From January 2013 to June 2014, a total of 142 patients undergoing PNL were evaluated prospectively. Patients with co-morbidities like hypertension, diabetes, renal failure were excluded from the study. All patients were classified according to GSS based on the findings of pre-operative intravenous urography (IVU) and per-operative retrograde pyelography (RGP). All PNL procedures were done by standard technique in prone position and success was defined as no residual stone visible on X-ray KUB done on the third postoperative day. Complications were classified according to modified Clavien grading system. The initial stone clearance rate was 71.1% and overall final stone clearance rate was 90.14%. The complication rate according to Clavien grading system was 40.1%. The final stone clearance rates were 93.9, 85.71, 90.47, and 77.77% in GSS I, II, III, and IV, respectively (p<0.001, <0.05, <0.05 and >0.05, respectively). The Clavien complication rates were 23, 61, 52, and 77.7% in GSS I, II, III, and IV, respectively (p<0.001). The GSS is a simple and easily reproducible system to preoperatively predict stone-free rate and perioperative complication rate. It helps in better patient counseling preoperatively.

Congenital giant male anterior urethral diverticulum with calculi.

Urethral diverticulum is a sac-like outpouching of urethral mucosa. It may be anterior or posterior according to anatomical locations. It is less common in men than in women. It can be congenital or acquired. Anterior urethral diverticula are usually congenital as compared to majority of posterior diverticula which are acquired. The most common aetiologies of male acquired diverticula are stricture, abscess, trauma or post-hypospadias repair. We report a case of congenital giant anterior urethral diverticulum with a calculus which has been managed successfully with surgical excision and repair in two layers.

Familial bulbar urethral strictures.

Strictures are commonly encountered in the urological practice. The most common aetiologies are infection, trauma and iatrogenic events. Familial occurrence of urethral stricture is exceptionally rare. We present a case in which bulbar urethral strictures developed in a father and his two sons.

Calvarial and cutaneous metastasis as the primary presentation of a renal cell carcinoma.

Renal cell carcinoma is an aggressive urological malignancy. Metastases from the lesion are encountered late in the course of the disease and most often involve the lung and the liver. It is rare that metastatic lesions are the primary presentation of an otherwise clinically silent renal cell carcinoma. We report a case who presented with calvarial and cutaneous lesions which were later found to be metastases from an asymptomatic renal cell carcinoma.

Tuberculosis of the glans penis healing with meatal stenosis.

A 45-year-old man presented with ulceroproliferative lesion of the glans penis. Clinical diagnosis was penile carcinoma and incisional biopsy was performed. Histopathology report came as penile tuberculosis. The lesion healed with antitubercular treatment. Meatal stenosis occurred at 2 months follow-up and was managed with meatotomy.

Analysis of urinary stone composition in Eastern India by X-ray diffraction crystallography.

BACKGROUND: Stones in the urinary system are common in our country. This study was done to assess the composition of the urinary stones in eastern part of India. MATERIALS AND METHODS: A prospective study was done over a period of thirty months. A total of 90 stones were analyzed in this time period by using X-ray diffraction crystallography. RESULTS: Of the 90 stones analyzed, 77 were renal stones, 12 were ureteric stones and one was a bladder stone. Six stones (all renal) did not have properties to be represented by X-ray diffraction crystallography. The overall prevalence of the oxalate containing stones was 85.7% with calcium oxalate monohydrate (COM) being the major constituent. Calcium oxalate dihydrate (COD) was the next most common constituent. Struvite stones constituted 9.5% of the stones analyzed. Pure calcium phosphate stones were found in 4.7% of the cases. CONCLUSION: Our study reveals that the stone composition in the eastern part of India is different from that in other parts of the country. We have a comparatively lower prevalence of oxalate stones while a higher prevalence of phosphate and struvite stones.

Management of an iatrogenic injury in a crossed ectopic kidney without fusion.

Crossed renal ectopia is a condition in which a kidney is located on the side opposite of its ureteral insertion. Ninety percent of crossed ectopic kidneys are fused to their ipsilateral uncrossed renal unit. Crossed renal ectopia without fusion is rare, with only 62 patients reported in the literature to date. These kidneys may suffer iatrogenic injury during an unrelated surgical intervention. The injury, unless self-limiting, may necessitate the removal of the ectopic kidney. We present a unique case of a dual injury, renal as well as ureteric, in a crossed ectopic kidney without fusion that was successfully managed without surgical excision.

Transobturator taping for the treatment of incontinence after neobladder reconstruction.

Incontinence in the patients with neobladder is a distressing condition. Although conservative management may be helpful in some, a significant number of patients require some form of surgical intervention. Any surgical intervention, especially from the abdominal route can be significantly morbid in these patients because of extensive surgery done previously. There is a need for a technique that can take care of the postoperative incontinence without subjecting the patient to significant surgical risk. Artificial sphincters have been used in male patients but their use in female patients can be technically difficult. There are limited options available for women like transurethral bulking agents and pubovaginal slings. These procedures do not have very good results and female patients often end up with a cutaneous stoma. We, in this report, describe a female patient with incontinence after orthotopic neobladder reconstruction that could be successfully treated with transobturator taping.

Fibroepithelial polyp of the ureter.

A 36-year-old woman presented with haematuria and a bladder mass on ultrasonogram. Cystoscopy revealed a tumour, cauliflower in shape with smooth stalk coming out from the ureteric orifice. Stalk of the polyp was identified in proximal ureter by ureteroscopy. The mass was excised endoscopically.

Bilateral single ectopic ureters draining into a grossly dilated vagina in an adolescent female.

A 16-year-old female presented with dribbling of urine along with voluntary voiding since birth. Renal imaging revealed hydroureteronephrosis on the right side; the uterus and ovary were normal. A radionuclide scan showed a left nonfunctional kidney. On cystovaginoscopy, the urethra was shown to be normal and the urinary bladder was tubular with small capacity and an absent trigone. Although the vagina was capacious, no ureteric orifices were found. Computed tomography corroborated the diagnosis of bilateral, single ectopic ureters draining into a grossly dilated vagina. This case is unique because it is a bilateral single-system ureteral ectopia in a completely differentiated female genital tract that presented late in adolescence. To the best of our knowledge, this is the second such ureteral abnormality reported in the literature so far. The patient underwent ileocystoplasty with right ureteric reimplantation and nephroureterectomy for the left nonfunctional kidney, which histopathology showed to be tuberculosis. The patient is continent with cystometric capacity of more than 300 mL.