Autologous versus synthetic midurethral transobturator sling: A systematic review and meta-analysis of outcomes.

INTRODUCTION: There have been concerns around the use of synthetic mesh for stress urinary incontinence (SUI) surgery with a renewed interest in the use of autologous tissues. Recently, an autologous transobturator sling (aTOT) has been described, but the comparative data with synthetic transobturator sling (sTOT) is limited. The objective of this systematic review and meta-analysis was to assess the outcome of aTOT and compare it with sTOT. METHODS: A systematic search of PubMed, Scopus, and Web of Science databases was performed and all articles available up to December 31, 2023 were screened. Studies reporting on the outcomes of aTOT and those comparing aTOT with sTOT were included. This review was performed as per Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS: Eleven studies evaluating 323 patients that met the criteria were included in the final analysis, of which 6 were single arm (155 patients) and 5 were comparative. In single-arm studies, the pooled success rate, defined as negative cough stress test at 12 months follow-up was 96.8%, 3.8% had postoperative urinary retention, 6.1% had graft site-related complications and 7.6% required additional intervention for persistent SUI. The overall complication rate was 20.6% and there were no Clavien III-V complications. aTOT had similar success and complication rates when compared with sTOT but had a significantly longer operative time (weighted mean difference: 22.35 min, p < 0.00001) and superior sexual function outcomes. CONCLUSIONS: aTOT, at short-term follow-up (12 months), has similar efficacy and complication rates when compared to sTOT. However, given that the data is limited and not of very good quality, and the fact that long-term follow-up is not available, further studies are required to better define the role of aTOT in the management of female patients with SUI.

"Primary" bulbar urethral ischemic necrosis following pelvic fracture urethral injury: A rare surgical challenge.

Ischemic necrosis of the bulbar urethra in a patient with pelvic fracture urethral injury without a prior history of surgical intervention is extremely rare and results in long-segment obliterative strictures that are difficult to manage. Instead of the more traditional approach of vascular reconstruction followed by transpubic end-to-end urethroplasty, these patients are better managed by up-front urethroplasty with a tubed flap or as a staged procedure with grafting and tubularization. Herein, we report a case of primary bulbar urethral ischemic necrosis due to pelvic fracture managed with tubularized preputial flap (McAninch flap) urethroplasty.

Urodynamic assessment of detrusor function in the very acute phase of traumatic spinal cord injury: A prospective cohort study.

Introduction: The bladder is believed to be acontractile due to the phase of spinal shock and there is a lack of data on the detrusor function within the first few days after spinal cord injury (SCI). This study intended to assess the detrusor function with invasive urodynamics (UDS) during the first 15 days of SCI. Methods: This prospective observational study was carried out from January 2020 to June 2021 and consecutive stable patients older than 18 years of age who had a history of traumatic SCI within the past 15 days were screened for inclusion. For each patient, the International Standards for Neurological Classification of SCI Worksheet was filled. All patients underwent bedside invasive UDS within 15 days of injury. Results: There were a total of 41 patients with a mean age of 35 years. The thoracic cord was most commonly involved (46.3%) with Type A AISA grade being the most common (68.2%). The mean duration of injury at the time of UDS was 6 days. Abnormality in the filling phase could be identified in six patients. Three patients had neurogenic detrusor overactivity (NDO), with one having a high-pressure phasic NDO and one having a sustained NDO. Two patients had poor compliance and one had borderline poor compliance. None of the patients generated any detrusor pressure during voiding cystometry. Conclusions: In patients with SCI, 14.5% of the patients had abnormal findings during the filling phase on the UDS performed within 15 days of the injury. These findings are in stark contrast to the traditional understanding that the detrusor is acontractile during the early phase of the SCI and merit further evaluation.

Elucidating the zinc-binding proteome of Fusarium oxysporum f. sp. lycopersici with particular emphasis on zinc-binding effector proteins.

Fusarium oxysporum f. sp. lycopersici is a soil-borne phytopathogenic species which causes vascular wilt disease in the Solanum lycopersicum (tomato). Due to the continuous competition for zinc usage by Fusarium and its host during infection makes zinc-binding proteins a hotspot for focused investigation. Zinc-binding effector proteins are pivotal during the infection process, working in conjunction with other essential proteins crucial for its biological activities. This work aims at identifying and analysing zinc-binding proteins and zinc-binding proteins effector candidates of Fusarium. We have identified three hundred forty-six putative zinc-binding proteins; among these proteins, we got two hundred and thirty zinc-binding proteins effector candidates. The functional annotation, subcellular localization, and Gene Ontology analysis of these putative zinc-binding proteins revealed their probable role in wide range of cellular and biological processes such as metabolism, gene expression, gene expression regulation, protein biosynthesis, protein folding, cell signalling, DNA repair, and RNA processing. Sixteen proteins were found to be putatively secretory in nature. Eleven of these were putative zinc-binding protein effector candidates may be involved in pathogen-host interaction during infection. The information obtained here may enhance our understanding to design, screen, and apply the zinc-metal ion-based antifungal agents to protect the S. lycopersicum and control the vascular wilt caused by F. oxysporum.

Upper moiety vascular ureteropelvic junction obstruction in an incomplete duplex kidney: A variant of the Fraley's syndrome?

Although duplication of the collecting system is fairly common, ureteropelvic junction obstruction of the upper moiety in a patient with duplex system is rare, more so if the obstruction is extrinsic and vascular. Herein, we report a case of obstruction of the upper moiety infundibulum by a crossing vein, in a patient with partially duplex system who presented with flank pain and focal hydronephrosis of the superior calyx, a clinical presentation similar to that of Fraley's syndrome. The infundibulum was transected and transposed anterior to the crossing vessel.

"Mesh free" autologous transobturator mid urethral sling placement for predominant stress urinary incontinence: A pilot study.

AIMS: To assess the efficacy and safety of autologous mid-urethral sling (MUS) in women with predominant stress urinary incontinence (SUI). MATERIALS AND METHODS: This prospective cohort study included adult women with predominant SUI seen in our urology clinic between January 2018 and March 2019. Patients with: negative cough stress test, history of prior incontinence surgery, urogenital malignancy, pelvic radiation, neurological disease, body mass index more than 40 kg/m2 , the presence of more than Stage I pelvic organ prolapse, active urinary tract infection, maximum flow rate less than 15 ml/sec, postvoid residual urine more than 100 ml, abdominal leak point pressure less than 60 cm of H2 O, and pregnant women were excluded. Eligible patients underwent a transobturator MUS procedure using rectus fascia as a sling. Before the procedure, patients filled the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptom (ICIQ-FLUTS) and the Female Sexual Function Index (FSFI) questionnaire. Urinary outcomes were assessed at 3- and 12-months while sexual outcomes were assessed at 12-months. RESULTS: Thirty patients with median age of 44.5 years were included. All patients had a negative cough stress test during follow up. A significant improvement was noted in the ICIQ-FLUTS scale, bother scale, filling and incontinence subscales at 3 and 12 month follow-up. A significant improvement was also noted in the FSFI full scale score and FSFI domains of mean sexual desire, arousal and lubrication at 12 months follow-up. Two patients developed voiding dysfunction requiring urethral dilatation. CONCLUSION: Autologous transobturator MUS surgery appears to be safe and efficacious in the short term. More research is needed to clarify its role in the surgical management of SUI in women.

Efficacy and safety of mirabegron for the treatment of neurogenic detrusor overactivity resulting from traumatic spinal cord injury: A prospective study.

OBJECTIVE: To assess the clinical, urodynamic efficacy, and safety of mirabegron in patients with neurogenic detrusor overactivity (NDO) consequent to traumatic spinal cord injury (SCI). METHODS: This prospective cohort study was performed between January 2018 and July 2019 and included adult patients with stable traumatic suprasacral SCI, performing clean intermittent catheterization (CIC), and demonstrating NDO on urodynamic study (UDS). A 3-day bladder diary was made at the baseline after which all patients were started on Mirabegron 50 mg. They were followed up at 6 weeks with a repeat bladder diary and UDS which were compared with those at the baseline. RESULTS: A total of 30 patients (4 females, 26 males, mean age: 30.07 years) were included. After 6 weeks of treatment, 5 out of the 29 incontinent patients became completely dry. The mean frequency of CIC decreased from 6.63 at the baseline to 5.37 at 6 weeks (p = .002), the mean CIC volume increased from 275 ml to 341 ml (p = .0002), the mean number of incontinence episodes in between CIC reduced from 3.97 to 2.27 (p < .0001) and time from CIC to leakage increased from 1.73 h to 2.75 h (p < .0001). The mean cystometric capacity increased from 348 ml to 406 ml (p = .008) and the maximum amplitude of NDO decreased from 54 cm H2 O to 41 cm H2 O (p = .005) at 6 weeks. Only two patients reported new onset dry mouth. No major adverse events were noted and none discontinued treatment. CONCLUSION: Mirabegron is efficacious and safe in patients with NDO consequent to traumatic SCI.

Neurological safety and efficacy of darifenacin and mirabegron for the treatment of overactive bladder in patients with history of cerebrovascular accident: A prospective study.

OBJECTIVES: To evaluate the neurological safety and clinical efficacy of darifenacin and mirabegron in patients with a history of cerebrovascular accident (CVA) who had overactive bladder (OAB) symptoms. METHODS: This prospective randomized study, approved by the institute's ethics committee, was carried out at a tertiary care center from December 2018 to June 2020. Treatment naïve adult patients with a past history of CVA with stable neurological status for atleast past 3 months with symptoms of OAB for 3 or more months were included. Eligible patients received either darifenacin or mirabegron for a period of 3 months and various parameters on the 3-day International Consultation on Incontinence Questionnaire (ICIQ) bladder diary, the Montreal Cognitive Assessment-Basic score (MoCA-B), and the adverse events at 3 months posttreatment were compared to that at the baseline. RESULTS: A total of 60 patients were included, 30 in each arm. After 3 months of treatment with darifenacin or mirabegron, the majority of the ICIQ bladder diary parameters improved and there was no deterioration in the cognitive function as noted on the MoCA-B score in either of the arms. On intergroup comparison, the mean change in bladder diary parameters and the MoCA-B scores was similar between the two groups. CONCLUSION: Darifenacin and mirabegron, in the short term, do not adversely affect the cognitive function in patients with a history of CVA with OAB symptoms. Both are safe and effective treatment options in patients with OAB post-CVA.

Pulmonary alveolar microlithiasis: Blizzard of lung.

Pulmonary alveolar microlithiasis (PAM) is a rare inherited disorder in which patients present with either nonspecific signs and symptoms or are asymptomatic. Clinical-radiological dissociation is a commonly seen feature of the disease. Majority of cases are diagnosed in second and third decade of life, although presentation in paediatric and elderly population is also reported. Pathognomonic radiological findings, with normal calcium and phosphate levels can confirm the diagnosis without the need of further investigations in large number of cases. A high index of suspicion and knowledge of the disease is of paramount importance as it has a wide range of presentation and variable course thus posing a diagnostic challenge. We present two cases of this rare disease in elderly females with distinct presentations although with similar and characteristic radiological findings along with a brief review of literature of the disease.

Efficacy and safety of mirabegron for the treatment of low compliance bladder resulting from sacral/infrasacral lesions: A prospective study.

OBJECTIVE: To assess the efficacy and safety of mirabegron in patients with sacral/infrasacral lesions who have an acontractile detrusor and develop a low compliance bladder. METHODS: This prospective study included adult patients with acontractile detrusor as a result of sacral/infrasacral lesions who develop a low compliance bladder (compliance <20 mL/cmH2 O). All patients were asked to make a 48-h clean intermittent catheterization diary and underwent invasive urodynamics evaluation at the baseline, and were started on mirabegron 50 mg once daily. Patients were re-evaluated at 6 weeks with a repeat clean intermittent catheterization diary and invasive urodynamics, and the efficacy and safety of mirabegron was assessed. RESULTS: A total of 17 patients were included. After 6 weeks of mirabegron therapy, the number of patients reporting leakage in between clean intermittent catheterization reduced from seven to two (P = 0.02), the end filling pressures reduced from 41.4 to 15.1 cmH2 O (P = 0.003), the compliance increased from 9.8 to 99.9 mL/cmH2 O (P = 0.000), and the number of patients where the end filling pressure was >40 cmH2 O reduced from eight to one (P = 0.02). The cystometric bladder capacity did not change significantly. Similar effects were noted in patients who were already on clean intermittent catheterization or were started on clean intermittent catheterization at inclusion in the study. Mirabegron was well tolerated, none of the patients discontinued therapy or reported major side-effects. CONCLUSIONS: Mirabegron reduces end filling pressure, improves compliance and is safe in patients with a low compliance bladder resulting from a sacral/infrasacral lesion.

Sleepless in COVID-19: how not to lose sleep in lockdowns.

The corona virus disease 2019 (COVID-19) outbreak started in December 2019 in Wuhan, China, and spread all over the world leading to declaration of a pandemic by World Health Organization (WHO) on 11th March 2020. Most countries around the world have been on lockdown in an effort to halt the spread of virus. People around the world have been pushed into uncharted waters of uncertainty, fear, anxiety, stress and depression due to economic crash down, job losses and fear for their own health and that of their loved ones. There is a known association between anxiety/stress and sleep disturbances and vice versa. The most vulnerable population in this isolation like condition, in this lockdown, are the chief earning member of the family, women, young ones, and people with psychiatric illness.

COVID-19: Avoiding a second tragedy in a tuberculosis burdened country.

To the Editor Novel Coronavirus disease (COVID-19) was first notified in December 2019 from Wuhan, China. Now, it has spread rapidly and has been declared a pandemic affecting over 200 countries with widespread morbidity and mortality. It has been postulated that the most vulnerable population are the elderly, people living in crowded areas, children and immune-compromised individuals, such as people living with human immunodeficiency virus (HIV). The correlation of tuberculosis (TB), HIV and malnutrition are well documented and hence, people with tuberculosis should be considered as special population in this pandemic. TB is an ancient disease among humans recorded as far back as seventy thousand years which was declared a global public health emergency in 1993 by the World Health Organisation (WHO). India has the highest TB burden in the world.

Chest percussion, a common yet underutilized art.

Dear Editor Long years of respiratory medicine practice lets one develop a clinical instinct which certainly aids in diagnostic acumen...

Evaluation of the clinical profile, laboratory parameters and outcome of two hundred COVID-19 patients from a tertiary centre in India.

COVID-19 is a pandemic with over 5 million cases worldwide. The disease has imposed a huge burden on health resources. Evaluation of clinical and epidemiological profiles of such patients can help in understanding and managing the outbreak more efficiently. This study was a prospective observational analysis of 200 diagnosed COVID-19 patients admitted to a tertiary care center from 20th march to 8th May 2020. All these patients were positive for COVID-19 by an oro-nasopharyngeal swab-rtPCR based testing. Analyses of demographic factors, clinical characteristics, comorbidities, laboratory parameters, and the outcomes were performed. The mean age of the population was 40 years with a slight male predominance (116 patients out of 200, 58%). A majority of the patients (147, 73.5 %) were symptomatic, with fever being the most common symptom (109, 54.5%), followed by cough (91, 45.5%). An older age, presence of symptoms and their duration, leukocytosis, a high quick SOFA score, a high modified SOFA score, need for ventilator support, an AST level more than 3 times the upper limit of normal (ULN), and a serum creatinine level of 2 mg/dl or greater were at a significantly higher risk of ICU admission and mortality. Presence of diabetes mellitus, AST > three times ULN, serum creatinine 2 mg/dl or higher, and a qSOFA score of 1 or higher were all associated with significantly greater odds of critical care requirement. Triage and severity assessment helps in deciding the requirement for a hospital stay and ICU admission for COVID-19 which can easily be done using clinical and laboratory parameters. A mild, moderate and severe category approach with defined criteria and treatment guidelines will help in judicious utilization of health-care resources, especially for developing countries like India.   *Other members of the Safdarjung Hospital COVID-19 working group: Balvinder Singh (Microbiology), MK Sen (Pulmonary Medicine), Shibdas Chakrabarti (Pulmonary Medicine), NK Gupta (Pulmonary medicine), AJ Mahendran (Pulmonary Medicine), Ramesh Meena (Medicine), G Usha (Anaesthesiology), Santvana Kohli (Anaesthesiology), Sahil Diwan (Anaesthesiology), Rushika Saksena (Microbiology), Vikramjeet Dutta (Microbiology), Anupam Kr Anveshi (Microbiology).

A comparative analysis of various surgical approaches of nephron-sparing surgery and correlation of histopathological grade with RENAL nephrometry score in renal cell carcinoma.

Background: Nephron-sparing surgery (NSS) is the standard of care for small renal masses whenever feasible. This study aims to evaluate the perioperative outcomes of NSS performed by open (open partial nephrectomy [OPN]) or laparoscopic (laparoscopic PN [LPN]) or robotic (robotic PN [RPN]) approach over the past 6 years and to study the correlation of histopathological grade of renal cell carcinoma with the RENAL score. Materials and Methods: A retrospective analysis of prospectively collected data of all patients who underwent NSS was done. Results: A total of 135 patients underwent NSS. The mean tumour size was 4.4 cm. About 61 patients underwent OPN, 24 had LPN and 50 had RPN. Although tumour size was larger in OPN group (P = 0.01), tumour complexity based on the RENAL score was similar in OPN and RPN groups (P = 0.15). The OPN group had shorter operative time (P = 0.008) but more blood loss (P = 0.001) and length of hospital stay (P = 0.049) as compared to LPN or RPN group. Maximum radiological diameter of tumour (P = 0.017) appeared to be a significant predictor of operative time, while the open surgical approach (P = 0.003) and tumour stage (P = 0.044) were found to be significant predictors of blood loss. Hilar clamping time was similar in OPN and RPN groups (P = 0.054) but higher in LPN group (P = 0.01). However, post-operative decline in renal function (estimated glomerular filtration rate) (P = 0.08) and margin status were comparable among the three groups. The most common histopathology was clear cell carcinoma (70%), and RENAL score was identified as a significant predictor of histopathological grade of tumour (P = 0.008). Conclusion: Open, laparoscopic and robotic approaches to PN provide similar patient outcomes. OPN was usually preferred for larger tumours. The post-operative decline in renal functions and complications were comparable among the three approaches. RENAL score correlated significantly with histopathological grade and hence could help in predicting tumour behaviour pre-operatively.

Frequency volume chart for the illiterate population: A simple solution.

INTRODUCTION: We aimed to assess the feasibility of a novel method of recording frequency volume chart (FVC) in adult patients who are either illiterate or are unable to make the required written record. MATERIALS AND METHODS: This prospective study included adult patients, in whom FVC was required as part of their urological evaluation, who were either illiterate or were not sufficiently literate to make the required written record. Three groups of people were involved in the study: (i) patient, (ii) nursing staff, and (iii) the investigator/coinvestigator. The investigator/coinvestigator briefed the patient and the nursing staff, separately, regarding their roles in detail. The patient-reported (investigator/coinvestigator interpreted) data were compared with the data recorded by the nursing staff to assess the feasibility of this novel method. RESULTS: A total of 30 patients were included in the study, with a mean age of 45.1 years and male: female ratio of 2:1. The patient-reported (investigator/coinvestigator interpreted) data including 24-h urine production, daytime urine volume, nocturnal urine volume, daytime urinary frequency, nocturia, average voided volume, and maximum voided volume were similar to the data reported by the nursing staff, with no significant differences. All patients completed the FVC satisfactorily, except one patient who failed to report the night time voids. CONCLUSIONS: Our novel method of recording FVC is feasible, reliable, and clinically as informative/applicable as the written FVC in patients who are illiterate/insufficiently literate to make a written record of FVC.

Comparison of percentage free PSA, MRI and GaPSMA PET scan for diagnosing cancer prostate in men with PSA between 4 and 20 ng/ml.

INTRODUCTION: We compared the diagnostic accuracy of percentage free prostate-specific antigen (PSA), multiparametric magnetic resonance imaging (mpMRI), and gallium-68 prostate-specific membrane antigen positron emission tomography (Ga-PSMA PET) to detect cancer prostate in men with PSA between 4 and 20 ng/ml in prebiopsy settings. MATERIALS AND METHODS: This prospective study evaluated men with PSA values between 4 and 20 ng/ml, and all patients underwent percentage free PSA estimation, mpMRI, and Ga-PSMA PET scan, followed by cognitive fusion/registration biopsy along with systematic 12-core biopsy to detect cancer prostate. The diagnostic accuracy of percentage free PSA, mpMRI, and Ga-PSMA PET scan was compared with results of cognitive fusion/registration biopsy. RESULTS: A total of 15 patients were included, of which 11 had an identifiable lesion on imaging and 9 had malignancy on the final histopathology report. The sensitivity, specificity, positive predictive value, negative predictive value (NPV), and diagnostic accuracy of mpMRI were 62.5%, 71.4%, 71.4%, 62.5%, and 66.6%, respectively, and that of Ga-PSMA PET scan were 88.8%, 66.6%, 80%, 80%, and 80%, respectively. The sensitivity of detection of clinically significant cancers for Ga-PSMA was higher (100%) compared to MRI (33.3%). However, Ga-PSMA also detected a greater number of insignificant lesions as compared to MRI. CONCLUSION: Ga-PSMA PET scan has high NPV and accuracy in predicting presence of cancer and can also be used to direct specific biopsy cores during systematic biopsy.