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Objective: To record the technical problems and complications associated with the use of da Vinci S robotic system (Intuitive Surgical, Sunnyvale, CA, USA) and to review previous reports., Methods: We analysed our records for all machine- or instrument-related errors during the course of 340 consecutive robot-assisted urological operations at our centre from July 2006 to March 2009, using one robotic machine. The cause of the error (machine or human), troubleshooting methods and consequences of the errors were evaluated., Results: The overall device failure rate was 10.9% (37/340). The most frequent technical problems were related to robotic instruments (23/37). Other failures included colour/hue changes in the console image, intermittent double vision, fused illuminator bulb and problems with the master tool-manipulator device (hand-piece unit), patient cart circuitry, patient-side manipulator arm, closed-circuit camera unit or camera cable. Of 37 problems, 28 (76%) were surmountable during the course of surgery. The overall conversions to standard open/laparoscopic procedure attributable to mechanical failures of the robot were 0.6% (2/340). There were no complications or direct harm to the patient in any case. Most faults could be corrected or bypassed with some addition to operating room time., Conclusions: Despite an association of various types of new technical problems with robotic surgery, it provides a safe mode of minimally invasive surgery with very low conversion rates attributable to it, and no direct patient injury.

Purpose: To assess the feasibility, describe the technique, and report our experience with use of the da Vinci S robotic surgical system in the management of pheochromocytoma., Patients and Methods: For four patients with metabolically active adrenal pheochromocytoma (two right, two left), standard preoperative preparation was performed. A robotic transperitoneal approach was used for all cases. Sparing of the adjacent normal parenchyma was performed in all cases. All relevant perioperative details were collected and analyzed., Results: Mean operative time was 77.5 minutes (range 40-140 min), and blood loss was 97.5 mL (range 50-160 mL). There were no conversions or perioperative complications. Average tumor size was 4.7 cm. There were three episodes of intraoperative hypertension necessitating therapeutic intervention. Average analgesic requirement was 150 mg of diclofenac, and patients were allowed oral intake after 6 hours. The drain was removed within 24 hours, with average hospital stay of 4 days. The histopathology report confirmed pheochromocytoma in all patients with free surgical resection margins. Average follow-up was 9 months (range 4-14 mos) with no evidence of recurrence or extra-adrenal tumor., Conclusion: Robot-assisted excision of pheochromocytoma is feasible, safe, and efficacious in our early experience. Sparing of the normal adjacent adrenal parenchyma is possible with little detrimental effect on the oncologic efficacy of the surgery. Long-term studies are needed to further confirm this issue.

Background & Objectives: The growing concern on transmission of genetic diseases in assisted reproduction technique (ART) and the lacunae in the conventional semen analysis to accurately predict the semen quality has led to the need for new techniques to identify the best quality sperm that can be used in assisted procreation techniques. This study analyzes the sperm parameters in the context of DNA damage in cytogenetically normal, AZF non deleted infertile men for DNA damage by comet assay., Methods: Seventy infertile men and 40 fertile controls were evaluated for the semen quality by conventional semen parameters and the sperms were also analyzed for DNA integrity by comet assay. The patients were classified into oligozoospermic (O), asthenozoospermic (A), teratozoospermic (T), oligoasthenoteratozoospermic (OAT) categories and infertile men with normal semen profile. The extent of DNA damage was assessed by visual scoring method of comets., Results: Idiopathic infertile men with normal semen profile (n=18) according to conventional method and patients with history of spontaneous abortions and normal semen profile (n=10) had high degree of DNA damage (29 and 47% respectively) as compared to fertile controls (7%). The O, A, T and OAT categories of patients had a variably higher DNA damage load as compared to fertile controls., Interpretation & Conclusion: The normal range and threshold for DNA damage as a predictor of male fertility potential and technique which could assess the sperm DNA damage are necessary to lower the trauma of couples experiencing recurrent spontaneous abortion or failure in ART.

We describe a very rare congenital anomaly of the inferior vena cava in a case who presented with renal calculi and transitional cell carcinoma on the right side. The diagnosis of 'periureteric venous ring' was made on preoperative imaging and confirmed on surgical exploration. We also review the literature and discuss the embryological origin of this anomaly along with its clinical significance.

Pheochromocytoma of the urinary bladder is rare, presenting usually with hypertension, hematuria and syncopal attacks. Such cases have usually been managed with open or laparoscopic partial cystectomy. We present a case of bladder pheochromocytoma that had unusual presenting symptoms, a paraneoplastic manifestation and was successfully managed with robotic technique.

Objective: To present our experience and outcomes of robot-assisted laparoscopic pyeloplasty (RALP) for pelvi-ureteric junction obstruction (PUJO)., Patients and Methods: This was a prospective study of 85 consecutive patients who had RALP for PUJO at our institute from July 2006 to December 2008. The preoperative evaluation included intravenous urography (IVU) and diuretic renography. The type of pyeloplasty was decided based on the size of the pelves, presence of crossing vessel, level of ureteric insertion and the length of obstruction. All surgery was done through a transperitoneal approach using four or five ports. The follow-up comprised IVU and renal dynamic scintigraphy. Relevant data were collected and analysed for perioperative morbidity, complications and long-term functional outcomes., Results: In all, 86 RALPs were performed, including one bilateral, 41 right-sided and 43 left-sided cases. The mean operative time was 121 min, including an anastomosis time of 47 min. The mean estimated blood loss was 45 mL. The drain was removed within 48 h. The mean hospital stay was 2.5 days. Three patients had stents that migrated upwards, and prolonged drainage. The success rate was 97% (82/85) with a mean follow-up of 13.6 months., Conclusions: RALP is highly effective for managing PUJO, with low morbidity, quick recovery and a durable success rate.

Purpose: Surgical reconstruction is an important treatment option for obstructive azoospermia. Vasoepididymostomy results have primarily been described in men with previous vasectomy. We evaluated vaso-epididymal anastomosis outcomes using a 2-suture microsurgical intussusception technique with longitudinal suture placement in men with idiopathic obstructive azoospermia., Materials and Methods: Between April 2007 and May 2009, 24 men with idiopathic obstructive azoospermia underwent 2-layer vaso-epididymal anastomosis using a 2-suture intussusception technique. Two double armed 10-zero polyamide sutures were placed parallel to each other longitudinally along the epididymal tubule to intussuscept the tubule into the lumen of the vas deferens for the inner layer of the anastomosis. Patency was assessed by return of sperm in the semen., Results: A total of 23 men with a mean age of 31 years provided at least 1 postoperative semen sample. All had a mean 67-month history of primary infertility. In 11 men (48%) patency was noted a mean of 6.6 months (range 3 to 15) after surgery. One patient reported pregnancy by natural conception. Men with motile sperm in the epididymal fluid and those with bilateral surgery were more likely to have a patent anastomosis., Conclusions: Within 1 year after surgery approximately half of the men who underwent longitudinal vaso-epididymal anastomosis for idiopathic azoospermia had return of sperm in the ejaculate., (Copyright (c) 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Excess reactive oxygen species (ROS) beyond the scavenging capacity of antioxidants leads to DNA damage and oxidation of lipoprotein components at the cellular and subcellular level. The oxidative stress (OS) adversely affects sperm function by altering membrane fluidity, permeability and impairs sperm functional competence. In the present study, the OS status in seminal plasma and blood serum in infertile men and its relationship with spermatozoa parameters have been investigated. Four groups of infertile men viz., oligozoospermic (n = 15), asthenozoospermic (n = 17), teratozoospermic (n = 19), and oligoasthenoteratozoospermic (n = 9), and healthy fertile controls (n = 40) have been analyzed for superoxide dismutase (SOD), catalase (CAT), glutathione (GSH) and malondialdehyde (MDA) in seminal plasma and blood serum. Significant correlation between blood serum SOD and sperm count has been observed in patients (p = 0.018) and controls (p = 0.021). Similarly, significant correlation between blood serum GSH and sperm progressive motility in patients (p = 0.036) and controls (p = 0.029) is observed. The low seminal MDA is associated with increase in sperm progressive motility in patients (p = 0.039) and controls (p = 0.028). Positive correlation is found between increased seminal MDA levels and abnormal sperm morphology in both patients and controls (r = 0.523, p = 0.029; r = 0.612, p = 0.034 respectively). Correlations between blood SOD and sperm count and between blood GSH levels and progressive motility suggest that these can be important biochemical markers in assaying the sperm count and motility. A negative correlation of motility with seminal MDA indicates that sperm membrane lipid peroxidation affects the fluidity and thus mobility of sperm axoneme. This affects functional competence of the sperm and acts like a biological safeguard. The results of the present study suggest the prospects of using the blood serum and seminal plasma antioxidants as a valuable tool to evaluate the sperm reproductive capacity and functional competence.

Objectives: To assess the accuracy of Gleason grading/scoring on preoperative needle core biopsy (NCB) compared to the radical prostatectomy (RP) specimen., Materials and Methods: Data of NCB and RP specimens was analyzed in 193 cases. Gleason grade/scoring was done on both NCB and RP specimens. Sixteen cases were excluded for various reasons. The Gleason scores of the two sets of matched specimens were compared and also correlated with the PSA, age, and number of needle biopsy cores. The overall change was also correlated with the initial score on NCB., Results: The mean age and PSA were 63.3+/-2(5.27) years and 18.48+/-2(28.42) ng/ml, respectively. The average Gleason score increased from 5.51 +/- 2(1.52) to 6.2 +/- 2(1.42) (P<0.02). The primary grade increased in 57 (32.2%) cases. Overall, 97 (54.8%) cases had an increase in Gleason score. Five other cases had a change from 3 + 4 = 7 to 4 + 3 = 7. Change in Gleason score was significantly more if the score on NCB was

Ectopic pelvic kidneys with ureteropelvic junction obstruction and stones present a treatment challenge for the minimally invasive surgeon. A pure laparoscopic approach is less invasive than an open approach but is technically difficult with longer operative time. The use of the da Vinci robotic interface has the potential to refine the laparoscopic technique and improve outcomes. Here, we present successful management using the robotic technique of one such case of concomitant pyeloplasty and pyelolithotomy.

Purpose: To evaluate the role of age, Gleason score, prostate-specific antigen (PSA), PSA doubling time (PSADT), and PSA half-time (PSAT(1/2)) as prognostic factors in metastatic prostate cancer to predict long-term outcome., Patients and Methods: 412 patients with metastatic prostate cancer diagnosed after January 1995, with at least 6 months of follow-up, were enrolled. Serum PSA was determined at diagnosis and every 3-6 months thereafter. All patients underwent medical or surgical castration. End points of the study were either death or disease progression. Univariate and multivariate Cox proportional hazard analysis was used to evaluate prognostic factors., Results: Median progression-free and overall survival was 3 and 5.7 years. Patients aged

Purpose: To assess the safety and effectiveness of transurethral vapor resection of prostate (TUVRP) for the management of prostate glands with a volume of >100 g., Patients and Methods: Thirty-nine patients who were found to have benign prostatic hyperplasia and prostate volume of >100 g, as determined by abdominal ultrasonography, were offered TUVRP between July 2002 and August 2008. International prostate symptom score (IPSS), prostate volume, postvoid residue (PVR), and maximum flow rate (Qmax) formed part of preoperative evaluation. We also assessed intraoperative and postoperative parameters, including operative time, irrigant fluid requirement, blood loss, duration of postoperative catheterization, hospital stay, and postoperative complications., Results: The mean prostate volume was 121.39 g (range 101-232 g). The mean age was 65.70 years (range 54-94 years). About 12 patients had a catheter preoperatively. Mean IPSS was 24.87 (21-28). Mean Qmax and PVR were 7 mL/seconds (4-12) and 133 mL (77-160), respectively. Mean operative time was 77 minutes (50-115), and mean irrigant fluid used was 26.48 L (18-36). Mean resected weight of prostate was 49.4 g (43-54). Average postoperative catheter duration was 2.38 days (2-2.5) with average postoperative hospital stay being 3.75 days (2-5). Effectiveness assessed at 6 months was IPSS 5.7, Qmax 20.5 mL/seconds, and insignificant PVR., Conclusions: TUVRP is an alternative treatment modality for prostates >100 g owing to its excellent intraoperative vision, shorter operative time, and reduced hospital stay.

Objectives: To evaluate the efficacy of docetaxel/prednisone and zoledronic acid in hormone refractory prostate cancer (HRPC) patients and to analyze prognostic factors predicting overall survival., Methods: Forty-four HRPC patients were given docetaxel (75 mg/m(2)), prednisone and zoledronic acid (4 mg) every three weeks. Overall and progression-free survival curves were calculated. Using the log-rank test, variables predicting overall survival (age, Gleason score, baseline prostate-specific antigen [PSA], percentage PSA decline, nadir PSA, number of chemotherapy cycles) were calculated., Results: Median age was 66 years and mean PSA 171.25 ng/mL. The average number of given cycles was 6.3. A good PSA response (>50% decline) was observed in 26/44 cases (59.1%). A total of 17/44 (38.6%) patients expired with a median overall survival of 62.4 weeks. Patients with a Gleason score less than 7, who received more than four cycles and with a more-than-50% decline in PSA had significantly better survival. Variables like age, baseline PSA and nadir PSA did not significantly affect survival., Conclusion: The combination of docetaxel/zoledronic/prednisone is safe and effective in the management of HRPC. Patients with a Gleason score <7, PSA decline >50% and those who receive more than four cycles have significantly better survival.

Reactive oxygen species (ROS) levels in semen are believed to play both physiological and pathological roles in male fertility. The study was aimed to find the clinical significance of ROS levels in infertile Indian men. This pilot study included 33 idiopathic infertile men and 18 proven fertile controls. ROS levels in the washed sperm were measured using chemiluminescence assay and expressed as 10(6) cpm per 20 million spermatozoa. Sperm count, percent sperm motility, and percent normal sperm morphology were found to be significantly (P < 0.0001) reduced in infertile men compared with the controls. Median (minimum, maximum range) ROS levels of the infertile group [24.90 (6.89, 44.71)] were found to be significantly (P < 0.0001) elevated compared with the fertile controls [0.167(0.15, 2.78)]. No significant correlation was seen between ROS levels and semen parameters. Elevated ROS levels in the idiopathic Indian infertile men may be one of the underlying reasons for impaired fertility. Therefore measurement of seminal ROS levels may be used in Indian infertile men for better understanding of the aetiology and selection of antioxidant regimen in the treatment of male infertility. However, large studies may be urgently warranted to find out the role of antioxidants in ROS elevated Indian infertile men through randomised, controlled clinical study.

Lasers have been given much hype as regards their use in surgical management of benign prostatic hyperplasia (BPH). Transurethral resection of prostate (TURP), especially with its modifications still remains the gold standard treatment for BPH, owing to its efficacy and proven advantages over laser prostatectomy. Cost, unproven long-term durability, steep learning curve, and no advantages of laser prostatectomy over TURP and its modifications, make lasers superfluous in the surgical management of BPH in developing countries.

Since the first transurethral resection of the prostate (TURP) was performed by Guyon at the Necker Hospital in Paris in 1901, this treatment modality has replaced open prostatectomy as the procedure of choice for more than 95% of patients. TURP has been used in surgical treatment of benign prostatic hyperplasia (BPH) and remains the gold standard treatment. Transurethral vapor resection of the prostate (TUVRP) and holmium laser enucleation of the prostate (HoLEP) are new treatment modalities for the treatment of BPH. Each procedure has its own advantages and disadvantages. Availability of instruments, surgical expertise, and specific indications for a particular procedure are of utmost importance for successful outcome, with minimal morbidity. TURP can be either monopolar or bipolar, using thin or thick loop. Bipolar TURP is associated with less bleeding and less chances of dilutional hyponatremia. TUVRP, using a thick wedge loop, causes vaporization and resection of the prostate, and is associated with less bleeding and short operative time. HoLEP is another effective alternative for the surgical treatment of BPH. The holmium laser possesses the ideal combination of cutting and coagulation; however, it has a learning curve.

Purpose: To demonstrate the technical feasibility of the transmesocolic approach of robotic pyeloplasty for left ureteropelvic junction obstruction (UPJO)., Patients and Methods: Between July 2006 and December 2007, 60 patients underwent robot-assisted pyeloplasty that included 33 cases on the right side and 27 cases on the left side. Of the 27 left-side cases, 24 were performed using a transmesocolic approach. Three left-side surgeries were performed by mobilizing the colon because of associated accessory vessel and renal calculi. A pure robot-assisted dismembered reduction pyeloplasty with excision of the ureteropelvic junction was performed in all cases., Results: The mean operative time was 125.33 minutes. The time to perform the anastomosis was 43.58 minutes, and mean blood loss 38.7 mL. Average hospital stay was 2.5 days, and the drain was removed within 48 hours. One patient had prolonged drainage with fever because of a misplaced ureteral stent. Of the 24 patients, 23 were followed for 1 year and 1 was lost to follow-up. No patient demonstrated clinical or radiographic evidence of repeated obstruction., Conclusion: In the transmesocolic approach, mobilization of the colon is not necessary, and the UPJO can be approached directly after incising the mesocolon. This approach is safe and feasible in patients with a thin mesentry and when extensive mobilization of the kidney is not needed for any associated problems. The technique is highly effective with durable success rates similar to those of open surgery.

Purpose: To report our experience of percutaneous nephrolithotomy (PCNL) in patients who were treated previously with open stone surgery., Patients and Methods: Sixty-six patients with a history of open stone surgery (group 1) were compared with 90 patients without previous surgical intervention (group 2). Both groups were almost similar in demographic profile (age, sex, laterality, stone burden and success rate, body mass index, and location of stones. Patients who had tubeless or bilateral PCNL were excluded from the study. Antibiotics were administered prophylactically to all the patients. Patients with positive urine culture were treated with appropriate antibiotics, and sterile urine was ensured before surgery. Normal saline was used as irrigation fluid. Statistical analysis was performed using the chi-square test for qualitative variables and the Student t test for quantitative variables. A P value <0.05 was considered significant., Results: Mean time interval between previous open surgery to PCNL in group 1 was 7.6 (range 1-18) years. Mean operative time was longer in group 1 (88.4 min vs 80.2 min), but it was not statistically significant. Average drop in hemoglobin level was comparable in both groups (2.3 vs 2.1 g/dL). A significant number of patients in group 1 needed a metallic dilator for tract dilation. Hospital stay and postoperative analgesic requirement were similar in both groups. Postoperative and intraoperative complications were also similar in both groups., Conclusion: Previous open stone surgery does not alter the outcome of subsequent PCNL significantly except that these patients more frequently need relook procedures for achieving complete clearance.

In the past decade several advances have been made in the field of nuclear magnetic resonance (NMR) imaging. MR spectroscopic imaging (MRSI) is one such advance which holds promise for detecting biochemical change on imaging of the prostate, and that can be used in several ways for improving the management of patients with prostate cancer. We review the literature, technique and basics of MRSI, with its current status in various situations as applied to the management of prostate cancer.

Accurate transmission of information coded in the sperm genome is vital to the pre- and post-natal development of the offspring. Recent advances in reproductive biology have proposed evaluation of sperm DNA integrity as an important assessment tool to infer the presence of DNA strand breaks, numerical abnormalities in sperm chromosome complement, and alterations in the epigenetic regulation of the paternal genome. Oxidative stress (OS), characterized by increased free radicals, may lead to the production of apurine sites, apyrimidine sites, oxidation of nucleotides of sperm genome. This study was performed to assess the impact of OS on DNA integrity in sperms. 52 infertile men [oligozoospermic-13, asthenozoospermic-15, teratozoospermic-19, oligoasthenoteratozoospermic-5] and 20 fertile controls were investigated for products of lipidperoxides as malondialdehyde; antioxidants such as superoxide dismutase, catalase and glutathione in seminal plasma by biochemical methods. DNA integrity of the sperms was analyzed by visual scoring method in which the comets were graded into 4 categories (A-D) on the basis of their tail length indicative of increasing levels of DNA damage. Significant increase in DNA damage (higher number of sperms in group D) in cases (oligozoospermic (O)-20%, asthenozoospermic (A)-24%, teratozoospermic (T)-28%, OAT-43%) as compared to controls (8%) was found. Increased malondialdehyde levels, abnormal sperm morphology and higher DNA damage were observed in the cases. The antioxidants superoxide dismutase, catalase and glutathione had a positive association with sperm count and motility while a negative association with the percentage of dead sperms and abnormal morphology was observed. This study highlights the influence of low antioxidants on sperm genome integrity and indicates sperm DNA integrity as a better and more reliable prognostic tool for infertility evaluation than simple quantitative and morphologic evaluation of spermatozoa.

Physiological function of reactive oxygen species (ROS) has been known since a long, but recently toxic effects of ROS on spermatozoa have gained much importance in male infertility. Mitochondrial DNA (mtDNA) is believed to be both source and target of ROS. mtDNA unlike nuclear DNA is not compactly packed and hence more susceptible to oxidative stress (OS) than nuclear DNA. In the present study, the role of OS in mitochondrial genome changes was studied in men with idiopathic infertility. The study included 33 infertile oligo-asthenozoospermic (OA) men and 30 fertile controls. Semen analyses were performed and OS was measured by estimating the level of malondialdehye (MDA) in the seminal plasma and ROS in the sperm. Sperm mtDNA was sequenced by standard PCR-DNA sequencing protocol for ATPase and nicotinamide adenine dinucleotide dehydrogenase (ND) groups of genes. Sperm count and progressive motility were found to be significantly lower in infertile group than the fertile controls. Semen MDA and ROS levels of infertile group were significantly higher (p<0.0001), when compared to the control group. However, catalase and glutathione peroxidase (GPx) levels were significantly lower in infertile group, compared to controls, but no significant difference in superoxide dismutase (SOD) activity was observed between control and cases. This might be due to higher expression of SOD alone in order to overcome OS in the semen. mtDNA analysis showed significant and high frequency of nucleotide changes in the ATPase (6 and 8), ND (2, 3, 4 and 5) genes of infertile cases compared to the controls. Hence excess ROS and low antioxidant levels in the semen might cause mtDNA mutations and vice versa in OA men that might impair the fertilizing capacity of spermatozoa. Thus, it is important to understand the etiology of mitochondrial genome mutations in idiopathic OA cases for better diagnostic and prognostic value in infertility treatment/assisted reproductive technique.

Objectives: To evaluate the outcome of percutaneous nephrolithotomy (PCNL) in anomalous kidneys performed at our center., Methods: A total of 46 patients (52 renal units) with renal abnormalities were offered PCNL from January 2000 to December 2007 at our department. Of these 46 patients, 35 had a fusion anomaly (31 with a horseshoe kidney and 4 with crossed fused ectopia), 7 had malrotation, and 4 had ectopic pelvic kidneys. All 4 patients with a pelvic ectopic kidney underwent laparoscopic-assisted PCNL. The mean age was 31.5 years (range 16-52). The male/female ratio was 1.55, the left-to-right ratio was 1.3, and 6 patients had bilateral renal stones (all in horseshoe kidneys). The mean stone size was 2.4 cm (range 1-5). In addition, 8 patients (5 with a horseshoe kidney, 2 with an ectopic pelvic kidney, and 1 with a malrotated kidney) had a history of failed extracorporeal shock wave lithotripsy., Results: Complete clearance was achieved in all renal units (45 at the first attempt and 7 with a "relook"). The stone was cleared by a single tract in 46 renal units (88.5%), and 6 required 2 tracts (3 horseshoe kidneys, 2 malrotated kidneys, and 1 crossed fused ectopic kidney). Five patients with a horseshoe kidney underwent tubeless PCNL. The mean operating time for PCNL was 82.5 minutes (range 30-150), and the mean hospital stay was 3.2 days (range 1-8). The average decrease in hemoglobin was 1.4 g/dL (range 0.5-4). One patient developed injury to the pleura that was managed by intercostal tube drainage. Two patients developed post-PCNL sepsis., Conclusions: Although PCNL in anomalous kidneys is technically demanding, it gives excellent results for large or extracorporeal shock wave lithotripsy-refractory stones, if performed carefully.

Background and Purpose: Laparoscopic radical nephrectomy (LRN) has benefits in terms of cosmesis, less postoperative pain, hospital stay, and early recovery when compared with open radical nephrectomy. One of the major points of concern of this surgery, especially in developing countries, is the additional cost because of the disposable instruments. We present our experience of laparoscopic radical nephrectomy with cost-reductive techniques., Material and Methods: From 1998 to 2008, 141 patients undergoing cost-reductive LRN using minimal disposable equipment for clinically localized renal tumors were included in the study. Clinical data, including operative and postoperative management and follow-up, were recorded and analyzed statistically., Results: The transperitoneal and retroperitoneal laparoscopic techniques were performed in 46.8% and 53.2 %, respectively. Overall, the mean operative time was 139.5 min, mean estimated blood loss was 192.3 mL, mean analgesic requirement was 12.69 mg morphine equivalent, and mean hospital stay was 3.6 days. There were eight conversions to open surgery. There were 10 major and 12 minor complications with no deaths. Mean follow-up was 54.2 months with no local recurrence. There were 17 distal recurrences with no port site metastasis. The cost of LRN, using the cost-reductive techniques, was reduced by approximately US $1,900 per case., Conclusions: Cost-reductive LRN is feasible for the management of clinically localized renal tumors. It provides all the advantages of laparoscopy and can be performed with minimal additional cost, making it more acceptable to the patients, especially in developing countries.

Objectives: To assess the efficacy of nuclear matrix protein 22 (NMP-22) in the diagnosis of recurrent, superficial bladder cancer and whether it can predict for future recurrence., Methods: Patients with diagnosed and treated superficial transitional cell carcinoma urinary bladder (Stage Ta, T1, Tis, Nx, and M0) presenting for surveillance follow-up were prospectively enrolled in this study from February 2004 to August 2005. These patients underwent urine cytology, NMP-22 testing, and cystopanendoscopy on enrollment in the study. For the next year, these patients underwent cystopanendoscopy and cytology at 3-month intervals. The ability of NMP-22 to predict for recurrence was determined using the cystoscopy findings as the reference standard., Results: A total of 145 patients were included in the study. Of these, 56 had recurrence at enrollment. Of the 56 patients, 48 had positive NMP-22 findings and 22 had positive urine cytology findings. The sensitivity, specificity, positive predictive value, and negative predictive value was 85.7%, 77.5%, 70.6%, and 89.6%, respectively, for NMP-22 alone and 92.9%, 75.3%, 70.3%, and 94.4%, respectively, when the cytology and NMP-22 findings were combined. During the subsequent follow-up of 1 year, 61 recurrences developed in 47 patients. Cox regression analysis showed that those with positive NMP-22 had a 9.57 times greater risk of recurrence during 1 year compared with those with negative NMP-22., Conclusions: The results of our study have shown that the addition of NMP-22 testing to cytology increases the sensitivity for recurrence detection in patients with superficial transitional cell bladder cancer. Patients with positive NMP-22 findings developed significantly more recurrences compared with those with negative NMP-22 findings.

Purpose: To evaluate the feasibility and safety of two concomitant robot-assisted procedures in the same patient in one anesthesia setting., Patients and Methods: Data were reviewed for 15 patients for whom two concomitant robot-assisted surgeries at our center were planned. Preoperative details, port position, intraoperative problems encountered, surgical and anesthesia time, blood loss, complications, hospital stay, and postoperative recovery were analyzed., Results: Fifteen patients underwent two concomitant robot-assisted procedures; at least one of the two surgeries was a urologic procedure. The second procedure added <50 mL of blood loss. Surgical time was increased by 58 minutes and 30 minutes in cases in which the primary procedure involved the upper and lower urinary tract, respectively, while anesthesia time was increased by 82 minutes and 30 minutes, respectively. There were no added complications during the second procedure, and hospital stay was not increased, being limited only by the first procedure., Conclusion: Planned robot-assisted surgery for two different operations is feasible in one anesthesia session, thereby reducing cost and overall hospital stay for the patient without any increased risk of perioperative morbidity. The decision to continue with the second procedure depends on the successful completion of the first procedure in a reasonable time and without any complications.

Aim: To review our experience and outcome of transpubic urethroplasty for complex posterior urethral strictures., Patients and Methods: 19 patients, mean age 17.8 (6-35) years, were treated with transpubic urethroplasty over the last 6 years. All had traumatic etiology (15 due to road traffic accidents and 4 due to falls from height). Mean stricture length was 4.4 (3.0-6.0) cm. All had a history of some intervention earlier. Three had rectourethral fistula, and 2 sinus tract in perineum which was connected to the periurethral cavity. One had a long fistulous tract connected through the anus to the anterior abdominal wall. One patient each had urethrocutaneous fistula, periurethral cavity and osteomyelitis of the pubic bone., Results: 16 of 19 (84.2%) patients had excellent outcomes with no evidence of stricture. Three had acceptable outcomes with some evidence of stricture. The mean operative time was 3.2 (2.5-4.0) h and average blood loss was 650 (500-900) ml. The mean hospital stay was 7.6 (6-12) days and average follow-up was 30 (7-66) months. Two patients developed mild wound infection. One patient each developed epididymoorchitis, perineal hematoma, fecal fistula and urine leak. One patient failed to void, and one patient developed erectile dysfunction., Conclusion: Transpubic urethroplasty is an excellent approach for patients with complex posterior urethral strictures., (Copyright 2009 S. Karger AG, Basel.)

Purpose: Ether-a-go-go (EAG) or EAG-related (ERG) voltage-gated potassium ion channels are involved in tumor generation and progression. Their over- and/or misexpression has been demonstrated in various tumors, and inhibition of these channels has suppressed proliferation of various cancer cells. We investigate and compare the pattern of expression of EAG and human ERG (HERG) channels in renal cell carcinoma and "normal" renal tissue., Method: Tissue samples, obtained at the time of radical nephrectomy from the tumor-bearing areas, and uninvolved renal tissue were preserved in 4% paraformaldehyde and cryosectioned at 20 mum. Immunohistochemical and Western blot analysis was performed on the tumor and uninvolved kidney parenchyma by incubating with polyclonal anti-HERG 1b (Alomone Lab, Israel), anti-EAG1, and anti-EAG2. Pattern of expression of EAG/HERG channels in normal renal tissue and carcinoma were noted and compared., Results: The study was performed on 16 radical and four partial nephrectomy specimens (n = 20). All tumors in the cohort were clear cell renal carcinoma. Normal renal tissue was found to exhibit heterogeneous cytoplasmic positivity for EAG1 and focal HERG immunoreactivity (IR) in the proximal (PCT) and distal convoluted tubules (DCT). EAG2 IR was absent in the normal renal tissue. Clear cell RCC demonstrated a loss of HERG expression while diffuse overexpression of EAG1 and EAG2 was noted. Western blot analysis corroborated the immunohistochemical observations., Conclusions: In our study both EAG1 and EAG2 potassium channels were overexpressed in clear cell renal cancer. In contrast to other adenocarcinomas, there is loss of HERG expression in clear cell RCC, which may possibly explain its chemoresistance. These ion channels may provide a potential for targeted therapy.

Objective: We review our experience of end-to-end urethroplasty for urethral strictures performed during the last 6 years., Material and Methods: From September 2001 to December 2006, 138 male patients underwent anastomotic urethroplasty at our center. Mean age was 28.1 years (range 6-71), average stricture length was 2.2 cm (range 0.7-6.0). One hundred and one patients (73.2%) had obliterative stricture while 37 (26.8%) still had some urethral passage. Ninety (65.2%) had a history of previous intervention. Sixty patients (43.5%) had associated complicating factors like urethrocutaneous fistula, rectourethral fistula, vesical calculus, blind tract and cavities, bony deformity, or urinary tract infection., Results: The mean operative time was 92 min (range 60-240). Average follow-up was 26.7 months (range 6-60). One hundred and fourteen (82.6%) had excellent outcome, 18 (13%) had acceptable outcome and 6 (4.3%) failed to respond. Seventeen patients developed complications: 5 developed wound infection, 3 epididymorchitis, 2 failed to void, 2 each had incontinence and perineal hematoma, and 1 each had erectile dysfunction, accidentally pulled his catheter out and had urethrocutaneous fistula., Conclusion: End-to-end urethroplasty is an ideal procedure for managing strictures of bulbous and posterior urethra in properly selected cases., (Copyright 2009 S. Karger AG, Basel.)

Pneumocephalus is collection of gas or air within the cranial cavity. This has been described with trauma, cranial surgery, air embolism, and rarely as a result of central nervous system infections. We report a case of diffuse pneumocephalus secondary to Enterobacter cloacae meningitis. The diagnosis was suspected by cranial ultrasound and confirmed by computer tomography.

Background: Chromosomal anomalies have been postulated to be one of the principal genetic factors in reproductive failure. The principal structural anomalies are Robertsonian translocations which occur at a total frequency of rate 1.23 per thousand in newborns. Since most infertile men with Robertsonian translocation are oligospermic, they are good candidates for assisted reproduction like in vitro fertilization and intracytoplasmic sperm injection. However, a large number of such men/couples experience recurrent assisted procreation failure., Material/methods: The aim of the study was to diagnose the genetic basis of recurrent assisted reproductive failure (in vitro fertilization /intracytoplasmic sperm injection) in infertile men. One hundred twenty infertile men with idiopathic infertility who experienced recurrent assisted procreation techniques failure were recruited into this study after giving informed consent and after ethical clearance had been obtained. Semen and cytogenetic analyses were done to assess the semen status and cytogenetic profile of these men., Results: Robertsonian translocations were found in 6 of 120 participants (5%). The men with Robertsonian translocation had recurrent assisted procreation techniques failure (>4 failed attempts; 3 in vitro fertilization and at least 1 unsuccessful intracytoplasmic sperm injection). In comparison, the men with a Yq microdeletion and other chromosomal abnormalities conceived after 1 to 2 in vitro fertilization cycles. These chromosomal anomalies may be the basis of failure of these assisted-reproductive procreation techniques., Conclusions: These results highlight the need for genetic investigations in all infertile men experiencing recurrent assisted procreation techniques failure.

Objectives: Screening for prostate cancer using serum prostate-specific antigen (PSA) determination has a positive predictive value of only 30% to 42% for a PSA level between 4 and 10 ng/mL. Magnetic resonance spectroscopic imaging (MRSI), which identifies cancer on the basis of changes in cellular metabolite levels, might be able to identify patients with noncancerous PSA elevation and help avoid unnecessary biopsies. We tested this hypothesis by evaluating the incidence of prostate cancer in men with a PSA level of 4 to 10 ng/mL and a negative MRSI study., Methods: A total of 155 men underwent a three-dimensional proton MRSI of the prostate before transrectal ultrasound-guided biopsy for clinical indications. MRSI was performed using an endorectal coil on a 1.5-T magnetic resonance scanner. Patients with no voxels positive for malignancy underwent standard sextant biopsy, and additional MRSI-targeted biopsies were obtained in men with suspicious or malignant voxels. Patients with a biopsy negative for cancer underwent repeat serum PSA estimation every 6 months for a minimum of 18 months., Results: Of the 155 men, 36 (mean PSA level of 6.47 ng/mL, range 4.25 to 9.9) had no malignant voxels on MRSI. None of them were positive for cancer on biopsy. Of these 36 men, 26 completed at least 18 months (mean 26.9, range 18 to 44) of follow-up. Four patients required repeat biopsies and one, with a persistently elevated PSA level was diagnosed with prostate cancer 29 months after the initial MRSI., Conclusions: The results of our study have shown that prostate biopsy can be deferred in patients with an increased serum PSA of 4 to 10 ng/mL if their MRSI does not show any malignant voxels.

Objectives: To evaluate the success rate of redo anastomotic urethroplasty and to compare it with primary anastomotic urethroplasty., Methods: We compared 52 patients with post-traumatic posterior urethral strictures (group 1, mean age 24.6 years, range 10-62) who had undergone redo urethroplasty with 66 patients (group 2, mean age 22.6, range 6-71) who had undergone primary anastomotic urethroplasty. Mean stricture length was 2.0 cm (1-4.5) and 2.5 cm (1.5-6), respectively. All of the patients in group 1 had a stricture located at the bulboprostatic anastomotic site. In group 2, 43 (65.2%) had a bulbomembranous stricture and 23 (34.8%) had a prostatomembranous stricture., Results: Mean operative time was 140 (100-240) and 90 min (75-200) in group 1 and 2, respectively. Mean blood loss was 180 (80-900) and 125 mL (50-700), respectively. Mean hospital stay was comparable (6.6 days vs 5.5 days) between the two groups. Mean follow up was 54 months (10-144) for group 1 and 62 months (12-122) for group 2. Corporal separation, inferior pubectomy, a transpubic approach and urethral rerouting were required in 22 (42.3%) and 12 (18.2%), 7 (13.5%) and 3 (4.5%), 12 (23%) and 5 (7.6%), 2 (3.8%) and nil patients in group 1 and 2, respectively. An excellent or acceptable outcome was achieved in 42 (80.8%) and 57 (86.4%), 8 (15.4%) and 7 (10.6%) patients, respectively. Two patients in each group failed., Conclusions: Previously failed end-to-end urethroplasty does not alter the success rate of redo end-to-end urethroplasty.

Objectives: To evaluate technical feasibility and analyze outcome of laparoscopic adrenalectomy (LA) for large adrenal masses more than 5 cm., Methods: The data of 22 patients (8 men, 14 women), who underwent LA for adrenal masses >5 cm between January 1995 and July 2007 were analyzed for this study., Results: Twenty-two patients with a mean age of 42.5 years underwent LA for large adrenal masses (>5 cm) between January 1995 and July 2007. Transperitoneal and retroperitoneal laparoscopic adrenalectomy (TPLA and RPLA) was performed in 15 and 7 patients, respectively. The mean-operative time, blood loss, tumor size and hospital stay were 149.33 and 132.1 min, 132.33 and 94.28 ml, 7.85 and 5.85 cm and 3.5 and 3.28 days, respectively. Histopathological examination of the specimen confirmed adrenal carcinoma in 5, pheochromocytoma in 14, myelolipoma in 2 and adenoma in 1 patient. Two patients of pheochromocytoma had required open conversion, one from each group (TPLA and RPLA). Three patients had postoperative complications (wound infection 1, pneumonitis with fever 1 and retroperitoneal collection 1)., Conclusions: The size of an adrenal mass on preoperative imaging studies alone should not be the primary factor in determining whether LA should be performed. LA for adrenocortical cancers could be performed safely and effectively in the selected group. Transperitoneal approach is most suitable and recommended for large adrenal tumor and adrenal carcinoma to employ laparoscopy. One approach (TP or RP) over the other also does not lead to the substantial benefits either to the patients or to the surgeon.

Objectives: To compare outcome and long term follow up of laparoscopic retroperitoneal nephroureterectomy with excision of cuff of bladder (LRPNUT-BCE) and standard open nephroureterectomy with excision of cuff of bladder (ONUT-BCE) in patients of upper urinary tract transitional cell carcinoma (UTTCC)., Material and Methods: From January 1998 to October 2006, we have performed over 55 cases of nephroureterectomy with excision of cuff of bladder for UTTCC. Out of these, 48 patients undergoing LRPNUT-BCE and ONUT-BCE were categorized retrospectively into group A (21), and group B (27), respectively. The clinical data including intraoperative, postoperative, and follow-up data was recorded for two groups and analyzed statistically., Results: The mean operating time was significantly higher in-group A (P < 0.001). The different techniques of bladder cuff excision were used in group A. The mean analgesic use, hospital stay and weeks to normal activity were significantly lesser in-group A (P < 0.001). The intraoperative, postoperative complications and mean follow up were comparable in two groups. There was no local recurrence in either group. The bladder recurrence and distant metastases were comparable in two groups (group A--9.52%, group B--11.1% and group A--9.52%, group B--11.1%, respectively). The 5-year recurrence free, cancer specific and overall survivals were comparable in two groups., Conclusions: On long-term follow-up of oncological efficacy, LRPNUT-BCE satisfactorily compares with traditional open surgery (ONUT-BCE) with longer operating time, while decreasing postoperative morbidity and extending benefits of minimally invasive surgery to the patients.

Purpose: To assess the efficacy, safety, and morbidity of tubeless percutaneous nephrolithotomy (PCNL) and compare it with standard PCNL., Patients and Methods: A total of 135 patients (140 renal units) undergoing tubeless PCNL (group 1) from June 2000 to September 2007 were compared with a similar group of 185 (194 renal units) patients undergoing standard PCNL (group 2) in the same period. Patients who needed more than two percutaneous tracts; who had significant intraoperative bleeding, intraoperative perforation of the pelvicaliceal system, excessive manipulation at the ureteropelvic junction, or a residual stone after the procedure; and who had a solitary kidney or azotemia were excluded from the study. The chi-square test was performed for statistical analysis of qualitative variables and the student's t test for quantitative variables. A P value < 0.05 was considered significant., Results: The mean age in group 1 was 34.4 years (range 9-66 yrs) and in group 2 was 32.6 years (range 6-74 yrs). Male/female ratio was 1.7 and 1.6 respectively. The average stone size in group 1 was 3.2 cm (range 2-5.5 cm) v 3.6 cm (range 2.2-6.0 cm). Sixteen patients in group 1 and 24 patients in group 2 were in the pediatric age group. Simultaneous bilateral PCNL was performed in 6 patients in group 1 and 10 patients in group 2. Both the groups were comparable in age, sex ratio, side ratio, stone size, location, preoperative incidence of urinary tract infection, method of tract dilatation, and mean operative time. The incidence of single tract (95 v 98 in group 1 and group 2) for complete stone clearance was significantly more in the tubeless group. Mean hospital stay (1.8 v 2.9 days) and the analgesic requirement (68 mg v 210.5 mg of pethidine) was also significantly less in the tubeless group. Blood loss and mean operative time were also less in the tubeless group but were not statistically significant., Conclusion: Tubeless PCNL is safe and effective. It has significantly less morbidity, a shorter hospital stay, and less postoperative analgesic requirement in comparison with standard PCNL.

Genitourinary tuberculosis (GUTB) occurs in 15-20% cases of pulmonary tuberculosis with a prevalence of 400 per 100,000 population. Reconstructive surgery for GUTB is required for cases with grossly distorted and dysfunctional anatomy that are unlikely to regress with chemotherapy alone. In the recent past, there has been a tremendous increase in the variety of reconstructive procedures for the urinary bladder, used in the management of GUTB. Augmentation cystoplasty includes the goals of increasing bladder capacity, while retaining as much of bladder as possible. Various bowel segments (from the stomach to the sigmoid colon) have been used for bladder reconstruction. The choice of material for reconstruction is purely the surgeon's prerogative--his skill, the ease, the mobility and length of mesentery (allowing bowel to reach the bladder neck without tension and maintaining an adequate blood supply). The presence or absence of concomitant reflux is of considerable importance. In the former, an ileocystoplasty with implantation of ureter to the proximal end of the isolated ileal loop and anastomosis of the distal end of the ileal loop to the bladder neck and trigone is advocated. In the latter case, the ureterovesical valve is preserved and colocystoplasty is preferred, wherein the sigmoid colon on being opened along its antimesentric border is joined to the trigone and bladder neck and then to itself to form a capacious pouch. Gastrocystoplasty reduces the risk of acidosis but is associated with complications like hypochloremic alkalosis and 'hematuria-dysuria' syndrome. Orthotopic neobladder reconstruction is a feasible option, suitable in cases of tubercular thimble bladder with a markedly reduced capacity (as little as 15 ml), where an augmentation alone may be associated with anastomatic narrowing or poor relief of symptoms. In this article, we review the various bladder reconstruction options used for the surgical management of GUTB, along with their indications and complications.

Background and Purpose: Supracostal access for percutaneous renal surgery raises concern for the intrathoracic complications of the puncture. We analyzed the incidence of pleural transgression and intrathoracic complications after supracostal punctures in relation to the site of puncture (medial v lateral placement) and the respiratory phase during the puncture., Patients and Methods: We conducted a prospective study of 28 consecutive supracostal accesses in our department. All the punctures were made by the treating urologist under fluoroscopic guidance. Punctures were made during the normal respiratory cycle, and dilatation was up to 30F. Postoperatively, chest radiography and CT of the chest and upper abdomen were performed for evaluation of complications., Results: All supracostal accesses were supra-12th rib only. The average distance from midline of the site of puncture on the skin was 8.2 cm (range 5.5-9.1 cm). Complete stone clearance was achieved in 27/28 (96.4%) of the renal units. One patient had symptomatic hydrothorax necessitating chest tube placement. None of the patients had any lung or solid organ (liver or spleen) injury on CT imaging. Three patients had mild pleural effusion without symptoms, which was detected on postoperative CT., Conclusion: Laterally placed supra-12th rib punctures made during the normal ventilatory cycle have an acceptably low pleural morbidity and no risk of lung injury.

Results of the preliminary study on the evaluation of the role of magnetization transfer imaging (MTI) of prostate in men who had raised prostate-specific antigen (PSA) (>4 ng/ml) or abnormal digital rectal examination (DRE) are reported. MT ratio (MTR) was calculated for 20 patients from the hyper- (normal) and hypo-intense regions (area suspicious of malignancy as seen on T2-weighted MRI) of the peripheral zone (PZ) and the central gland (CG) at 1.5 T. In addition, MTR was calculated for three healthy controls. Mean MTR was also calculated for the whole of the PZ (including hyper- and hypo-intense area) in all patients. Out of 20 patients, biopsy revealed malignancy in 12 patients. Mean MTR value (8.29+/-3.49) for the whole of the PZ of patients who were positive for malignancy on biopsy was statically higher than that observed for patients who were negative for malignancy (6.18+/-3.15). The mean MTR for the whole of the PZ of controls was 6.18+/-1.63 and is similar to that of patients who were negative for malignancy. Furthermore, for patients who showed hyper- (normal portion) and hypo-intense (region suspicious of malignancy) regions of the PZ, the MTR was statistically significantly different. These preliminary results reveal the potential role of MT imaging in the evaluation of prostate cancer.

Objective: To analyze the feasibility and outcome of retroperitoneoscopic nephrectomy for benign nonfunctioning kidneys and compare it with open simple nephrectomy., Materials and Methods: From January 1998 to December 2006, 505 retroperitoneoscopic nephrectomies were performed. In the same time period, 112 open nephrectomies were also performed. In the retroperitoneoscopic group, the mean age was 39 years (range 15-74 years); 204 (40.4%) were men and 301 (59.6%) were women. Forty in this group had a history of surgery. Thirty-six patients had a pyonephrotic kidney; 33 of these patients had undergone percutaneous nephrostomy preoperatively. The cause of the nonfunctioning kidney was ureteropelvic junction obstruction in 198 patients, calculus disease in 193 patients, genitourinary tuberculosis in 48 patients, renal dysplasia in 19 patients, anomalous kidney in 20 patients, and renovascular hypertension in 16 patients. In 11 patients, there were other causes for the nonfunctioning kidney., Results: Retroperitoneoscopic nephrectomy was performed in 476 (94.2%) patients. Conversion to open nephrectomy was necessary in 25 patients. The mean operative time was 85 minutes (range 45-240 min) in the retroperitoneoscopic group and 70 minutes (range 35-120 min) in the open group. The mean blood loss was 110 mL (range 30-600 mL) in the retroperitoneoscopic group and 170 mL (range 70-500 mL) in the open group. Four (0.8%) patients in the retroperitoneoscopic group needed a blood transfusion, whereas 5 (4.5%) patients in the open group had a blood transfusion. The hospital stay in the retroperitoneoscopic group was 3 days (range 1-7 d) and was 5 days (range 3-12 d) in the open group., Conclusions: Retroperitoneoscopic nephrectomy, although technically challenging, is becoming a gold standard for patients with nonfunctioning kidneys caused by benign conditions.

Purpose of Review: A cooperative patient is essential in maintaining stone targeting for optimal fragmentation during extracorporeal shock wave lithotripsy (ESWL). Therefore, it is important to choose an appropriate analgesic with minimal adverse effects. The guidelines for pain management during ESWL have not been established., Current Status: Various analgesic agents including opioids (morphine, pethidine, and fentanyl), nonsteroidal anti-inflammatory drugs (NSAIDS - diclofenac, propofol, ketorolac, and piroxicam), local anesthetic agents and a number of combinations have been used during ESWL by various techniques (general anesthesia, regional anesthesia, subcutaneous and intravenous injections, patient-controlled analgesia, and monitored anesthesia care). Cutaneous creams like eutectic mixture of local anesthesia (EMLA) whether used alone or in combination with oral NSAIDS have also been used and are able to reduce analgesic requirements. Topical application of a combination of dimethyl sulfoxide and lidocaine has also been found to be effective., Conclusion: The ideal analgesic, offering optimal pain control, minimal side effects, and cost-effectiveness is still elusive. Opioids administered using various techniques, provide effective analgesia, but require active monitoring of patient for potential adverse effects. Combination therapy (oral NSAID and occlusive dressing of EMLA, DMSO with lidocaine) offers an effective alternative mode for achieving analgesia with minimal morbidity. This therapy avoids the need for general anesthesia, injectable analgesics, and opioids along with their side effects.

Infertility is a major health problem affecting about 10-20% of couples in the reproductive age group. Male factor is assumed to be responsible in about 50% cases of infertility. The origin of reduced testicular sperm function is unknown in about 50-70% of cases and for such couples assisted reproduction techniques (ART) are a boon. Male infertility is often due to poor semen quality and may be associated with genetic defects. ART has revolutionized management of infertility and intracytoplasmic sperm injection (ICSI) is the ART procedure of choice in 60-80% cases. Despite major technological advancements and professional expertise in ART, the success rate and carry-home live birth rate of ICSI is low (18-25%). This study was aimed to understand the genetic etiopathology of recurrent ART failure. For this, 110 couples with 3 or more failed ART cycles were recruited. A detailed history was taken and only idiopathic ART failure cases were enrolled for this study. They were subjected to cytogenetic and Yq microdeletion analysis. Genetic abnormalities were detected in 19 couples. Since a large number (18.2%) cases harboured genetic abnormalities, it is important for all couples opting for ART to undergo a thorough genetic analysis to prevent recurrent emotional, physical and financial stress.

Background & Objective: Analysis of the microdeletions in the azoospermia factor (AZF) region of Y chromosome by PCR is an important screening tool in the work-up of infertile males opting for assisted reproductive techniques. In the present study, the Y chromosome microdeletions were analyzed by PCR using primers corresponding to 16 sequence tagged sites (STS) and three genes of the AZF region in infertile Indian men. Feasibility of developing a simplified multiplex PCR for screening of the Y chromosome microdeletions has been explored., Methods: A total of 271 male subjects were analyzed, of which, 170 were infertile patients (51 oligospermic and 119 azoospermic) and 101 were fertile controls. Subjects showing normal karyotype only were included in the study. The semen analysis was done and plasma follicle stimulating hormone (FSH) concentrations were determined by radioimmunoassay. Testicular histopathology was analyzed by fine needle aspiration cytology (FNAC)., Results: Y chromosome microdeletions were observed in nine out of 170 (5.29%) infertile males all of whom were azoospermic. Of the nine subjects, two had deletions in AZFa, one in AZFb, three in AZFc and three in AZFb+c regions. No deletions were observed in the infertile severe oligospermic men (< 5 million sperm/ml semen) and fertile controls. No difference in the FSH concentrations of infertile patients with and without deletions (18.36 and 18.10 mIU/ml respectively) was observed. A clear relationship between Y chromosome microdeletions and testicular phenotypes could not be established. Two multiplex PCRs were designed using 7 STSs markers, which could detect Y chromosome microdeletions in infertile male subjects as efficiently as PCR based on larger number of PCR reactions., Interpretation & Conclusion: The multiplex PCRs described in the present study may be a suitable, cost-effective and less time consuming method for screening the Y chromosome deletions in infertile males in routine clinical diagnosis and counselling prior to assisted reproduction.

Introduction: The aim of the study was to evaluate the status of Her2/neu protein expression in patients with muscle-invasive urothelial carcinomas of the bladder treated with radical cystectomy and to determine its prognostic significance., Material and Methods: We retrospectively analyzed the data of 90 patients who had undergone cystectomy for invasive transitional cell carcinoma of the urinary bladder. Immunohistochemical analysis for Her2/neu was done on paraffin-fixed tissues with CB11 antibodies (BioGenex, San Ramon, CA, USA). Sections with grade 2 and grade 3 staining were considered positive for Her2/neu., Results: Over a median follow-up period of 46 months (24-96 months) 46 patients are living without disease recurrence and six with recurrent disease either at the local site or with distant metastases. The remaining 38 patients have died. The median overall survival time was 50 months, and median disease-free survival time was 40 months. The Her2/neu status was significantly related to the tumor stage (P = 0.001), lymph node involvement (77% in N+ vs 23% in N0; P = 0.001) and the grade of the disease (32% of grade 2 vs 71% of grade 3; P = 0.037). Kaplan-Meier curves showed a significantly worse disease-related survival period (log rank P = 0.011) for patients with Her2 overexpressing tumors than for those without overexpression. In addition to tumor stage [P = 0.001; relative risk (RR) = 2.62] and lymph node status (P = 0.0001; RR = 2.95), Her2 status (P = 0.020; RR = 2.22) was identified as an independent predictor for disease-related survival in a multivariate analysis., Conclusion: These results suggest that Her2 expression might provide additional prognostic information for patients with muscle-invasive bladder cancer. Future studies on Her2 expression with chemosensitivity and the efficacy of Her2-targeted therapies in urothelial carcinomas are warranted.

Objectives: To report our experience with laparoscopic radical cystectomy and extracorporeal urinary diversion for high-grade muscle invasive bladder cancer in a consecutive series of 48 patients with 3 years of follow-up., Methods: From June 1999 to April 2006, 48 patients (42 men and 6 women; mean age 59 years, range 24 to 80) with bladder cancer underwent laparoscopic radical cystectomy and bilateral pelvic lymph node dissection at our institution. Urinary diversion was done extracorporeally through the specimen extraction incision., Results: The mean operating time was 310 minutes, and the mean blood loss was 456 mL. In 1 patient, conversion to open surgery was required because of severe hypercarbia. Three major complications were observed intraoperatively (rectal injury in 2 and external iliac vein injury in 1 patient). However, all these complications were managed laparoscopically, with completion of the procedure laparoscopically. The mean hospital stay was 10.2 days (range 7 to 25). One patient died in the postoperative period of severe lower respiratory tract infection and septicemia. Histologic examination showed organ-confined tumors (Stage pT1/pT2/pT3a) in 34 patients (71%) and extravesical disease (pT3b/pT4) in 14 (29%). Of the 48 patients, 12 (25%) had lymph node involvement. The mean number of nodes removed was 14 (range 4 to 24). At a mean follow-up period of 38 months (range 10 to 72), 35 patients were alive with no evidence of disease (disease-free survival rate 73%)., Conclusions: The results of our study have shown that laparoscopic radical cystectomy is a safe, feasible, and effective alternative to open radical cystectomy. Extracorporeal urinary diversion through a small incision decreases the operating time, while maintaining the benefits of laparoscopic surgery. The 3-year oncologic efficacy was comparable to that of open radical cystectomy.

Purpose: To investigate the effect of position on voiding using uroflowmetric variables and postvoid residual urine volume assessment in healthy normal women., Materials and Methods: 67 healthy females volunteered to participate in this study. Their mean age was 32 years. Each female attended the urodynamic suite on 2 separate days. They performed 2 voids, 1 in a sitting and another in a squatting posture each day. Maximum flow rate (Q(max)), average flow rate (Q(ave)), voided volume and corresponding postvoid residual urine (PVR) were compared for each position using paired Student's t test., Results: The mean Q(max) values obtained for sitting and squatting postures were 18.4 +/- 3.2 and 24.8 +/- 4.9 ml/s, respectively, and corresponding Q(ave) values were 9.2 +/- 1.9 and 12.3 +/- 3.3 ml/s, respectively. Mean PVR values for sitting and squatting were 51.8 +/- 22.2 and 21.6 +/- 12.7 ml, respectively., Conclusion: The posture adopted for micturition affects uroflowmetric variables. The squatting posture is associated with a significantly higher maximum flow rate and a lower postvoid residue. Therefore, when low urine flow rates or high residual urine volumes are encountered during urodynamic study, the patients should be asked whether they normally micturate in a sitting or squatting position. If the former position is used, repeat studies with the patients squatting should be considered before accepting an abnormal test result as indicative of lower-urinary-tract dysfunction., ((c) 2008 S. Karger AG, Basel.)

Unlabelled: We present the outcomes of a large series of patients treated with radical cystectomy and pelvic lymphadenectomy for transitional cell carcinoma of bladder., Materials and Methods: A total of 502 patients underwent radical cystectomy (RC) for bladder cancer from 1992 till December 2006. Of these, 432 patients with primary transitional cell carcinoma of bladder underwent RC with bilateral pelvic lymphadenectomy with a curative intent. The clinical course, pathologic characteristics and long-term clinical outcomes were evaluated in this group of patients., Results: The median follow-up was 62 months. There were 30 (6.9%) perioperative deaths and 111(25.7%) early complications. The recurrence-free survival (RFS) and overall survival (OAS) were 66% and 62% at five years and 62% and 40% respectively at 10 years. The RFS and OAS were significantly related to the pathological stage and lymph node status with increasing pathological stage and lymph node positivity associated with higher rate of recurrence and worse OAS (P < 0.001). A total of 145 patients (33.5%) developed bladder cancer recurrence. Of these, 40 (27.6%) developed local pelvic recurrence and 105 patients (72.4%) developed distant recurrence. The median time to local and distant recurrence was 12 and 16 months respectively., Conclusion: The clinical results reported from this large group of patients demonstrate that radical cystectomy provides good survival results for invasive bladder cancer patients with low incidence of pelvic recurrence.

Background and Purpose: The morbidity associated with transurethral resection of the prostate (TURP) for large-volume prostates has prompted attempts to modify the standard equipment and techniques. Patients with large prostates (>70 g) need longer operative time, and have greater blood loss and higher irrigant fluid requirements; therefore, the traditional surgical recommendation for the management of benign prostatic hyperplasia (BPH) >70 g is open surgery. We assessed the effectiveness and safety of transurethral vapor resection of the prostate (TUVRP) for the management of prostate glands with a volume >70 g., Materials and Methods: Eighty-nine patients with a diagnosis of BPH who had a prostate volume >70 grams determined by abdominal ultrasonography underwent TUVRP between July 2002 and March 2006. Preoperative evaluation included assessment of International Prostate Symptom Score (IPSS), prostate volume, postvoid residual (PVR), and maximum flow rate (Q(max)). Intraoperative and postoperative parameters, including operative time, total irrigant requirement, blood loss, duration of postoperative catheterization, hospital stay, and complications were also analyzed., Results: The mean prostate volume for the 89 patients was 83.3 g (range 70-169 g). The mean age was 67.25 years (range 55-87 yr). Symptom duration varied from 2 months to 7 years. Twenty-two patients used a catheter preoperatively. The mean IPSS score, Q(max), and PVR were 23, 7.1 mL/sec, and 116 mL, respectively. The mean operative time was 64 minutes, and mean irrigant used was 21.4 L. The mean weight of resected tissue was 31.3 g. The average postoperative catheter duration was 2.25 days. Complications included transient dysuria in 11 patients, hyponatremia in two patients, and urethral stricture in two patients. No patient required a blood transfusion postoperatively. The effectiveness as assessed at 6 months was IPSS 5.1, Q(max) 22.5 mL/sec, and PVR not significant., Conclusions: TUVRP is safe and effective in patients with large prostates (>70 g) with minimal complications and faster postoperative recovery. This technique helps to avoid the morbidity associated with open surgery.