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Objective: The authors examined gender differences in d-amphetamine-induced displacements of [(18)F]fallypride in the striatal and extrastriatal brain regions and the correlations of these displacements with cognition and sensation seeking., Method: Six women and seven men underwent positron emission tomography (PET) with [(18)F]fallypride before and after an oral dose of d-amphetamine. Percent displacements were calculated using regions of interest and parametric images of dopamine 2 (D(2)) receptor binding potential., Results: Parametric images of dopamine release suggest that the female subjects had greater dopamine release than the male subjects in the right globus pallidus and right inferior frontal gyrus. Gender differences were observed in correlations of changes in cognition and sensation seeking with regional dopamine release., Conclusion: Findings revealed a greater dopamine release in women as well as gender differences in the relationship between regional dopamine release and sensation seeking and cognition.

Purpose: To report our experience in managing nine patients with forgotten ureteral stents that resulted in chronic renal failure (CRF)., Patients and Methods: We reviewed our stent records from January 1994 to January 2004 to analyze cases of forgotten indwelling ureteral stents in solitary kidneys that had led to CRF (serum creatinine 4-14 mg/dL). These patients had normal renal function prior to the interventions at which stents were placed. They were subjected to multimodal endourologic management, including cystolithotripsy and ureteroscopic and percutaneous lithotripsy, to make them stent and stone free in a single operative session., Results: The median dwell time of the retained stents was 39 months. Three patients were not aware of the stent, while six chose to ignore it. All patients underwent a temporizing percutaneous nephrostomy with an 8F pigtail catheter and were operated on 2 to 4 weeks later. All nine patients were rendered stone and stent free; however, one patient succumbed to septic complications 3 weeks after the operation. At last follow-up (6-56 months), two patients are on the transplant waiting list, while six are living with mild to moderate renal failure on conservative treatment., Conclusions: Chronic renal failure caused by encrusted stents in a functionally solitary kidney is a disastrous complication of forgotten stents. Prevention is, of course, ideal, but such cases are still seen despite increasing awareness. Temporizing percutaneous nephrostomy, renal support, and skilled endourologists are the cornerstones of management of such high-risk cases.

This study examined D-amphetamine (D-AMPH)-induced displacements of [18F] fallypride in striatal and extrastriatal regions and the correlations of these displacements with cognition, affect, and sensation-seeking behavior. In all, 14 normal subjects, six females and eight males (ages 21-32, mean age 25.9 years), underwent positron emission tomography (PET) with [18F]fallypride before and 3 h after a 0.43 mg/kg oral dose of D-AMPH. Levels of dopamine (DA) D2 receptor density were calculated with the reference region method of Lammerstma. Percent displacements in striatal and extrastriatal regions were calculated for the caudate, putamen, ventral striatum, medial thalamus, amygdala, substantia nigra, and temporal cortex. Correlations of changes in cognition, affect, and sensation seeking with parametric images of D-AMPH-induced DA release were computed. Significant displacements were seen in the caudate, putamen, ventral striatum substantia nigra, and temporal cortex with a trend level change in the amygdala. Greatest displacements were seen in striatal subdivisions-5.6% in caudate, 11.2% in putamen, 7.2% in ventral striatum, and 6.6% in substantia nigra. Lesser decrements were seen in amygdala-4.4%, temporal cortex-3.7%, and thalamus-2.8%. Significant clusters of correlations of regional DA release with cognition and sensation-seeking behavior were observed. The current study demonstrates that [18F]fallypride PET studies using oral D-AMPH (0.43 mg/kg) can be used to study D-AMPH-induced DA release in the striatal and extrastriatal regions in humans, and their relationship with cognition and sensation-seeking behavior.

We describe an unusual case of balanitis xerotica obliterans (BXO) involving the entire anterior urethra and the scrotum that had presented as a palpable nodular scrotal mass with obstructive voiding symptoms in middle aged man. He was managed by a staged urethroplasty. We report the first such case of BXO involving the scrotum resulting in a nodular mass that has not been described and reported till date.

There have been conflicting reports as to whether olanzapine produces lower occupancy of striatal dopamine D(2)/D(3) receptor than typical antipsychotic drugs and preferential occupancy of extrastriatal dopamine D(2)/D(3) receptors. We performed [(18)F] fallypride PET studies in six schizophrenic subjects treated with olanzapine and six schizophrenic subjects treated with haloperidol to examine the occupancy of striatal and extrastriatal dopamine receptors by these antipsychotic drugs. [(18)F] setoperone PET studies were performed in seven olanzapine-treated subjects to determine 5-HT(2A) receptor occupancy. Occupancy of dopamine D(2)/D(3) receptors by olanzapine was not significantly different from that seen with haloperidol in the putamen, ventral striatum, medial thalamus, amygdala, or temporal cortex, that is, 67.5-78.2% occupancy; olanzapine produced no preferential occupancy of dopamine D(2)/D(3) receptors in the ventral striatum, medial thalamus, amygdala, or temporal cortex. There was, however, significantly lower occupancy of substantia nigra/VTA dopamine D(2)/D(3) receptors in olanzapine-treated compared to haloperidol-treated subjects, that is, 40.2 vs 59.3% (p=0.0014, corrected for multiple comparisons); in olanzapine-treated subjects, the substantia nigra/VTA was the only region with significantly lower dopamine D(2)/D(3) receptor occupancy than the putamen, that is, 40.2 vs 69.2% (p<0.001, corrected for multiple comparison). Occupancy of 5-HT(2A) receptors was 85-93% in the olanzapine- treated subjects. The results of this study demonstrated that olanzapine does not produce preferential occupancy of extrastriatal dopamine D(2)/D(3) receptors but does spare substantia nigra/VTA receptors. Sparing of substantia nigra/VTA dopamine D(2)/D(3) receptor occupancy may contribute to the low incidence of extrapyramidal side effects in olanzapine-treated patients.

Purpose: To determine the safety and efficacy of retroperitoneoscopic decortication of symptomatic renal cysts., Patients and Methods: A total of 24 patients with symptomatic 6- to 14-cm (mean 10.9-cm) simple renal cysts, right sided in 13 and left sided in 11, underwent retroperitoneoscopic decortication for pain relief at our center between January 1997 and December 2002. The diagnosis was based on an ultrasonogram and contrast-enhanced CT. Symptom severity, assessed using a visual analog pain scale, averaged 7.2/10 (range 6.5-9). The mean duration of symptoms was 4 months. Operative and follow-up data were collected prospectively and analyzed for symptomatic and objective evidence of improvement., Results: The mean operating time was 95 minutes, and no major complications were observed. The average hospital stay was 2.9 days (range 2-7 days). At a mean follow-up of 2.8 years (range 1.5-5 years), pain relief was reported by 22 patients (change of pain score from 7.2 to 1.4). One patient had worsening of pain at 6 weeks postoperatively. Asymptomatic recurrence of the cyst was seen in two patients on the follow-up ultrasound scans., Conclusions: Retroperitoneoscopic renal-cyst decortication is a safe, minimally invasive, and efficacious procedure for the treatment of painful renal cysts, with a durable response.

Background: With the advent of prostate specific antigen the number of patients undergoing prostate biopsy has dramatically increased. The sextant biopsy technique has been conventionally used for the diagnosis of prostate cancer. Recently, concern has arisen that the original sextant method may not include an adequate sample of the prostate, hence it may result in high false negative rates. We conducted a prospective study to determine whether the 5-region prostate biopsy technique significantly increases the chance of prostate cancer detection as compared to the sextant biopsy technique., Aims: To evaluate the efficacy of TRUS guided sextant and 5-region biopsy techniques in detecting carcinoma prostate in patients with PSA between 4 and 10 ng/ml and normal digital rectal examination., Methods and Material: Between December 2001 and August 2003 one forty-two men, aged 49-82 years, who presented with LUTS, normal digital rectal examination (DRE) and PSA between 4 and 10 ng/ml underwent TRUS guided sextant prostate biopsy. Serum PSA was reassessed after 3 months in patients whose biopsies were negative for cancer. If PSA was still raised, the patients underwent extensive 5-region biopsy., Results: Mean patient age was 64 years and median PSA was 6.9 ng/ml. TRUS guided sextant biopsy revealed adenocarcinoma prostate in 34 men (24%). Median Gleason score was 7. Seven men (4.9%) had cellular atypia and 3(2.1%) had prostatic intraepithelial neoplasia (high grade). On repeat PSA estimation after 3 months, 48 patients showed stagnant or rising trend for which they underwent TRUS guided 13-core biopsy. Five (10.4%) patients were detected to have adenocarcinoma on repeat biopsy. Biopsy negative patients are on regular follow up with yearly PSA estimation. Complications included transient mild haematuria in14 patients (9.82%) and haematospermia in 4 (2.8%). Urinary retention developed in one patient and required an indwelling catheter for 4 days., Conclusion: Transrectal ultrasound guided sextant biopsy has shown a false negative rate of approximately 11%. A repeat 5- region (13-core) biopsy strategy can decrease the false negative rate of conventional sextant biopsy in patients with previously negative biopsies but persistently high PSA levels, high grade PIN or cellular atypia.

Objective: To evaluate the usefulness of urinary calculi attenuation values from non-contrast computed tomography (NCCT) in predicting the outcome of treatment by extracorporeal shock wave lithotripsy (ESWL)., Patients and Methods: We evaluated 112 patients with solitary renal and upper ureteric calculi of 0.5-2 cm undergoing ESWL. All patients had NCCT at 120 kV and 240 mA on a spiral CT scanner. During each ESWL session 3000 shock waves were given to a maximum of 3.0 kV. A final X-ray of the kidney, ureters and bladder was taken 12 weeks after the last ESWL session. Fragments of < or = 5 mm were regarded as clinically insignificant residual fragments (CIRF). The calculi retrieved were analysed by X-ray diffraction and the results assessed by comparing the mean density (as measured in Hounsfield units, HU) with the number of ESWL sessions and clearance., Results: In all, 82 (76%) patients had complete clearance of stones and 26 (24%) had CIRF. There was a linear relationship between the calculus density and number of ESWL sessions required. Of patients with calculi of < or = 750 HU, 41 (80%) needed three or fewer ESWL sessions and 45 (88%) had complete clearance. Of patients with calculi of > 750 HU, 41 (72%) required three or more ESWL sessions, and 37 (65%) had complete clearance. The best outcome was in patients with calculus diameters of < 1.1 cm and mean densities of < or = 750 HU; 34 (83%) needed three or fewer ESWL sessions, and the clearance rate was 90%. The worst outcome was in patients with calculus densities of > 750 HU and diameters of > 1.1 cm; 23 (77%) needed three or more ESWL sessions and the clearance rate was only 60%. The calculus density was a stronger predictor of outcome than size alone., Conclusions: The use of NCCT for determining the attenuation values of urinary calculi before ESWL might help to predict the treatment outcome, and so might help in planning alternative treatment in patients with a likelihood of a poor outcome from ESWL.

Despite being one of the most common malignancies, the preventable measures for prostate cancer remain poorly defined. Dietary intake of tomatoes and tomato products containing lycopene have been shown in cell culture, animal, epidemiologic and case-control studies to be inversely associated with the risk of prostate cancer. Its unique structural and biologic properties enable lycopene to prevent free-radical damage to cells caused by reactive oxygen species, thus acting as a potent antioxidant. Although some studies have provided contradictory results, these should not be considered incongruous to the many larger studies which have shown reliable results in favor of prostate cancer. Further research involving large randomized case-control trials would confirm the potential anticancer effect of this molecule, which might provide new dimensions not only to the prevention but also the treatment of prostate cancer.

A 35-year-old man with a left ectopic pelvic kidney and a prior history of open pyelolithotomy presented with recurrent multiple stones in the pelvic kidney. Complete clearance of calculi was achieved by laparoscopy-assisted PCNL (percutaneous nephrolithotomy). To the best of our knowledge this is the first report of laparoscopy-assisted PCNL in a previously operated ectopic pelvic kidney.

Background: The purpose of the present paper was to study the spectrum of stone composition of upper urinary tract calculi by X-ray diffraction crystallography technique, in patients managed at All India Institute of Medical Sciences., Methods: Between 30 April 1998 and 31 March 2003, a total of 1050 urinary calculi (900 renal, 150 ureteric) were analyzed. The stone fragments were collected after extracorporeal shock-wave lithotripsy, or retrieval by endoscopic (percutaneous nephrolithotomy, ureterorenoscopy), laparoscopic and various open surgical procedures. The structural analysis of the stones was done using X-ray diffraction crystallography., Results: Four types of primary and three secondary X-ray diffraction patterns were obtained. The primary patterns were as follows. Pattern A, well organized crystalline structure; pattern B, moderately organized crystalline structure; pattern C, poorly organized crystalline structure; pattern D, very poorly organized crystalline structure. The three secondary patterns mainly highlighted the mixed variety of stones. These patterns were further analyzed and compared with standard X-ray diffraction (powder) photographs. Of the 1050 stones analyzed, 977 (93.04%) were calcium oxalate stones, out of which 80% were calcium oxalate monohydrate (COM) and 20% were calcium oxalate dihydrate (COD). Fifteen were struvite (1.42%) and 19 were apatite (1.80%). Ten were uric acid stones (0.95%) and the remaining 29 (2.76%) were mixed stones (COM + COD and calcium oxalate + uric acid, calcium oxalate + calcium phosphate, and calcium phosphate + magnesium ammonium phosphate). A total of 89.98% of staghorn stones were made of oxalates (COM/+COD) and only 4.02% were struvite., Conclusion: Urinary stone disease in the Indian population is different from that in Western countries, with a larger percentage of patients having calcium oxalate stones, predominantly COM. Also, the majority of staghorn stones (89.98%) were made of oxalates.

Foreign body granulomas and pseudotumors due to retained surgical linen are well known in surgical practice. These lesions usually correspond to the actual size of residual foreign body and have characteristic presentation according to the anatomy involved. Renal suture granuloma is a rare postoperative complication of renal surgery due to persistence of sutures used to close the pelvicalyceal system/nephrotomy incisions and usually present as incidentally detected small mass lesions. This case of a suture foreign body granuloma presenting with hematuria, large peripheral mass lesion and characteristic computed tomography picture of renal cell carcinoma confounded the diagnosis and underwent laparoscopic radical nephrectomy. In retrospect, such lesions warrant the use of selective needle biopsy and intraoperative frozen section confirmation to clinch diagnosis. Mass lesions occurring in a previously operated kidney should have granuloma as a differential diagnosis.

Background: To compare the efficacy of orchiectomy alone and orchiectomy plus flutamide in treating patients with advanced carcinoma prostate., Materials and Methods: The study was initiated on 1 July 1997 and closed after enrolling 100 patients on 30 June 2000. Patients were prospectively randomized to orchiectomy alone (O) and orchiectomy plus flutamide (OF). A complete response (CR) was defined as the normalization of bone scans and serum prostate-specific antigen (PSA) levels returning to normal (< 4 ng/mL). A partial response (PR) was defined as a 50% reduction in metastasis mass compared to the initial study or a decrease in the PSA level of 50% of the initial value. Progressive disease (PD) was defined as the development of any new hot spot on bone scan or any increase in previously existing PSA level by 25%., Results: A total of 100 patients were entered in the study. The maximum percentage change in PSA levels in both groups was found in the first 3 months after orchiectomy, that is, 95% and 97% for the O and OF groups, respectively. In more than 80% of the patients this decrease in PSA was maintained for 3 years. The mean percentage change at 3 years in the O and OF groups was 70% and 75% (P = 0.95), respectively, and the overall response rate (CR + PR) was 88.50% and 86.53% in the two groups, respectively (P = 0.85). The follow-up period ranged between 3 and 5 years (mean, 3.5 years). The mean time to progression was 27 and 29 months in the O and OF groups, respectively. The overall survival rate at 3 and 5 years in two treatment groups was 45.83% and 48.07%, 20.83% and 23.07% in the O and OF groups, respectively (P = 0.75)., Conclusions: Maximum percentage decrease in PSA is seen within the first 3 months of therapy. Orchiectomy alone is as effective as combination therapy in decreasing serum PSA. Overall survival at 3 and 5 years in the orchiectomy only group was as good as that of combination therapy. These data suggest that the routine addition of flutamide to orchiectomy is not advisable.

Purpose: Laparoscopic nephrectomy has become a routine procedure at specialized centers with the advantages of less postoperative pain, minimal scars, rapid recovery and short convalescence. We report our experience with the establishment of retroperitoneoscopic nephrectomy as the standard of care for benign nonfunctioning kidneys., Materials and Methods: We retrospectively compared the records of patients who underwent simple nephrectomy retroperitoneoscopically or by open surgery from January 1998 to October 2003 at our center., Results: A total of 351 simple nephrectomies were done retroperitoneoscopically, while 83 were done as an open procedure. Mean operative time was significantly longer in the retroperitoneoscopic group. However, mean blood loss, complication rate, hospital stay and convalescence were significantly less in the retroperitoneoscopic group., Conclusions: Retroperitoneoscopic nephrectomy has become a standardized procedure. It should be offered as the primary treatment modality to patients with benign renal disease scheduled for elective nephrectomy except in those in whom it is contraindicated.

Objective: In a prospective study we evaluated the efficacy of lycopene for the treatment of patients with metastatic hormone refractory prostate cancer., Material and Methods: Between January 2001 and December 2002, 20 consecutive patients (median age 72; range 56-90) with metastatic HRPC were enrolled in the study. Lycopene in the dose of 10 mg/day was administered for a period of 3 months. Inclusion criteria were patients previously treated with hormonal therapy now with clinical and biochemical evidence of disease progression. A complete response (CR) was defined as a normalization of PSA (<4 ng/mL) and the disappearance of any sign of disease for at least 8 weeks. A partial response was defined as a >50% decrease in PSA level for at least 8 weeks associated with improvement (or no worsening) in ECOG PS and relief of bone pain if present. Stable disease (SD) was defined as a <50% decrease or <25% increase in the PSA level associated with no worsening of ECOG PS and/or bone pain for at least 8 weeks., Results: One patient (5%) had complete response. Partial response was achieved in 6 (30%), disease remained stable in 10 (50%) and progressed in three (15%) patients. ECOG PS was Grade 0 in five, Grade I in 10 and Grade II in five of the 20 patients. It improved from Grade I to 0 in seven and Grade II to I in three patients. It deteriorated in three and remained unchanged in the rest seven patients. Bone pain was present in 16 (Grade 1 in six and Grade 2 in 10) of the 20 patients. Grade 1 changed to Grade 0 in five and Grade II changed to Grade 1 in five patients. Bone pain remained unchanged in 5 (31%) and worsened in 1 (6%). Ten (62%) patients managed to cut down the dose of analgesics on daily basis. Eighteen patients had associated LUTS, which improved (Q max > or = 12 mL/sec) in 11 (61%) patients. The median duration of response was 25 weeks (range 12-72 weeks). No drug intolerance or toxicity was encountered in any patient., Conclusions: Lycopene therapy appears to be effective and safe in the treatment of HRPC. It not only takes care of the rising PSA but also improves the ECOG performance status, bone pain and LUTS. Because of its relative innocuousness it should be tried before the use of more toxic substances.

Objectives: To determine the safety and efficacy of holmium laser core-through urethrotomy (HolCTU) for the treatment of post-traumatic obliterative stricture of the urethra., Methods: From June 2002 to March 2003, 29 men underwent the core-through procedure. All the patients had obliterative strictures of the bulbomembranous urethra. The length of the stricture was 2.5 cm or less, with good alignment between the two urethral ends. The holmium laser was used to vaporize the obliterative fibrotic tissue. The procedure was guided by a metal sound introduced through the suprapubic tract. Catheter removal and voiding cystourethrography were done at 6 weeks after the procedure and urethroscopy 1 month after catheter removal., Results: At a mean follow-up of 15 months (range 10 to 19), the results were excellent in 19 (65.51%) of 29 patients. Nine (31.03%) had acceptable results; these patients failed to maintain good flow after HolCTU and required internal urethrotomy/endoscopic dilation once or twice for stabilization (maximal flow rate 15 mL/s or greater). Failure was seen in 1 patient (3.44%) who had recurrent obstruction despite repeated internal urethrotomy and finally required formal transpubic urethroplasty. The mean operating time was 40 minutes (range 30 to 90), with mean hospital stay of 8 hours (range 6 to 48). No perioperative complications occurred, except in 1 patient who developed small extravasation of fluid locally. All the patients were continent, and potency status was unaffected by HolCTU., Conclusions: HolCTU is a safe and simple treatment for obliterative urethral strictures. The procedure is less morbid than open repair with a slightly greater failure rate.

Spinning top urethra (STU) denotes a particular urethral configuration that is a dilated posterior urethra mainly seen in young girls or women. STU deformity arises secondary to detrusor instability, leading to a rise the intravesical pressure against a closed sphincter. We describe a case of spinning top urethra in a 30-year-old woman who presented with lower urinary tract symptoms and left flank pain.

Objective: To present the technique of dorsal buccal mucosal graft urethroplasty through a ventral sagittal urethrotomy and minimal access perineal approach for anterior urethral stricture., Patients and Methods: From July 2001 to December 2002, 12 patients with a long anterior urethral stricture had the anterior urethra reconstructed, using a one-stage urethroplasty with a dorsal onlay buccal mucosal graft through a ventral sagittal urethrotomy. The urethra was approached via a small perineal incision irrespective of the site and length of the stricture. The penis was everted through the perineal wound. No urethral dissection was used on laterally or dorsally, so as not to jeopardize the blood supply., Results: The mean (range) length of the stricture was 5 (3-16) cm and the follow-up 12 (10-16) months. The results were good in 11 of the 12 patients. One patient developed a stricture at the proximal anastomotic site and required optical internal urethrotomy., Conclusion: Dorsal buccal mucosal graft urethroplasty via a minimal access perineal approach is a simple technique with a good surgical outcome; it does not require urethral dissection and mobilization and hence preserves the blood supply.

Although the UroLume wallstent has been proven effective in the treatment of recurrent urethral stricture, obstruction may recur in some cases. A likely cause of obstruction is hyperplastic tissue reaction, which may necessitate the removal of the stent. The hyperplastic tissue reaction may be severe, resulting in a completely obliterative stricture. Stent removal with a completely obliterative stricture and the stent in situ is a tedious job, as there is no lumen in which to place the laser fiber to cut the stent wires. We report on a patient in whom a UroLume urethral stent was placed one year ago for post-traumatic recurrent bulbomembranous urethral stricture. The stricture recurred in spite of the stent in place and the lumen was finally completely obliterated. A holmium laser was used for core through internal urethrotomy and the explantation of the stent.

The distribution of dopamine (DA) D(2)-like receptors in the human thalamus was studied using in vitro autoradiographic techniques and in vivo positron emission tomography in normal control subjects. [(125)I]Epidepride, which binds with high affinity to DA D(2) and D(3) receptors, was used in autoradiographic studies to determine the distribution and density of D(2)-like receptors, and the epidepride analogue [(18)F]fallypride positron was used for positron emission tomography studies to delineate D(2)-like receptors in vivo. Both approaches revealed a heterogeneous distribution of thalamic D(2/3) receptors, with relatively high densities in the intralaminar and midline thalamic nuclei, including the paraventricular, parataenial, paracentral, centrolateral, and centromedian/parafascicular nuclei. Moderate densities of D(2/3) sites were seen in the mediodorsal and anterior nuclei, while other thalamic nuclei expressed lower levels of D(2)-like receptors. Most thalamic nuclei that express high densities of D(2)-like receptors project to forebrain DA terminal fields, suggesting that both the thalamic neurons expressing D(2)-like receptors and the projection targets of these neurons are regulated by DA. Because the midline/intralaminar nuclei receive prominent projections from both the ascending reticular activating core and the hypothalamus, these thalamic nuclei may integrate activity conveying both interoceptive and exteroceptive information to telencephalic DA systems involved in reward and cognition.

We report a case of 20-year-old farmer with penile amputation and emasculation secondary to crushing injury inflicted by agricultural machinery. His entire penis, scrotum and both the testis had been avulsed after falling onto a rotating axel wheel of an electronically driven thrashing machine. After resuscitation the wound was thoroughly washed with saline, hemostasis achieved and a perineal urethrostomy was made from the remnant urethra.

Objectives: To evaluate the role of newer imaging modalities in the diagnosis and evaluation of management according to extent of renal vein (RV) or inferior vena cava (IVC) thrombi in patients with renal cell carcinoma., Material and Methods: Fifty-nine patients with renal cell carcinoma and tumor thrombus extension into the RV or IVC were studied. Diagnosis was based on contrast-enhanced CT, magnetic resonance imaging or color-Doppler ultrasonography. Surgical treatment was contemplated in 42 suitable patients and complete resection could be done in all but 3 cases., Results: There were 48 males and 11 females with mean age of 51.8 years. Isolated RV involvement was seen in 27 cases whereas IVC extension was present in 32 cases. The thrombus extent was infrahepatic in 62.5% (20/32) patients with IVC extension. With the newer imaging modalities like contrast-enhanced CT, color-Doppler ultrasound and/or magnetic resonance imaging, correct diagnosis of the extent of the thrombus was possible in 95% of the patients. The accuracy of color-Doppler ultrasound was same as magnetic resonance imaging in the evaluation of the extent of the thrombus. In the present series a median follow-up of 4 years revealed a high incidence of local and distant recurrences and decreased survival in patients presenting with advanced disease, who had venous wall invasion., Conclusions: The extent of RV or IVC thrombi can be accurately diagnosed with contrast-enhanced CT scan and in case of doubt color-Doppler ultrasound is a good alternative to magnetic resonance imaging. Management can be planned according to the level of the tumor thrombus. Invasion of the venous wall was found to be a bad prognostic factor affecting survival., (Copyright 2004 S. Karger AG, Basel)

Squamous cell carcinoma of the renal pelvis is a rare neoplasm and is usually associated with long standing stone disease. The disease is aggressive in nature and usually has a poor prognosis. We report a case of renal lithiasis who underwent successful percutaneous nephrolithotomy (PCNL) for renal pelvic calculus, and eight months later presented with a large invasive squamous cell carcinoma in the same location.

Introduction: Clinical results of radical cystectomy performed on elderly bladder cancer patients over 70 years old were assessed to determine whether age is one of the critical points for the application of this type of surgery., Materials: From January 1992 to December 2002, 41 radical cystectomy performed in septuagenarian population were compared with 197 performed in patients less than 70 years of age., Results: The early and late complication rate for septuagenarians was 29.7% and 12%, compared with 26.9% and 9.6% for patients younger than 70 years respectively. The overall mortality rate for septuagenarians was 4.9%, compared with 8.6% for patients younger than 70 years. There was no significant difference between the two groups with regard to pathologic stage or length of hospital stay. The 5-year overall survival rate for septuagenarians was 53% compared with 59% for patients younger than 70 years., Conclusions: When indicated after adequate preoperative assessment and optimization of the patient, radical cystectomy is a safe procedure in the septuagenarians and patient should not be denied surgery dependent on chronologic age.

We report an unusual case of 40-year-old adult man who presented as a case of urolithiasis but was found to be harboring an incidental renal cell adenocarcinoma. He underwent an uneventful radical nephrectomy. The literature regarding incidental renal cancer and it's association with urolithiasis has been reviewed and discussed.

We report two unusual cases of spontaneous nephrocutaneous fistulas. They were discovered to be the cases of neglected calculous disease in a poorly functioning kidney and tuberculous pyelonephritis respectively. A timely nephrectomy cured their debilitating condition and prevented further morbidity. We have discussed the etio-pathogenesis, clinical and diagnostic approach towards the cases of nephrocutaneous fistula. The literature regarding nephrocutaneous fistula has been reviewed and discussed. A stepwise algorithm has been proposed to manage cases of nephrocutaneous fistulas.

A 65-year-old man who presented with right renal mass and a giant CBD stone. The patient was managed with right radical nephrectomy and choledocotomy. Both the lesions of two different systems could be easily accessed via a subcostal incision in the same sitting.

Skeletal metastases from genitourinary tract are common, but metastatic tumors involving the hand and foot are rare. We herein present a case of 55-year-old man who presented with painful swelling of right foot and no urological complaints. Investigations revealed left renal mass and fine needle aspiration cytology from the swelling revealed findings consistent with metastatic clear cell carcinoma.

Benign anterior urethral fibroepithelial polyps in the adult are extremely rare lesions. We report the presentation and management of such a case of recurrent bulbar urethral poly in a young adult who had presented with obstructive voiding symptoms mimicking a urethral stricture. He was successfully managed by urethrotomy excision and primary urethral repair.

Objectives: To evaluate the efficacy of different imaging modalities for visualization of small poorly functioning hypoplastic and dysplastic kidneys and to assess the role of laparoscopy in localization and treatment., Methods: Between 1998 and 2002, 10 female patients who presented with urinary incontinence, flank pain, or hypertension secondary to small, poorly functioning hypoplastic or dysplastic kidneys were treated at our institute. We reviewed the results of the imaging studies, cystoscopy, and evaluation under anesthesia for these patients. After the diagnosis, all patients were treated with laparoscopic retroperitoneal or transperitoneal nephroureterectomy or nephrectomy., Results: Intravenous urography and ultrasonography failed to visualize the affected renal units in all 10 cases. Computed tomography could locate small dysplastic renal units in only 5 patients (50%). Dimercaptosuccinic acid renal scintigraphy was diagnostic in all 10 cases (100%). Magnetic resonance urography was done in 2 cases only, and the affected renal units were identified in both. Cystoscopy and vaginoscopy were inconclusive in all but 2 cases. Laparoscopy efficiently located the offending renal units in all 10 cases. In 9 cases, the affected renal units were located in the lumbar region, and in 1 case it was situated ectopically in the pelvis. All 10 patients underwent laparoscopic retroperitoneal or transperitoneal nephroureterectomy or nephrectomy and were asymptomatic after surgery., Conclusions: Dimercaptosuccinic acid scintigraphy is an accurate and specific imaging modality for visualization of small hypoplastic renal units that are not visualized by conventional radiologic imaging techniques. Laparoscopy can be recommended as the ideal method of management, because it provides a minimally invasive technique for detecting the kidney and simultaneously correcting the problem.

Objective: To compare the efficacy of lycopene plus orchidectomy with orchidectomy alone in the management of advanced prostate cancer., Patients and Methods: Fifty-four patients with histologically confirmed metastatic prostatic cancer (M1b or D2) and a performance status of 0-2 (World Health Organization) were entered into the trial between March 2000 and June 2002. The trial comprised two treatment arms, i.e. patients were randomized to orchidectomy alone or orchidectomy plus lycopene (OL), each of 27 patients. Lycopene was started on the day of orchidectomy at 2 mg twice daily. Patients were evaluated clinically before and every 3 months after the intervention, with measurements of prostate-specific antigen (PSA), a bone scan and uroflowmetry, with the clinical response assessed as the change in these variables., Results: At 6 months there was a significant reduction in PSA level in both treatments, but more marked in the OL group (mean 9.1 and 26.4 ng/mL, P = 0.9). After 2 years these changes were more consistent in the OL group (mean 3.01 and 9.02 ng/mL; P < 0.001). Eleven (40%) patients in orchidectomy and 21 (78%) in the OL group had a complete PSA response (P < 0.05), with a partial response in nine (33%) and four (15%), and progression in seven (25%) and two (7%), respectively (P < 0.05). Bone scans showed that in the orchidectomy arm only four (15%) patients had a complete response, vs eight (30%) in the OL group (P < 0.02), with a partial response in 19 (70%) and 17 (63%), and progression in four (15%) and two (7%), respectively (P < 0.02). There was a significant improvement in peak flow rate in the OL group, with a mean difference of +1.17 mL/s (P < 0.04). Of the 54 patients who entered the trial, 19 (35%) died, 12 (22%) in orchidectomy and seven (13%) in OL group (P < 0.001)., Conclusion: Adding lycopene to orchidectomy produced a more reliable and consistent decrease in serum PSA level; it not only shrinks the primary tumour but also diminishes the secondary tumours, providing better relief from bone pain and lower urinary tract symptoms, and improving survival compared with orchidectomy alone.

Objectives: Primary obstructive megaureter is an uncommon presentation in adult patients. Although not reported frequently in published studies, the anomaly exists and warrants aggressive surgical management in contrast to its presentation in children., Methods: This study was composed of 55 patients (47 with unilateral and 8 with bilateral megaureters) with adult primary obstructive megaureter who were treated from January 1989 to December 2001. Their clinical presentation, renal function, radiologic data, treatment, complications, and follow-up were studied., Results: Of the 55 patients, 36 were male and 19 were female (age range 13 to 52 years). All patients were symptomatic except two. Forty-four patients (50 renoureteral units) required ureteral reimplantation, with tailoring in 33. Five patients were treated with endoscopic techniques (ureteral meatotomy in 3 and ureteroscopic retrieval of ureteral calculi in 2). Four patients required nephroureterectomy for nonfunctioning kidneys. Associated renal calculi were managed by extracorporeal shock wave lithotripsy and pyelolithotomy and ureteral calculi by endoscopic methods or calculi removed at the time of ureteroneocystostomy. All but 4 patients showed improvement in hydroureter and hydronephrosis and developed no complications during the follow-up period of 1 to 12 years (mean 7). Five patients with bilateral megaureters had uremia. Only one improved after surgery with adequate drainage and 2 patients died despite reimplantation., Conclusions: Most adult patients with megaureter are symptomatic. Complications such as stone formation and deranged function of the affected kidney are common and almost all require surgical intervention. Surgery in those with bilateral megaureters with advanced renal failure is mostly unrewarding.

Ectopic ureter occurs most commonly in association with ureterocele or duplication of the ureter. It is caused by a delay in or failure of separation of the ureteric bud from the mesonephric duct during embryologic development. Vaginal agenesis is the second most common cause of primary infertility in women after gonadal dysgenesis. Agenesis of the vagina in karyotypic females may be accompanied by other defects of the urogenital system [1]. We describe a rare combination of Mayer-Rokitansky-Kuster-Hauser syndrome and ectopic ureter with urinary incontinence.

von Hippel-Lindau (VHL) disease is an autosomal dominant disorder characterized by cysts and cystadenoma in the kidney, pancreas and epididymis and angiomas of the central nervous system and retina as well as renal cell carcinoma (RCC), phaeochromocytoma, islet tumors of the pancreas, and endolympatic sac tumors. VHL for its multicentric-characteristic and bilateralism often puts the surgeon in challenging situation. We present a case of VHL with bilateral RCC and retinal angiomas managed with right radical nephrectomy and left repeat partial nephrectomy.

Objective: To analyse the impact of stone composition on stone fragility (fragmentation) and clearance of upper urinary tract stones after shock wave lithotripsy (SWL)., Material and Methods: Between 1st July 1998 and 31st July 2001, 300 renal and ureteric units of 290 patients (10 being bilateral) underwent SWL for upper urinary tract calculi. The degree of fragmentation was divided into four types: (I) Excellent, (II) Good, (III) Fair and (IV) No fragmentation. Stone composition was done by X-ray diffraction crystallography. A statistical comparison was made between degree of fragmentation, number of shock waves delivered, voltage setting, number of sessions required and requirements of adjuvant procedures according to the stone composition., Results: Stone analysis revealed that 90% of the patients had calcium oxalate stones. Of these 80% were calcium oxalate monohydrate (COM) and 20% calcium oxalate dehydrate (COD). Struvite, apatite and uric acid stones comprised of 6%, 3% and 1% respectively. Type-I fragmentation was achieved up to 63.96%, 50% and 100% in COD, struvite and uric stones respectively as compared to 44.9% and 44.44% for COM and apatite stones. Type-III fragmentation was seen up to 8.79% and 33.3% respectively in COM and apatite as compared to 5.55% or less in other types of the stones suggesting that COM and apatite stones produce larger fragments. The mean number of shock waves, voltage and number of treatments was significantly higher for COM and apatite stones (p value < 0.005) with a stone free rate of only 65-66% and 65-68% respectively at three months (p value < 0.001). Similarly the number of adjuvant procedures required in COM alone was more, i.e. 31 as compared to 17 procedures in rest of the other kinds of stones (p value < 0.05)., Conclusion: Stone composition in Indian subcontinent is different from the western world. Fragility of a stone varies with the composition of the stone and affects the therapeutic results.

The fact that a prostate carcinoma metastasizes to the skeleton is well known. The metastatic deposits are generally multiple and osteoblastic. Moreover, these involve the axial skeleton or the proximal part of long bones. A pure osteolytic metastasis from a prostate carcinoma is extremely rare. This is believed to be the 1st case report of a osteolytic solitary radial head metastasis from a prostate carcinoma in a 60-year-old male. The rare clinical presentation of wrist drop, the absence of metastases at any other site, and a significant decrease in the size of lesion on follow-up in response to hormonal therapy are of interest in this case. The rare clinical presentation of a common malignancy (prostate carcinoma) is reported with a brief review of the literature.

A 17-year-old male boy presented with clinical features of pseudohypospadias (small penile stump with absent distal penile urethra) associated with very small capacity bladder and bilateral grade IV vesicoureteric reflux following suprapubic urinary diversion for multiple urethro-cutaneous fistula and periurethral abscess which developed as a consequence of inappropriate initial management of urethral trauma. This case highlights the importance of the initial management of urethral trauma and the management of its rare complication.

Fertility preserving radical cystectomy has been reported in young males with leiomyosarcoma and transitional cell carcinoma but not in females. We present a case of 19-year-old lady with mesenchymal tumour of urinary bladder with myogenic differentiation who was managed with fertility preserving radical cystectomy. As the patient was just 19-year-old a consensus was made to preserve the internal genitalia (both the ovaries and uterus) in order to restore the fertility. Immunohistochemistry was compatible with mesenchymal tumour with myogenic differentiation. Adjuvant chemotherapy (Ifosfamide, CDDP and Etocid) was given. Patient is doing well at a follow-up of 6 months.

Introduction: The diverse manifestations of urolithiasis provide a very interesting epidemiological study from the standpoints of geography, socioeconomic status, nutrition and culture. Stone disease not only affects the patient, but also the national economy, as the disease is prevalent in the productive age group. There has been a continuous search for the cost-effectiveness of different treatment modalities not only to treat the patient but also to prevent its recurrence., Materials and Methods: The various socioeconomic and dietary factors playing roles in the etiology of urinary calculi in the stone-prevalent areas of the world were analyzed. The impact of urinary tract stone disease on the socioeconomic infrastructure of the patient and national economy was studied. A cost-effectiveness analysis vis-à-vis the safety and efficacy of various treatment modalities in both developed and developing countries was done., Results: The standard of living and level of nutrition have directly influenced the process of urolithiasis amongst the communities of the world. A low socioeconomic status has been linked to endemic bladder calculi seen in many poor countries with people subsisting on a deficient diet. The incidence of upper urinary tract calculi increases with prosperity and more nutritious diets. Replacement of open surgery with minimally invasive techniques (ESWL, PCNL, URS) for treating stones in the urinary tract has greatly reduced the patients' morbidity and mortality and the period of hospitalization and convalescence. This change in treatment has also led to less days of absence from work and could minimize the loss to national economy. Minimally invasive surgery is more cost effective in developed countries because of the short hospital stay. However, in developing countries open surgery still appears to be cost-effective in certain subset of the patients., Conclusions: There is a need for proper health care and a medical insurance system to take care of the financial burden, especially in developing countries, of a disease with a high magnitude of recurrence and morbidity. The need and type of medical treatment should be appraised continually to accommodate advances in techniques of stone removal. Lastly, the quest for etiology, cost-effective treatment and prevention still continues and even today we cannot stay better than Frère Jacques, 'I have removed the stone, it is up to God to cure the patient'.

We describe a case of small bowel obstruction in a thirty-year-old adult male, which was discovered to be on account of a large hydronephrotic nonfunctioning kidney. An emergency percutaneous nephrostomy alleviated the massive abdominal distension and symptoms of small bowel obstruction. We have reviewed the causes, differential diagnosis and discussed the manner of such a unique and rare presentation.

Introduction: Many studies confirm the fact that radiographic anatomy of inferior calyx has a significant role in the clearance of a stone lodged in it [Br. J. Urol. 50 (1978) 449; Invest. Urol. 18 (2) (1980) 167; BJU Int. 83 (Suppl) (1999) 24; J. Urol. 132 (1984) 1085]. Acutely angled and narrow infundibular neck of a inferior calyx has a poorer stone clearance in comparison to that with a less acute angled and wider infundibular neck [Br. J. Urol. 50 (1978) 449; Invest. Urol. 18 (2) (1980) 167; Br. J. Urol. 82 (1998) 12; BJU Int. 83 (Suppl) (1999) 24]. Incidence of bilateral stones in clinical practice is significantly less than unilateral stones. This study was taken up to define the significance of radiographic anatomy of the inferior calyx as a risk factor predisposing to stone formation in a patient and compared the anatomy of inferior calyx of the stone forming and contralateral kidney. The fact that inspite of the similar known etiological factors (intrinsic and extrinsic) of stone formation, why stone forms unilaterally?, Material and Methods: 100 consecutive cases of non-obstructed unilateral inferior calyceal calculus with non-metabolically active stones were studied. The infundibuloureteropelvic angle (IUPA) and infundibular width of the stone forming and non-stone forming contralateral side were compared., Results: IUPA of stone forming side was more acute than the non-stone forming side, in 74% of the cases, more obtuse in 18% of the cases, and same in 8% of the cases. The difference in the IUPA of the stone forming and that of non-stone forming contralateral side was statistically significant (p<0.0002). The infundibular width of the stone forming side ranged from 1 to 16 mm and that of non-stone forming side from 2 to 11 mm. There was no statistically significant difference between the infundibular width of both the sides. Exactly, how and more importantly under what influences the macromolecules in the urine transforms into a calculus in the pelvicalyceal system is still not known till date but from our observations we conclude that IUPA is a significant risk factor which predisposes to calculus formation in inferior calyx., Conclusion: IUPA is a significant risk factor, which predisposes to urolithiasis in inferior calyx.

1H NMR assignment of seven differently N-substituted-3-methyl-4,1-benzoxazepine-2,5-diones (I) revealed that with the exception of allyl, N-methylene protons of the substituents exhibit diastereotopy due to presence of a chiral centre in the heterocyclic ring at C-3. The significant finding is that the methylenes at C-2' in the substituents n-propyl and n-butyl (Id, Ie) also show diastereotopy. However, the one closer to the chiral centre (at C-1') exhibits greater non-equivalence of its protons. The diastereotopic methylene groups reported in this study correspond to the simplest system AB on one hand and as complex as ABMM'X2 or ABMM'X3 on the other. Calculated spectra obtained from assigned set of data for most of the coupled protons were in good agreement with the observed ones.

Urachal anomaly in an adult is extremely rare, as the majority of urachal remnants obliterate shortly after birth. A 55-year-old man presented with irritative voiding symptoms. A plain film demonstrated a radiopaque shadow in the region of the urinary bladder. Ultrasonography showed a fixed echogenic focus in relation to the anterior bladder wall. With these investigations, the patient was referred to us with a diagnosis of a vesical stone. We suspected it to be a case of a urachal calculus. Therefore, a CT scan of the pelvis was obtained, which showed a midline tubular tract containing a cylindrical stone, further extending into the bladder as a pedunculated stone. The patient was managed by a combination of endoscopic and laparoscopic techniques. A urachovesical stone like a cherry (pedunculated) has not been reported previously in the English-language literature. This case also illustrates for the first time the combined use of endoscopy and laparoscopy to retrieve a urachovesical stone and the excision of the urachus.

As noted under the natural history, the bone of axial skeleton and the ileopelvic lymphnodes specially the obturator groups are the commonest sites of metastasis spread of cancer prostate. Visceral metastasis in the absence of the above is extremely rare. We present a 50-year-male patient of cancer prostate with pleural metastases, pleural effusion and lung collapse on right side. Bone scan was essentially normal. Bilateral orchiectomy was done. Pleural effusion subsided and PSA dropped to 1.4 ng/ml from the initial 120 ng/ml at three months. Patient is on regular follow-up at three monthly intervals and last PSA done at 9 months was 2.1 ng/ml.