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Background: To analyse causes of failure of medical management in benign prostate enlargement (BPE) in patients who undergo surgery following medical treatment and to elucidate parameters which warrant for early surgical treatment. Methods: Records of 747 patients who underwent surgery for BPE were reviewed for prostate volume, median lobe enlargement, post void residual urine, duration and type of medical treatment given for BPE. We used univariate and multivariate analysis to find out significant parameters for medical treatment failure. Results: A total of 601 patients (80.45%) received medical treatment for their lower urinary tract symptoms (LUTS), for a duration ranging between 3 months and 2 years. Statistically significant difference was found between age, prostate volume, intravesical projection, PSA and acute urinary retention with failure of medical treatment. Conclusions: BPE patients with failure to respond with medical management within 3–6 months and/or associated with large size prostate, intravesical projection and raised serum PSA should better be offered surgical treatment. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 OBJECTIVE • To critically analyze and compare surgical, oncological and functional outcomes of robot-assisted radical prostatectomy (RARP) in patients with and without previous transurethral resection of prostate (TURP). PATIENTS AND METHODS • The study comprised 158 cases of RARP for clinically localized prostate cancer, including 26 cases that had undergone previous TURP (Group A). • Surgical, oncological and functional (short- and intermediate-term) outcomes of Group A were compared with 132 cases without previous TURP (Group B). RESULTS • Post TURP patients were found to have significantly greater blood loss (494 vs 324 mL) and a need for bladder neck reconstruction (26.7% vs 9.7%) compared to the non-TURP group. • Surgical time (189 vs 166 min), conversion rate, margin positivity rate and biochemical recurrence rate were also higher. • Incontinence rates were higher both at 6 (14% vs 11.8%) and 12 (25% vs 8%) months follow-up. CONCLUSIONS • RARP is feasible but challenging after TURP. It entails a longer operating time, greater operative difficulty and compromised oncological or continence outcomes. • These cases should be handled by an experienced robotic surgeon with the appropriate expertise. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 OBJECTIVE To evaluate the efficacy and safety of using bipolar energy at low-power setting for transurethral resection (TUR) of bladder tumours. MATERIALS AND METHODS In total, 108 patients (100 males and eight females) with superficial bladder carcinoma undergoing bipolar TUR of bladder tumours (B-TURBT) with the GyrusTM Plasma kinetic Tissue Management System (Gyrus Medical Ltd, Cardiff, UK) were studied. The initial ten patients were operated at a default setting of 160 W cutting and 80 W coagulation. Subsequently, the current settings were modified to 50 W cutting and 40 W coagulation. The present study reports on the 98 patients who underwent TURBT with low-power settings. Tumour number, size, shape, location, operating time, hospital stay, blood loss, as well as intraoperative and postoperative complications, were all recorded .The resected tissues were examined by a pathologist who recorded grade, invasion of the muscularis propria and the presence of muscular invasion. RESULTS Out of the ten patients who were operated at the recommended default settings of 160 W cutting and 80 W coagulation, three patients had obturator jerks leading to two-bladder perforation. The results of 98 patients operated on at the low-power settings of 50 W cutting and 40 W coagulation are reported. Mean ± SD age was 56.34 ± 13.51 years. Tumours were multiple in 62 (63%) patients and single in 36 (37%) patients, with 68 (69%) in the lateral wall and six (6%) involving the ureteric orifice. Mean ± SD tumour size was 2.5 ± 0.81 cm with a mean ± SD resection time of 36.64 ± 16.5 min. The mean drop in haemoglobin was 0.94 ± 0.71 (0.20-4.0), with a mean ± SD (range) drop in haematocrit of 1.33 ± 1.29 (1-7). Five (5%) patients required blood transfusion as a result of preoperative low haemoglobin. Mean ± SD drop in sodium was 2.06 ± 0.66 mEq/L, with no patient developing TUR syndrome. None of the 98 patients developed obturator jerks and perforation at low-power settings. Complete resection was achieved in 94 (96%) patients. Mean postoperative hospital stay was 3 days. CONCLUSIONS TURBT using bipolar energy is safe and effective in the treatment of bladder tumours at power settings lower than the conventionally recommended settings. Lower power settings reduce the number of obturator jerks and perforations. [ABSTRACT FROM AUTHOR]

Purpose: To assess the feasibility and outcomes of robotic pyeloplasty for complicated cases of ureteropelvic junction obstruction (UPJO). Methods: Complicated UPJO cases included patients with the following: concomitant multiple or calyceal stones, secondary UPJO (post-ureteroscopy, open or percutaneous surgery), malrotated kidney, horseshoe kidney, ectopic kidney, giant hydronephrosis, poorly functioning kidney (glomerular filtration rate <20 ml/min), non-redundant renal calyces (requiring nephroplication), ptosis of the kidney (requiring nephropexy), long stricture (>2 cm), age <5 or >60 years and duplex pelvis. All cases underwent dismembered robotic pyeloplasty. Data were collected for operative time, blood loss, stone clearance, analgesic usage and time to recovery. Follow-up was done with intravenous urography and dynamic renal scan. Results: A total of 29 cases underwent dismembered robotic pyeloplasty with an average operative time and blood loss of 130 min and 50 ml. Stone clearance could be achieved in 8 out of 10. The average follow-up period was 15 months with a symptomatic and objective success rate of 96.6% (28/29). No perioperative complications were noted. Conclusions: Robotic pyeloplasty for complicated cases of UPJO is feasible, safe and effective, and has a durable success rate. [ABSTRACT FROM AUTHOR]

Study Type – Therapy (case series) Level of Evidence 4 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. [ABSTRACT FROM AUTHOR]

Study Type – Therapy (case series) Level of Evidence 4 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. [ABSTRACT FROM AUTHOR]

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. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

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 (Qmax), average flow rate (Qave), voided volume and corresponding postvoid residual urine (PVR) were compared for each position using paired Student’s t test. Results: The mean Qmax values obtained for sitting and squatting postures were 18.4 ± 3.2 and 24.8 ± 4.9 ml/s, respectively, and corresponding Qave 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. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Laparoscopic nephrectomy has been established as the standard of care for the management of benign non-functioning kidneys and has gained worldwide popularity over the past decade. In this article, we have reviewed the current literature to elucidate the indications, contraindications, surgical techniques, results and complications of laparoscopic nephrectomy. [ABSTRACT FROM AUTHOR]

BACKGROUND: Increasing numbers of patients with renal cell carcinoma (RCC) are incidentally detected and can be potentially cured by surgery alone. In treating metastatic RCC, worthwhile survival rates are achieved in cases of low burden recurrences. This necessitates a rational follow up protocol, which picks up early recurrences and avoids costly surveillance for those with a favorable prognosis. AIMS: We studied the patterns of metastases occurring in patients operated for localized or locally advanced renal cell carcinoma in the Indian setting and tried to evolve a suitable follow up protocol. SETTING AND DESIGN: Institution-based, retrospective data. METHOD AND MATERIALS: Records of patients from January 1988 to December 2003, operated for initially localized RCC were reviewed. Follow up was performed using an established protocol. Occurrence of metastases and their patterns were studied. STATISTICAL ANALYSIS USED: Comparison of the different survival times was performed using the one-way analysis method. Multiple comparisons ( post hoc test) were performed using the Bonferroni method. RESULT: Follow up was available on 209 patients. Mean survival was 43.75 months (SD ± 28.72). Thirty-nine patients developed 59 metastases. Lungs were the commonest site of metastases (37%), followed by bone (22%), liver (19%), and brain (8%). Relapse and survival showed significant correlation with pathological stage ( p < 0.001), with higher stage being associated with greater relapses and lesser survival. There was no correlation between site of recurrence and stage of disease. CONCLUSIONS: Occurrence of metastases correlate with the pathological stage of the disease at primary presentation. Tailored, stage-based follow up protocols allow adequate surveillance for disease activity and progression without escalating the overall costs. [ABSTRACT FROM AUTHOR]

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). 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≤ 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. 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≤ 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≤ 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. 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. [ABSTRACT FROM AUTHOR]

Introduction: To assess the efficacy, safety and morbidity of tubeless percutaneous nephrolithotomy. Materials and Methods: One hundred and fifty-two patients with renal and upper ureteric calculi were included in this study. Sixty-nine patients (71 renal units; group 1) in whom no nephrostomy tube was placed at the conclusion of the procedure was compared with a similar control group of 83 patients (group 2) in whom a nephrostomy tube was placed. Operating time, blood loss, analgesia requirement, puncture site urinary leakage, hospital stay and mean convalescence period were compared in both groups. Results: Both groups were similar with respect to age, sex distribution and stone size. Operating time and blood loss were less in group 1 although they did not reach statistical significance. The mean analgesic requirement, puncture site urinary leakage and hospital stay were significantly less in group 1. Conclusion: Tubeless percutaneous nephrolithotomy is a safe and effective procedure in this selected group of patients. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

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.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.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.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. [ABSTRACT FROM AUTHOR]

To compare the efficacy of orchiectomy alone and orchiectomy plus flutamide in treating patients with advanced carcinoma prostate.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%.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).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. [ABSTRACT FROM AUTHOR]

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 [ABSTRACT FROM AUTHOR]

Introduction: Varicoceles have been established to be the commonest correctable cause of male infertility. Among the various methods available, microsurgical varicocelectomy has one of the lowest complication rates with low failure. Patients and Methods: Over a 4-year period, 100 patients underwent microsurgical varicocelectomy at our center. One hundred and forty-four surgeries were performed on 90 of these patients through a subinguinal approach and these form the study group. Only clinically diagnosed varicoceles were operated. Pre-operative semen values were compared with the post-operative values and statistical analysis performed using a non-parametric test. All 90 patients provided at least 1 post-operative semen report 3 months after surgery while 50 are on complete follow-up. Results: Sperm count improved in 71% patients, normal motility in 60% and normal morphology in 49%. Seventeen of the 50 patients on full follow-up (34%) achieved pregnancy, with 16 of these being spontaneous. All patients achieving pregnancy showed improvement in sperm count, 13 improved in motility and 12 in morphology. All improvements were statistically significant. There were 21 (14.6%) minor complications with no testicular atrophy and 1 recurrence. Conclusion: Microsurgical varicocelectomy is a safe and effective option for the managment of varicocele-induced male infertility. It leads to improvement in all semen parameters and increases the possibility of spontaneous pregnancies.Copyright © 2003 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objectives: To assess the significance of asymptomatic residual stone fragments of less than 4 mm (clinically insignificant residual fragments [CIRFs]) after extracorporeal shock wave lithotripsy (ESWL).Methods: Eighty-one patients were followed up for 6 to 60 months (mean 15) after ESWL to determine the fate of the CIRFs.Results: Of the 81 patients, 6 were lost to follow-up, leaving 75 patients. During follow-up, fragments passed spontaneously in 18 patients, remained stable in 13 patients, and became clinically significant in 44 patients who developed one or more complications. For the latter patients, repeated ESWL was done in 16, percutaneous nephrolithotomy in 3, and ureteroscopic stone removal in 4 patients. The remaining 21 patients were treated conservatively with analgesics. We found that 53% of the CIRFs located in the pelvis passed spontaneously, and most of the CIRFs in caliceal location became clinically significant. Also, as the stone burden and number of stone fragments increased, the risk of CIRFs becoming clinically significant increased. The outcome was the same whether a metabolic abnormality was present or not, provided the patient received appropriate treatment. The clearance rate was highest in the first 6 months. Finally, as the duration of follow-up increased, the rate of complications increased.Conclusions: Patients with residual stones after ESWL require close follow-up and timely adjuvant therapy. As the number and size of residual fragments increased, the risk of complications increased. A pelvic location was a favorable factor for spontaneous passage. Metabolic defects, if treated adequately, did not increase the regrowth rate. Although the complete clearance rate of CIRFs with repeated ESWL was lower than for the operative interventions, most patients improved with this modality. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Laparoscopic adrenalectomy for pheochromocytoma and laparoscopic dismembered pyeloplasty are both technically difficult procedures. We describe the case of a 61-year-old female patient who presented with a right adrenal pheochromocytoma and bilateral pelvi-ureteric junction obstruction with renal failure who underwent a successful simultaneous transperitoneal laparoscopic adrenalectomy and pyeloplasty. [ABSTRACT FROM AUTHOR]

Objectives : Classic radical cystectomy in females involves anterior exenteration for the treatment of invasive urothelial cancer. Pathological features of reproductive organs removed during exenteration were evaluated to determine the incidence of malignant pathology in these organs and need for removal. Methods : Case records of 26 females who underwent radical cystectomy with urinary diversion from January 1993 to December 2002 were reviewed. We reviewed preoperative, operative and pathological findings in these patients. Results : Median patient age was 46 years (range 17-64). Gynecologic organs were available for pathological examination in 26 patients. Invasive urothelial carcinoma involving uterus was identified in 1 specimen with invasion suspected preoperatively on computerized tomography and intraoperatively. Conclusions : Preserving reproductive organs in modified radical cystectomy is feasible in a carefully selected group of young women without jeopardizing the oncological basis of the operation. [ABSTRACT FROM AUTHOR]

Spontaneous perirenal hematoma (SPH) is a clinical entity that poses a diagnostic and therapeutic challenge. We report a case of SPH in an adult where the cause could not be determined at first presentation, even with computed tomography (CT) of the abdomen and angiography. He was under close follow-up, and it was only with a repeat CT scan after 3 months that a mass lesion in the kidney was identified as the underlying cause. We also present a review of the literature so that a logical approach can be adopted for this problem.Copyright © 2000 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: The occurrence of renal cell carcinoma in the solitary remnant kidney after donor nephrectomy is rare and, to our knowledge, has not been previously reported. We encountered 2 such patients in whom cancer occurred 19 and 40 years after the donation. Both patients underwent successful partial nephrectomy for the tumor using two different techniques. [Copyright &y& Elsevier]

A case of successful management of spontaneous perforation of an orthotopic sigmoid colon neobladder 18 months following radical cystectomy for muscle-invasive transitional cell carcinoma is described. Conservative management of such perforations has rarely been described in the literature; however, this is the first case report of sigmoid colon neobladder perforation and of its successful conservative management, to the best of our knowledge.Copyright © 2002 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Laparoendoscopic Single-Site Pyeloplasty: A comparison with the Standard Laparoscopic Technique."

Presents a response to the letter to the editor about a comparison of lycopene and orchidectomy vs orchidectomy.

Objectives: To present our experience and outcomes of robot-assisted laparoscopic surgery (RALS) performed for different ureteral pathologies and to discuss the true utility of robotics in ureteral surgery. Methods: We reviewed a total of 44 procedures performed for diverse ureteral pathologies involving the proximal and distal ureter in 2 institutions from July 2006 to July 2009. Operative time, blood loss, length of stay, complications, and subjective and objective follow-up were evaluated. Results: The 44 cases included 18 distal ureteral procedures including 5 distal ureterectomy with ureteroneocystostomy; 1 ureteroneocystostomy with psoas hitch; 2 ureteroneocystostomy with vesicovaginal fistula repair; 9 megaureter repairs in 8 cases; there were 12 proximal ureteral procedures including 7 ureteroureterostomies and 4 retrocaval ureter repairs; 10 ablative procedures consisting of 5 nephroureterectomies with cuff of bladder and 5 nephroureterectomies and 4 miscellaneous procedures. The mean operative time was 137.9 minutes (range: 70-240). Mean blood loss was 98.2 mL (range: <50-400). There were no urine leaks. Mean drain tube duration was 1.4 days (range: 1-2.5) and mean hospital stay was 2.4 days (range: 1-6). Complications included 1 case of sepsis and 1 antibiotic-induced infection. Average follow-up period was 13.5 months. Operative success as defined by symptom resolution and imaging was 100%. Conclusions: RALS is feasible, safe, and an effective option for ureteral pathologies at any level of the ureter with minimal peri-operative morbidity. However, appropriate port placement, patient positioning, and versatile experience of team is critical in handling such cases for better outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the role of age, Gleason score, prostate-specific antigen (PSA), PSA doubling time (PSADT), and PSA half-time (PSAT1/2) 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 ≤65 years at diagnosis, high baseline PSA and high nadir PSA were associated with poor overall survival. Patients with a PSAT1/2 of <6 months, high baseline alkaline phosphatase, and PSADT of <1 month had significantly poorer progression-free and overall survival. Conclusion: Prostate cancer is a common malignancy in the elderly population. We have found that younger patients with high baseline and nadir PSA, shorter PSADT and PSAT1/2 have poorer overall and progression-free survival. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

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/m2), 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. [ABSTRACT FROM AUTHOR]

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). 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. 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. 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. [ABSTRACT FROM AUTHOR]

We present the short and long-term oncologic outcome of 132 patients with pathologically confirmed T1–T2, N0M0 renal cell carcinoma (RCC), who underwent laparoscopic radical nephrectomy with intact specimen removal at our institution. Beginning January 1998, we prospectively collected data of 132 patients undergoing laparoscopic radical nephrectomy, whose final pathologic stage was T1 or T2, N0M0, RCC. The clinical data of three groups categorized as group (pT1a)—36 patients, group (pT1b)—51 patients and group (pT2)—45 patients were analyzed statistically to assess oncological outcome. The specimens were removed intact without morcellation in all patients in a homemade plastic bag. The total median follow-up was 56 months (range 3–80 months) and there were no local or port-site recurrences or hernia. Patients with pT2 tumors had significantly greater operating time, blood loss and analgesic requirements than pT1a/pT1b tumor patients. The distant metastases were found in 1, 4 and 5 patients in group pT1a, pT1b and pT2, respectively. The 5-year cancer-specific survival was 97.2, 86.3 and 82.2%, respectively, in pT1a, pT1b and pT2 tumor patients (significantly lower in pT2 than pT1a, P = 0.008). The 5-year recurrence-free survival was 97.2, 84.3 and 82.2%, respectively, in pT1a, pT1b and pT2 tumor patients (significantly lower in pT2 than pT1a, P = 0.02). Laparoscopic radical nephrectomy (retroperitoneal and transperitoneal route) with intact specimen removal for localized renal cell carcinoma (T1-2N0M0) provides satisfactory short and long-term oncologic efficacy. [ABSTRACT FROM AUTHOR]

Aim: Supracostal superior calyceal access has been shown to be the most suitable approach for staghorn calculi, calculi in the upper ureter and complex inferior calyceal calculi, as well as for antegrade endopyelotomy. However, many urologists hesitate in using this approach because of the potential for chest complications. The aim of this study was to analyze one institution's data regarding the safety and efficacy of this approach for percutaneous renal surgery. Methods: A total of 890 renal units (762 patients) were treated with percutaneous renal surgery (849 percutaneous nephrolithotomy, 41 antegrade endopyelotomy) from July 1998 to July 2004. Supracostal access was obtained in 332 (37.3%) patients. The indications for a supracostal approach were ureteropelvic junction obstruction, staghorn and complex inferior calyceal calculi, and stones in the upper calyx or the upper ureter. All punctures were made by the urologist under C-arm fluoroscopic guidance in the prone position. Results: The interspace between 11th and 12th rib was used in all except four patients in whom the puncture was made above the 11th rib. Eleven patients (3.31%) had a pleural breach presenting with fluid in the chest. Insertion of a chest tube was required in seven patients, while other four were managed conservatively. No patient had injury to the lung or other viscera. Hospital stay was not significantly prolonged as a result of the pleural breach in any patient. Except for staghorn calculi where multiple tracts were a necessity for maximal clearance, a single supracostal superior or middle posterior calyceal access served the purpose in 86% (177/205) of patients who underwent percutaneous surgery for renal or upper ureteric calculi. Conclusions: The supracostal superior calyceal approach was found to be effective as well as safe, with an acceptably low risk of chest complications. [ABSTRACT FROM AUTHOR]

OBJECTIVES To prospectively evaluate the results of vaso-epididymostomy, using a two-suture microsurgical invagination technique, when used for men with azoospermia due to an obstruction at the vaso-epididymal junction. PATIENTS AND METHODS Between December 2002 and November 2004, 29 men with idiopathic obstructive azoospermia underwent vaso-epididymostomy with the two-suture invagination technique. The patency rate was assessed by return of sperm in the semen after surgery. RESULTS In all, 23 men provided at least one postoperative semen sample. The mean (range) follow-up was 7.6 (1.5–30) months. In 11 of these men (48%), patency was shown at a mean of 3.2 (1.5–7) months after surgery. The median sperm density was 17 (10–65) million/mL. Four men had normal sperm density and motility (>20 million/mL; >50% total motility). CONCLUSIONS Men with idiopathic vaso-epididymal junction obstruction can have significant sperm positivity after vaso-epididymostomy. With a patency rate of nearly half within a year of surgery, vaso-epididymostomy should be the first line of therapy for these men. [ABSTRACT FROM AUTHOR]

Objective: To compare the risks of fever from different lithotrites after percutaneous nephrolithotomy (PNL). Materials and Methods: The Clinical Research Office of the Endourological Society (CROES) PNL database is a prospective, multi-institutional, international PNL registry. Of 5,803 total patients, 4,968 received preoperative antibiotics, were supplied with complete information and included in this analysis. The lithotrites assessed included no fragmentation, ultrasonic, laser, pneumatic and combination ultrasonic/pneumatic. Risk of fever was estimated using multivariate logistic regression with adjustment for diabetes, steroid use, a history of positive urine culture, the presence of staghorn calculi or preoperative nephrostomy, stone burden and lithotrite. Results: The overall fever rate was 10%. Pneumatic lithotrites were used in 43% of the cohort, followed by ultrasonic (24%), combination ultrasonic/pneumatic (17.3%), no fragmentation (8.4%) and laser (7.3%). Fever rates were no different between patients who underwent no or any fragmentation (p = 0.117), nor among patients when stratified by lithotrite (p = 0.429). On multivariate analysis, fragmentation was not significantly associated with fever [Odds Ratio (OR) 1.17, p = 0.413], while diabetes (OR 1.32, p = 0.048), positive urine culture (OR 2.08, p < 0.001), staghorn calculi (OR 1.80, p < 0.001) and nephrostomy (OR 1.65, p < 0.001) increased fever risk. Fever risk among lithotrites did not differ (p ≥ 0.128). Conclusions: Risk of post-PNL fever was not significantly different among the various lithotrites used in the CROES PNL study. Copyright © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objectives: Advancement in technology has led to a decrease in invasiveness for surgical management of malignant renal neoplasms. Laparoscopic radical nephrectomy is an established treatment for renal tumors. Since the introduction of robotic surgery in the realm of urology, many procedures have been done robotically. We evaluated the feasibility, safety, and oncological outcomes of robotic radical nephrectomy (RRN). Methods: We retrospectively reviewed the records of patients who underwent RRN for renal tumors at our institute from September 2007 to March 2011. Patients with standard indications for a radical nephrectomy were offered a robot-assisted procedure. Intraoperative parameters (operative time, blood loss, transfusion of blood products), postoperative parameters and complications were recorded. Results: Twenty-three patients who underwent RRN were included. Mean operative time was 132.7 min and mean blood loss 270 ml. The majority of patients were able to tolerate liquid diet, were free from drain, and were fit for discharge by postoperative day (POD) 1, POD 2 and POD 3, respectively. After the mean follow-up of 29.4 months, no patient had residual tumor, local recurrence or metastasis. Conclusion: We conclude that RRN is a feasible and safe procedure with good oncological outcome on short-term follow-up. Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objectives: Open pyeloplasty is the standard treatment for ureteropelvic junction obstruction in children. The introduction of robotic surgical system has facilitated precise intracorporeal suturing and shortened the learning curve for minimal invasive procedures for the surgeons. There is sparse data over the outcomes of robot-assisted laparoscopic pyeloplasties in children. We describe our technique and outcomes of robotic pyeloplasty in children. Patients and Methods: Operative data for all patients undergoing a robot-assisted procedure at our center is prospectively recorded in a database. We retrieved data of patients below the age of 16 years undergoing robot-assisted pyeloplasty between July 2007 to March 2011 and evaluated their operative parameters, recovery, and functional outcomes. Results: In the period under review, 34 pediatric patients (mean age 12 years, range 5-15 years) underwent robot-assisted laparoscopic pyeloplasty at our center. All patients underwent unilateral pyeloplasty but one patient underwent a simultaneous contralateral pyelolithotomy. The mean total operative time (range) was 105 minutes (75-190 minutes), average dissection time and the anastomosis time was 23 minutes (20-58 minutes) and 46.5 minutes (28-70 minutes) respectively. The mean blood loss was 30 mL. Follow-up of 36, 24, 18, 12, and 6 months was completed in 14, 21, 24, 28, and 31 patients respectively. Postoperatively, one patient had an omentum herniation through the camera port site and another had an ileocaecal volvulus. With a mean follow-up of 28.5 months (2-56 months), the success rate was 97% (32/33), whereas postoperatively one patient had deterioration of function. Conclusion: Robot-assisted laparoscopic pyeloplasty is a safe and effective minimally invasive treatment modality in children. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]

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. [Copyright &y& Elsevier]

Abstract: Proton magnetic resonance spectroscopic imaging (MRSI) and diffusion-weighted imaging (DWI) were carried out in men with increased prostate-specific antigen (PSA) level. Forty subjects [controls (Group I) and patients (Groups II and III with PSA >20 and 4–20 ng/ml, respectively)] were investigated using endorectal coil at 1.5 T prior to transrectal ultrasound (TRUS)-guided biopsy. Metabolite ratio [citrate/(choline+creatine)] and apparent diffusion coefficient (ADC) were calculated for identical voxels. In patients, voxels that showed lower metabolite ratio showed reduced ADC in the peripheral zone (PZ) of the prostate, and voxels with increased metabolite ratio showed higher ADC. Metabolite ratios were used to predict areas of malignancy if the ratio was <1.4 and if ADC value was <1.17×10−3 mm2/s. Patients in Group II had lower metabolite ratio and ADC in the PZ compared to controls and Group III. All 13 were positive for malignancy in MR, while 12 of 13 were positive on TRUS-guided sextant biopsy. In Group III, certain voxels of PZ that showed reduced metabolite ratio also showed lower ADC. A positive correlation was observed between metabolite ratio and ADC. MR predicted areas of malignancy in PZ in 15 of 20 patients; however, only six were positive on TRUS-guided biopsy perhaps due to high false-negative rate of TRUS-guided biopsy. Results show positive correlation between MRSI and DWI and their potential in detection of malignancy, thereby improving the diagnosis especially in patients with PSA level of 4–20 ng/ml. [Copyright &y& Elsevier]

Introduction: The treatment of large complete staghorn calculi requires a sandwich combination of percutaneous nephrolithotomy (PCNL) and shockwave lithotripsy (SWL) or sometimes open surgery. Many urologists hesitate to place more than 2–3 tracts during PCNL because of the belief that this may increase complications. We present data to support multi-tract PCNL for large (surface area >3,000 mm2) complete staghorn calculi. Patients and Methods: From July 1998 to October 2003, 121 renal units (103 patients) with large complete staghorn renal calculi were treated with PCNL. All procedures were performed in the prone position after retrograde ureteral catheterization. Fluoroscopy-guided punctures were made by the urologist followed by track dilation to 34 french. When multiple tracts were anticipated all punctures were usually made at the outset and preplaced wires were put into the collecting system or down the ureter. Stones were fragmented and removed using a combination of pneumatic lithotripsy and suction. Postoperative stone clearance was documented on X-ray KUB. Results: 121 renal units of 103 patients (15 women and 88 men, mean age 43 years) were treated. Six patients had associated bladder calculi that were treated simultaneously. The stone surface area was 3,089–6,012 (mean 4,800) mm2. 10 patients (9.7%) had renal insufficiency with a mean (range) serum creatinine of 3.0 (1.5–5.5) mg/dl. The number of tracts required per patient were 2 tracts in 11, 3 tracts in 68, 4 tracts in 39, and 5 tracts in 3, giving a total of 397 tracts in 121 renal units, over a total of 140 procedures (including second-look procedures in 19 renal units). The points of entry of these tracts were 121 upper calyx (30.4%), 178 middle calyx (44.8%), and 98 lower calyx (24.6%). All 121 units had one upper polar access tract of which 92 (76%) were supracostal. Complications were blood transfusion (n = 18), pseudoaneurysm (n = 2), fever (n = 22), septic shock (n = 1) and hydrothorax (n = 3). PCNL monotherapy achieved an 84% complete clearance rate that improved to 94% with SWL in 8 renal units with small residual fragments. Stone compositions were calcium oxalate (91%), uric acid (2%) and mixed (7%). Conclusion: Aggressive PCNL monotherapy using multiple tracts is safe and effective, and should be the first option for massive renal staghorn calculi. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Introduction: Tubeless PNL (percutaneous nephrolithotomy), in a highly selected group of patients, is a modification aimed at reducing the morbidity of PNL. We present a simple technique of achieving tract hemostasis as an adjunct to the safe performance of a tubeless PNL. Materials and Methods: Charts of 40 consecutive patients who underwent tubeless PNL at our center were reviewed. In the latter 20 consecutive patients, diathermy coagulation of the intrarenal bleeders and tract was done and these patients were compared with the earlier 20 patients in whom fulguration was not done. Drop in hemoglobin, postoperative analgesic requirement, operating time, length of hospitalization and postoperative complications were compared. Results: No statistical difference was found between the operative times and drop in hemoglobin for both the groups. The length of hospitalization and postoperative analgesic requirement were significantly less in the fulguration group. No significant complications were noted in either of the two groups. Conclusions: Fulguration of visible intrarenal and tract bleeders is a simple, safe and effective hemostatic adjunct in patients undergoing tubeless PNL. Copyright © 2004 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Authors from New Delhi assessed the efficacy of superior pole access for complex lower pole calyceal calculi; they found this to be the best way of approaching such complex stones, allowing faster and better clearance with a single puncture.The second paper in this section is from authors from the UK who set out to describe the frequency of renal symptoms and complications in patients with tuberous sclerosis complex, and to relate the history of renal haemorrhage with renal lesions identified on renal scan.To assess the efficacy of superior pole access for complex lower pole calyceal calculi.In all, 102 patients with complex inferior calyceal calculi were included in a prospective unrandomized study. Complex inferior calyceal calculi were defined as multiple calculi in two or more inferior calyces of the lower polar group, with each calyx draining through a separate infundibulum and at an acute angle to each other. In 33 patients (32%; group 1) an inferior calyceal puncture was made and in 69 (68%; group 2) access was obtained through a superior calyceal puncture. The stone-free rates, decrease in haemoglobin, operative duration, requirement for additional tracts and second procedures in the two groups were compared.Stone clearance rates and blood loss values were better in group 2, although they were not significantly different. The mean operative duration, number of tracts required and the re-look procedure rate was significantly less in group 2. Two patients (3%) in group 2 had hydrothorax related to supracostal puncture and required chest tube insertion.Superior calyceal puncture (supracostal or infracostal) affords optimum access to complex inferior calyceal stones, providing faster and better clearance with a single puncture, and less requirement for second-look procedures. [ABSTRACT FROM AUTHOR]

Radical cystectomy is the standard of care for patients with muscle invasive bladder cancer. While open radical cystectomy is now a standard procedure, laparoscopic radical cystectomy is still in its infancy. We performed this surgery laparoscopically in 11 patients and review the procedure specific complications. Beginning in February 1999, 11 patients underwent laparoscopic radical cystectomy at the Department of Urology, All India Institute of Medical Sciences, New Dehli. Urinary diversion was performed by an open-hand sewn ileal conduit. There were three intraoperative complications specifically related to the laparoscopic radical cystectomy. These included injury to the external iliac vein in one patient and a small rectal tear in two. All were repaired with laparoscopic free hand suturing with normal postoperative recovery. Other laparoscopy-related complications were subcutaneous emphysema in one patient and hypercarbia necessitating conversion to open surgery in a patient who, four weeks after surgery, died of multiple organ failure. One patient had margins positive and received cisplatinum-based chemotherapy. All patients had normal renal function and preserved upper tracts with no evidence of metastasis at a mean of 18.4 months follow up (range 1–48 months). Though there were three complications specific to the laparoscopic radical cystectomy, none necessitated a conversion to open surgery or hampered the overall outcome. Absence of local recurrence or metastatic disease at four years of follow up suggests that the procedure is oncologically valid. Laparoscopic radical cystectomy is a new procedure and it is important to critically analyze the complications in order to reduce their occurrence and allow the development of a better technique. [ABSTRACT FROM AUTHOR]

We evaluate the feasibility of proton magnetic resonance spectroscopy (1H MRS) using a spine coil receiver (body coil) in the diagnosis of carcinoma prostate. Seventeen patients with biopsy-proven prostate carcinoma, five patients of benign prostatic hyperplasia (BPH) and five healthy young volunteers underwent 1H MRS investigation. MRS was performed at 1.5 Tesla using a spine receiver coil for signal reception. In vivo citrate levels are reported as a ratio of citrate peak area to the sum of the areas of choline and creatine peak. MRS spectrum with good sensitivity and signal to noise (S/N) ratio was obtained in all 27 subjects. The citrate to creatine plus choline ratio was 0.31±0.25 in patients with cancer, 1.43±0.58 in BPH and 2.16±0.56 in controls. The difference in ratios between cancer and BPH and cancer and control was statistically significant (p<0.01). Within the cancer group, there was a statistically significant decline in levels with higher-grade malignancy (p<0.05). There were no complications of the procedure. There is a statistically significant decline in the ratio of citrate to choline plus creatine in the regions of cancer prostate when compared with BPH or normal control. The study demonstrates that MRS data can be reliably acquired using a spine coil receiver. MRS may also play a role in differentiating well-differentiated tumors from the anaplastic variety. [ABSTRACT FROM AUTHOR]

Background: Prostate cancer (PCa) incidences vary with genetic, geographical and ethnic dietary background of patients while angiogenesis is modulated through exquisite interplay of tumor-stromal interactions of biological macromolecules. We hypothesized that comprehensive analysis of four biomarkers modulating angiogenesis in PCa progression in two diverse populations might explain the variance in the incidence rates. Results: Immunohistochemical analysis of 42 PCa biopsies reveals that though Anx-II expression is lost in both the Indian and American population with Gleason scores (GS) ranging between 6 and 10, up to 25 % of cells in the entire high grade (GS > 8) PD PCa samples from US show intense focal membrane staining for Anx-II unlike similarly graded specimens from India. Consistent with this observation, the prostate cancer cell lines PC-3, DU- 145 and MDA PCa 2A, but not LNCaP-R, LNCAP-UR or MDA PCa 2B cell lines, express Anx-II. Transcriptional reactivation of Anx-II gene with Aza-dC could not entirely account for loss of Anx-II protein in primary PCa. Cyclooxygenase-2 (COX-2) was moderately expressed in most of high grade PIN and some MD PCa and surrounding stroma. COX-2 was not expressed in PD PCa (GS ~7--10), while adjacent smooth muscles cells stained weakly positive. Decorin expression was observed only in high grade PIN but not in any of the prostate cancers, atrophy or BPH while stromal areas of BPH stained intensively for DCN and decreased with advancing stages of PCa. Versican expression was weak in most of the MD PCa, moderate in all of BPH, moderately focal in PD PC, weak and focal in PIN, atrophy and adjacent stroma. Conclusions: Expression of pro- and anti-angiogenic modulators changes with stage of PCa but correlates with angiogenic status. Focal membrane staining of Anx-II reappears in high grade PCa specimens only from US indicating differential expression of Anx-II. COX-2 stained stronger in American specimens compared to Indian specimens. The sequential expression of DCN and VCN in progressive stages was similar in specimens from India and USA indicating no population-based differences. The mechanistic and regulatory role of Anx-II in PCa progression warrants further investigation. [ABSTRACT FROM AUTHOR]

Introduction: The objective of the study was to determine the pattern of p53 expression in patients with muscle invasive bladder cancer treated with cystectomy and to assess the prognostic value of p53 expression in this group of patients. Materials and Methods: We retrospectively analyzed data of 100 patients who underwent cystectomy for invasive transitional cell carcinoma of the urinary bladder. These patients were seen at 3-monthly intervals during the first 2 years, 6-monthly in the third year, and yearly thereafter. Immunohistochemical analysis for p53 was done on paraffin-fixed tissues with DO-7 antibodies. The tumours with >30% cells staining for p53 proteins were considered p53 positive. Results: There were 95 males and 5 females with a mean age of 54 years. Two patients died in the perioperative period and were excluded from analysis. Over a median follow-up period of 2 years (range 3 months to 10 years) 62 patients are alive without disease while 36 had relapse and of these, 31 have died. The p53 expression was significantly related to stage and grade of the tumour. p53-negative tumours were more likely to be organ confined and of lower grade as compared to p53-positive tumours. The stage of tumour was significantly related to outcome but grade and p53 immunohistochemistry did not provide any prognostic information. Conclusions: p53 immunostaining was positive in 57% of muscle invasive urinary bladder tumours. The p53 positivity correlated well with the stage and grade of the disease, whereas it has no additional prognostic value.Copyright © 2003 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Anterior urethral valve (AUV) is a long known but rare anomaly, which is occasionally encountered in boys with obstructive uropathy. We present a case of AUV with a diverticulum which was misdiagnosed at other center as neurogenic bladder resulting in chronic renal failure. The case was further complicated by breakage of tip of the catheter used for clean intermittent catheterization (CIC) in the diverticulum presenting as a foreign body in the urethra. This article highlights the frequently missed diagnosis of AUV by most practitioners wrongly labeling it as neurogenic bladder, leading to improper management and renal failure in young boys. [ABSTRACT FROM AUTHOR]