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   Table of Contents - Current issue
Coverpage
July-September 2019
Volume 35 | Issue 3
Page Nos. 177-243

Online since Tuesday, July 2, 2019

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EDITORIALS  

The health-care crisis in India – Can urology remain untouched? Highly accessed article p. 177
Arabind Panda
DOI:10.4103/iju.IJU_105_19  
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Round up p. 179
Apul Goel
DOI:10.4103/iju.IJU_193_19  
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What's inside p. 183
Rajeev Kumar
DOI:10.4103/iju.IJU_195_19  
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The Urological Society of India Guidelines for the Evaluation and Management of Nonneurogenic Urinary Incontinence in Adults (Executive Summary) p. 185
Sanjay Sinha, Mayank Mohan Agarwal, Pawan Vasudeva, Nikhil Khattar, Vijay Kumar Sarma Madduri, Shirish Yande, Kalyan Sarkar, Anita Patel, Ajit Vaze, Shailesh Raina, Amita Jain, Manu Gupta, Nagendranath Mishra
DOI:10.4103/iju.IJU_125_19  
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REVIEW ARTICLE Top

The resurgence of estrogens in the treatment of castration-resistant prostate cancer p. 189
H Krishna Moorthy, GG Laxman Prabhu, P Venugopal
DOI:10.4103/iju.IJU_56_19  
Use of exogenous estrogens in manipulating the androgenestrogen equilibrium was one of the earliest therapeutic strategies developed to treat prostate cancer which followed close on heels the discovery of hormone dependence of this tumor. Despite its well-documented benefit, estrogen therapy fell out of favor with the advent of other forms of androgen deprivation therapy (ADT) as the former registered a higher incidence of cardiovascular complications and poorer overall survival. Clearer understanding of the mechanism of action of estrogen coupled with the adoption of alternative routes of administration has triggered a renewed interest in estrogen therapy. Since then, many studies have not only proved the therapeutic benefit of estrogens but also explored the ways and means of minimizing the dreaded side effects deterring its use. Further, the fact that estrogen therapy offered a clear advantage of reduced cost of treatment over other treatments has led many countries to readopt it in the treatment of advanced prostatic cancer. We reviewed the published data on the use of estrogens in CRPC, which may affect its revival as an efficacious treatment option having minimal side effects, with modified dosage and route of administration. Estrogen therapy would be a less expensive option having equivalent or even better therapeutic effect than ADT in advanced carcinoma of prostate.
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ORIGINAL ARTICLES Top

Development of an innovative intrarenal pressure regulation system for mini-PCNL: A preliminary study p. 197
Ashish V Rawandale-Patil, Arvind P Ganpule, Lokesh G Patni
DOI:10.4103/iju.IJU_261_18  
Introduction: Miniaturized percutaneous nephrolithotomy (mini-PCNL) requires saline irrigation at high-pressures to maintain visual clarity. However, this may raise the intrarenal pelvic pressures (IRPs) beyond a safe range and may result in a higher complication rate. The aim of this study was to make and validate an automated pressure saline irrigation system to regulate IRPs during mini-PCNL. Materials and Methods: A ureteric catheter was connected to an urodynamic machine and the minimum, maximum, and average IRPs reached during a standard 15 Fr mini-PCNL were measured in ten cases. Next, an intrarenal pressure regulation system (IPRS) was conceptualized, designed, patented, and constructed. IPRS was then tested on a mannequin model using the routine instruments. Lastly, the IPRS was evaluated on – five cases of 15 Fr mini-PCNL. The mean maximum IRP as recorded in the baseline data was set as the maximum permissible pressure on IPRS. The efficacy of IPRS was assessed by measuring the IRP, recorded in parallel, on both the IPRS and the urodynamic machine at various stages of the procedure. Results: The mean maximum IRP reached during baseline evaluation was 25 cm of water which was set as the maximum permissible limit of the IPRS. Evaluation of the IRPS on mannequin models and validation clinical cases showed that IPRS measured the IRP accurately and prevented the pressure surge above the set limits Overall, higher IRPs were recorded during stone pulverization as compared to the other surgical steps. Conclusions: The current IPRS is the first of its kind open platform, portable, automated pressure saline irrigation system. It precisely monitors and controls the IRP and has the potential to reduce the irrigation pressure-related complications.
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Comparison of percentage free PSA, MRI and GaPSMA PET scan for diagnosing cancer prostate in men with PSA between 4 and 20 ng/ml p. 202
Niraj Kumar, Siddharth Yadav, Sandeep Kumar, Kumar Saurav, Vishnu Prasad, Pawan Vasudeva
DOI:10.4103/iju.IJU_91_19  
Introduction: We compared the diagnostic accuracy of percentage free prostate-specific antigen (PSA), multiparametric magnetic resonance imaging (mpMRI), and gallium-68 prostate-specific membrane antigen positron emission tomography (Ga-PSMA PET) to detect cancer prostate in men with PSA between 4 and 20 ng/ml in prebiopsy settings. Materials and Methods: This prospective study evaluated men with PSA values between 4 and 20 ng/ml, and all patients underwent percentage free PSA estimation, mpMRI, and Ga-PSMA PET scan, followed by cognitive fusion/registration biopsy along with systematic 12-core biopsy to detect cancer prostate. The diagnostic accuracy of percentage free PSA, mpMRI, and Ga-PSMA PET scan was compared with results of cognitive fusion/registration biopsy. Results: A total of 15 patients were included, of which 11 had an identifiable lesion on imaging and 9 had malignancy on the final histopathology report. The sensitivity, specificity, positive predictive value, negative predictive value (NPV), and diagnostic accuracy of mpMRI were 62.5%, 71.4%, 71.4%, 62.5%, and 66.6%, respectively, and that of Ga-PSMA PET scan were 88.8%, 66.6%, 80%, 80%, and 80%, respectively. The sensitivity of detection of clinically significant cancers for Ga-PSMA was higher (100%) compared to MRI (33.3%). However, Ga-PSMA also detected a greater number of insignificant lesions as compared to MRI. Conclusion: Ga-PSMA PET scan has high NPV and accuracy in predicting presence of cancer and can also be used to direct specific biopsy cores during systematic biopsy.
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MRI - ultrasound fusion guided biopsy of the prostate: lesion volume as a predictor of cancer in patients with repeat biopsies p. 208
Scott Alan Blaine, Haidar M Abdul-Muhsin, Nicholas J Jakob, Paul E Andrews, Robert G Ferrigni, Stephen S Cha, Ashkahn Golshani, Alvin C Silva, Akira Kawashima, Mitchell R Humphreys
DOI:10.4103/iju.IJU_49_19  
Introduction: The objective was to analyze the diagnostic value of multiparametric magnetic resonance imaging (MRI) prostate lesion volume (PLV) and its correlation with the subsequent MRI–ultrasound (MRI-US) fusion biopsy results. Materials and Methods: Between March 2014 and July 2016, 150 men underwent MRI-US fusion biopsies at our institution. All suspicious prostate lesions were graded according to the Prostate Imaging Reporting and Data System (PIRADS) and their volumes were measured. These lesions were subsequently biopsied. All data were prospectively collected and retrospectively analyzed. The PLV of all suspicious lesions was correlated with the presence of cancer on the final MRI-US fusion biopsy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Results: There were 206 suspicious lesions identified in 150 men. The overall cancer detection rate was 102/206 (49.5%). The mean PLV for benign lesions was 0.63 ± 0.94 cm3 versus 1.44 ± 1.76 cm3 for cancerous lesions (P < 0.01). There was a statistically significant difference between the PLV of PIRADS 5 lesions when compared to PIRADS 4, 3, and 2 lesions (P < 0.0001, < 0.0001, and 0.006, respectively). The area under the curve for volume in predicting prostate cancer (PCa) was 0.66. The optimal volume for predicting PCa was 0.26 cm3 with a sensitivity, specificity, PPV, and NPV of 80.7%, 42.7%, 41.2%, and 74.6%, respectively. Conclusion: PLV may serve as a useful measure to triage patients prior to MRI-US fusion biopsy and help better understand the limits of this technology for individual patients.
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Clinicopathological features and outcomes of adrenocortical carcinoma: A single institution experience p. 213
Lekha Madhavan Nair, KM Jagathnath Krishna, Aswin Kumar, Susan Mathews, John Joseph, Francis Vadakkumparambil James
DOI:10.4103/iju.IJU_19_19  
Introduction: Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with aggressive behavior. Most of our knowledge about this rare tumor is based on retrospective case series. This study aimed at analyzing the clinicopathological features and outcomes of patients treated at a tertiary cancer center in India. Patients and Methods: We retrospectively reviewed the data of patients with ACC registered from January 2006 to December 2015. Results: Thirty-seven patients were included in the study, 20 males and 17 females. Median age was 49 (18–78) years. Hormonal overproduction was noticed in 27% of patients. Median tumor size was 10 cm (2–22). Seventeen patients had metastatic disease and 20 patients were localised at diagnosis. Median follow-up was 22 months and median overall survival (OS) was 23.46 months. OS at 2 years and 5 years was 46.1% and 21%, respectively. The median disease-free survival (DFS) was 20 months. DFS at 2 years and 5 years was 45% and 24%, respectively. Age, sex, tumor size, hormonal overproduction, tumor laterality, and stage of the disease did not influence survival. However, advanced stage was associated with higher risk for recurrence. (P = 0.03). Conclusion: ACC is a rare endocrine malignancy with very poor survival rates. Rate of recurrence is high even after complete surgery. Systemic treatment options are limited. Newer agents are needed to improve outcome.
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Native ureteroureterostomy in renal allograft recipient surgery: A single-center 5-year experience p. 218
Vipin Tyagi, Saurabh Jain, Mahendra Singh, Mrinal Pahwa, Sudhir Chadha, Shahnawaz Rasool
DOI:10.4103/iju.IJU_20_18  
Introduction: In renal transplant, surgeons use a myriad of ureteral anastomotic techniques. Although ureteroneocystostomy (UNC) using Lich-Gregoir extravesical anastomosis is used most commonly, ureteroureterostomy with native ureter has its own importance in certain situations. Materials and Methods: We retrospectively reviewed records of patients who underwent renal transplantation at our center from March 2011 to February 2016. Records of patients who underwent ureteroureterostomy with the native ureter were reviewed for the indications and complications of the procedure. Results: Of 1050 renal transplants during the study period, 32 patients underwent native ureteroureterostomy. Among these 32 patients, 20 patients were planned preoperatively for native ureteroureterostomy (elective), and intraoperative decision was made in 12 patients (emergency). On follow-up, only one patient had ureteral obstruction due to kink just distal to ureteroureterostomy and was managed by double-J stenting. Other patients had an expected postoperative course. Conclusion: In our experience, ureteroureterostomy with native ureter is technically and functionally good option for ureteric reimplantation in kidney transplant patients. It can be used selectively for elective and emergency situations where UNC is not possible. Hence, the kidney transplant surgeon should be well versed with both techniques.
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Does caudal analgesia increase the rates of urethrocutaneous fistula formation after hypospadias repair? Systematic review and meta-analysis p. 222
Prabudh Goel, Shikha Jain, Minu Bajpai, Puneet Khanna, Vishesh Jain, Devendra Kumar Yadav
DOI:10.4103/iju.IJU_252_18  
Introduction: Caudal block analgesia is administered to lower the requirements of systemic and inhaled anesthetic drugs during hypospadias surgery. However, recent reports, all clustered in a short time-span have generated controversial and mutually opposing results while evaluating caudal block as an independent risk factor for urethroplasty-related complications after hypospadias repair. There is no consensus statement on the role of caudal block analgesia in formation of urethrocutaneous fistula (UCF) after hypospadias surgery. We performed a systematic review and meta-analysis of the studies evaluating the relative rates of UCF formation after hypospadias surgery in patients who were administered caudal block analgesia versus in those who were not. Methods: Electronic searches were performed using PubMed, PubMed Central, Google Scholar, Ovid, and the Cochrane library. Statistical analysis was performed using a fixed-effect model, odds ratios, risk ratios (RR), and heterogeneity (I2) were calculated. Funnel plot was used to assess for publication bias. Results: Seven studies with 1706 patients were included. Caudal block analgesia is associated with a significantly higher risk of UCF formation (RR: 1.81; 95% confidence interval [CI]: 1.30–2.53), (P = 0.0004) and other urethroplasty-related complications (RR 2.01; 95% CI: 1.48–2.74), (P < 0.00001) after hypospadias surgery. Funnel plots indicate some publication bias. Conclusions: In patients undergoing hypospadias repair, administration of caudal analgesia is associated with a higher risk of UCF formation and other urethroplasty-related complications.
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VIDEO Top

”Polar flip” technique for transperitoneal laparoscopic partial nephrectomy – Evolution of a novel technique for posterior hilar tumors p. 230
Mallikarjuna Chiruvella, Syed Mohammed Ghouse, Ashwin Sunil Tamhankar
DOI:10.4103/iju.IJU_235_18  
Posterior hilar renal tumor extirpation by partial nephrectomy is a unique challenge for transperitoneal laparoscopy. We describe our novel technique of “polar flip” for these tumors. Kidney is rotated by around 45 -60 degrees after mobilisation so that lower pole faces anteriorly and upper pole faces posteriorly, thereby exposing the posterior surface for maneuverability. Technical highlights are hilar control, complete kidney mobilisation, initial flipping with dissection in Gil Vernet's plane to clip posterior segmental renal artery, en mass hilar clamping in normal lie, polar flipping, dissection in Gil Vernet's plane till renal sinus fat, completion of tumor excision, selective vascular ligation, renorhaphy and nephropexy.
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CASE REPORTS Top

Intra-abdominal vas deferens cyst p. 232
Aditya M Gupta, Raisa Naveen Shetty, Deepak R Kuanr
DOI:10.4103/iju.IJU_36_19  
We report a case of a 62-year-old man with complaints of lower abdominal pain who, on radiological investigations, was found to have an approximately 6-cm cystic lesion in the left iliac fossa region abutting the posterolateral wall of the urinary bladder. However, its origin could not be confirmed. On laparoscopy, the cyst was found to be arising from the vas deferens and was excised. Histopathology confirmed it to be arising from the vas deferens.
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Complete duplicated hindgut anomaly presenting in adolescence: Six Ostia in perineum p. 234
Rishi Nayyar, Bharti Uppal, Asuri Krishna
DOI:10.4103/iju.IJU_264_18  
A 17-year-girl presenting with features of intestinal obstruction and managed with colostomy was referred for continuing to pass feces per anus despite a functioning colostomy. She was diagnosed with a rare congenital anomaly with duplication of urethra, bladder, vagina, uterus, anus, and distal colon; all openings close together in the perineum. Excision of the obstructed duplicated colon was done. The anomaly and its features are discussed with review of literature.
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Primary prostatic extra-gastrointestinal stromal tumor causing giant prostatomegaly p. 237
Gaurav Garg, Ashish Sharma, Satya Narayan Sankhwar
DOI:10.4103/iju.IJU_43_19  
Prostatic extra-gastrointestinal stromal tumors (E-GIST) are rare mesenchymal tumors with only 9-cases reported in the English literature so far. We herein describe a case of E-GIST causing massive enlargement of the prostate gland. A 55-year-old male was diagnosed with localized prostatic E-GIST causing massive prostatomegaly (1230 cc) during workup for lower urinary tract symptoms (LUTS). The patient was managed with Imatinib mesylate therapy as high anesthetic risks precluded surgery. Given the rarity, E-GISTs should be included in the differential diagnosis of patients presenting with LUTS as it may influence the treatment decisions.
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UROLOGICAL IMAGES Top

Alkaline-encrusting pyelitis – A rare disastrous complication postPCNL leading to chronic renal failure p. 240
Kalpesh Parmar, Abhishek Thakur, Shantanu Tyagi
DOI:10.4103/iju.IJU_126_19  
Alkaline-encrusting pyelitis (AEP) is a severe form of infectious disease characterized by encrustation along the lining of the urinary tract leading to loss of renal function. Common predisposing factors are chronic infection, immunosuppression, and endourology procedures. Urea-producing organisms arefrequently associated, and urine alkalization leads to calcific deposition in the pelvicalyceal system. We present a 23-year male with AEP in a solitary kidney leading to chronic renal failure postpercutaneous nephrolithotomy for renal stones.
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SURGICAL CRAFT Top

A safe technique of finger-guided biopsy of the prostate Highly accessed article p. 242
C Danny Darlington
DOI:10.4103/iju.IJU_95_19  
Prostatic biopsy is the gold standard of diagnosis of prostatic cancer. In the era of transrectal ultrasound-guided biopsy of the prostate, finger-guided prostatic biopsy still has a role in underdeveloped and developing countries. We describe a safer technique of performing a finger-guided prostatic biopsy.
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