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   Table of Contents - Current issue
Coverpage
April-June 2017
Volume 33 | Issue 2
Page Nos. 97-177

Online since Thursday, March 30, 2017

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EDITORIALS  

Revisiting prostate cancer: Can we separate the wheat from the chaff? p. 97
Arabind Panda
DOI:10.4103/iju.IJU_95_17  
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What's inside p. 99
Arabind Panda
DOI:10.4103/iju.IJU_96_17  
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Roundup p. 101
Santosh Kumar
DOI:10.4103/iju.IJU_86_17  
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GUEST EDITORIAL Top

Bladder cancer: 2017 and beyond p. 104
Ashish M Kamat
DOI:10.4103/0970-1591.203419  
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REVIEW ARTICLES Top

Advances in surgical management of muscle invasive bladder cancer p. 106
Janet Baack Kukreja, Jay B Shah
DOI:10.4103/0970-1591.203416  
Introduction: Bladder cancer remains a disease of the elderly with relatively few advances that have improved survival over the last 20 years. Radical cystectomy (RC) has long remained the principal treatment for muscle-invasive bladder cancer (MIBC). Methods: A literature search of PubMed was performed. The content was reviewed for continuity with the topic of surgical advances in MIBC. Articles and society guidelines were included in this review. Results: Despite the associated morbidity, even in the elderly, RC is still a reasonable option. Modifications during RC may have a positive or negative impact on survival and quality of life. The extent of pelvic lymph node dissection is one such factor which may positively impact survival outcomes. In addition, preservation of pelvic organs, robotic surgery and the adoption of enhanced recovery after surgery principles continues to improve the postoperative recovery and quality of life in RC patients. Conclusion: There are some ongoing studies in many of these areas, but overall the new advances in MIBC may improve patient quality and quantity of life. The advances in surgical treatment of MIBC are important and the focus of the review here.
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Where are we with bladder preservation for muscle-invasive bladder cancer in 2017? p. 111
Woodson Wade Smelser, Marcus A Austenfeld, Jeffrey Maxwell Holzbeierlein, Eugene Kang Lee
DOI:10.4103/iju.IJU_279_16  
Introduction: In 2017, neoadjuvant, cisplatin-based chemotherapy followed by radical cystectomy (RC) is considered the gold standard therapy for muscle-invasive bladder based on randomized controlled trials. Across all tumor stages, this approach has been associated with the highest rates of disease-specific survival. However, RC is one of the most challenging procedures performed by urologic surgeons and carries with it significant risks of complications, hospital readmission, and even a small risk of mortality, in addition to lifestyle changes that can have long-term effects on well-being. For these reasons, bladder-sparing approaches are utilized in some highly selected patients. We reviewed the most recent evidence for bladder-sparing modalities for muscle-invasive urothelial bladder cancer and summarize those findings in this review article. Methods: We performed a PubMed literature review utilizing the key words “bladder preservation,” “trimodal therapy,” “muscle-invasive bladder cancer,” and “partial cystectomy” written in English, dating back to 1990. We excluded case reports. Results: Our search yielded more than 2000 articles which we screened. Some articles were then rejected due to inappropriate topic. In addition, we reviewed the most recent American Urological Association, National Comprehensive Cancer Network (NCCN), and European guidelines on muscle-invasive bladder cancer. We identified fifty relevant articles which are summarized in this text. In some rare instances, recommendations are based on expert opinion. Conclusions: Bladder preservation is often considered for quality of life considerations or in the setting of multiple medical comorbidities, and this remains oncologically appropriate even in 2016 in highly selected patients with muscle-invasive urothelial carcinoma of the bladder.
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Systemic therapy in bladder cancer p. 118
Ian G Pinto
DOI:10.4103/iju.IJU_294_16  
Systemic chemotherapy is essential for the management of muscle-invasive bladder cancer (MIBC) and metastatic bladder cancer (BCa). Neoadjuvant chemotherapy is key to the management of MIBC with many cisplatin-based regimens. Adjuvant chemotherapy may be considered for selected patients who did not receive neoadjuvant therapy. Systemic chemotherapy with radiotherapy is a critical component of a trimodal bladder-preserving approach and is superior to radiotherapy alone. Cisplatin-based chemotherapy has been the mainstay for metastatic BCa. Immunotherapy in the form of checkpoint inhibitors is a promising new drug for the treatment of BCa. Molecular characterization of each individual BCa is likely to lead to a target-directed therapeutic revolution.
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Bladder cancer: Micro RNAs as biomolecules for prognostication and surveillance p. 127
Nilay Mitash, Swasti Tiwari, Shalini Agnihotri, Anil Mandhani
DOI:10.4103/0970-1591.203412  
Introduction: Bladder cancer (BC) has varied clinical behavior in terms of recurrence and progression. Current pathological characteristics are insufficient to prognosticate the outcome of a given treatment. Cellular metabolic regulatory molecules, such as micro RNA (miRNA), could be a potential biomarker to prognosticate the treatment outcomes. Materials and Methods: PubMed and Google Scholar databases were searched for publications from 1990 to 2016, related to miRNA biogenesis, its function, and role in the pathogenesis of bladder as well as other cancers. Articles were searched using MeSH terms micrornas, micrornas AND neoplasm, and micrornas AND urinary bladder neoplasm. Out of the 108 publications reviewed 75 references were selected based on the clinical relevance. Articles were reviewed to assess the role of miRNA in various cancers and those in BC as a diagnostic or therapeutic tool. Results: More than 35 miRNAs were found to be associated with different pathways of cellular dedifferentiation, proliferation, and progression of BC as well as other cancers. A normal looking mucosa may show molecular changes preceding phenotypic changes in the form of varied expression of miR-129, miR-200a, and miR-205. miR-214, miR-99a, and miR-125b have been shown to be potential urinary biomarkers of BC. miRNAs could act as a repressor for protein molecule functioning or activator of different pathways to be used as a therapeutic target too. Conclusions: Despite certain limitations, such as instability, rapid plasma clearance, and targeting antagonist proteins of cellular metabolic pathways, miRNAs have potential to be studied as a biomarker or a therapeutic target for BC.
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ORIGINAL ARTICLES Top

Multiparametric magnetic resonance imaging-transrectal ultrasound fusion prostate biopsy: A prospective, single centre study p. 134
Somendra Bansal, Narmada P Gupta, Rajiv Yadav, Rakesh Khera, Kulbir Ahlawat, Dheeraj Gautam, Rajesh Ahlawat, Gagan Gautam
DOI:10.4103/0970-1591.203414  
Introduction: Transrectal rectal ultrasound (TRUS)-guided systematic biopsy is the gold standard for diagnosis of prostate cancer. However, systematic biopsy has high false-negative rate and often misses anteriorly located tumors. Magnetic resonance imaging (MRI)-TRUS fusion biopsy can potentially improve cancer detection by better visualization and targeting of cancer focus. We evaluated the role of fusion biopsy in detection of prostate cancer and the association of prostate imaging reporting and data system (PI-RADS) score for predicting cancer risk and its aggression. Methods: Ninety-six consecutive men with suspected prostate cancer underwent MRI-TRUS fusion-targeted biopsy of suspicious lesions and standard 12 core biopsy from May 2014 to July 2015 in our institution. All patients underwent 3.0 T multiparametric MRI before biopsy. mp-MRI included T2W, DWI, DCE and MRS sequences to identify lesions suspicious for prostate cancer. Suspected lesions were scored according to PI-RADS scoring system. Comparison of cancer detection between standard 12 core biopsy and MRI-TRUS fusion biopsy was done. Detection of prostate cancer was primary end point of this study. Results: Mean age was 64.4 years and median prostate-specific antigen was 8.6 ng/ml. Prostate cancer was detected in 57 patients (59.3%). Of these 57 patients, 8 patients (14%) were detected by standard 12 core biopsy only, 7 patients (12.3%) with MRI-TRUS fusion biopsy only, and 42 patients (73.7%) by both techniques. Of the 7 patients, detected with MRI-TRUS fusion biopsy alone, 6 patients (85.7%) had Gleason ≥7 disease. Prostate cancer was detected on either standard 12 core biopsy or MRI-TRUS fusion biopsy in 0%, 42.8%, 74%, and 89.3% patients of suspicious lesions of highest PI-RADS score 2, 3, 4, and 5, respectively. Conclusions: MRI-TRUS fusion prostate biopsy improves cancer detection rate when combined with standard 12 cores biopsy and detects more intermediate or high-grade prostate cancer (Gleason ≥7). With increasing PI-RADS score, there is an increase chance of detection of cancer as well as its aggressiveness.
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Perioperative complications and postoperative outcomes of partial nephrectomy for renal cell carcinoma: Does indication matter? p. 140
Vivek Venkatramani, Santosh Kumar, J Chandrasingh, Antony Devasia, Nitin S Kekre
DOI:10.4103/0970-1591.203420  
Introduction: The aim of the study was to determine whether perioperative complications and postoperative outcomes varied with the indication of partial nephrectomy (PN). Materials and Methods: We reviewed data of 184 consecutive PN for suspected renal cell carcinoma operated between January 2004 and December 2013. Complications using the Clavien-Dindo classification were compared between surgeries for absolute indications (chronic renal failure, bilateral tumors, or solitary kidney), those for relative indications (comorbid illnesses with the potential to affect renal function) and elective indications (patients without risk factors). Complex tumors were defined as size >7 cm, multiple, hilar, and endophytic tumors. Results: Patients with an absolute indication had larger tumors (P = 0.001) and tumors of a higher pathological T-stage (P = 0.03). Minor complications (Clavien 1 and 2) occurred in 25.4% patients in the elective arm versus over 40% in the other arms (P = 0.049). Major complications (Clavien 3+) were less common in the elective arm (3.2% cases vs. 12.7% in the relative arm and 13.8% in the absolute arm) with a trend to significance (P = 0.09). On multivariate analysis, absolute indication (odds ratio [OR] = 2.4, P = 0.04) and surgery for a complex renal mass (OR = 2.5 times, P = 0.03) remained significant predictors of minor complications. Major complications were more common in the relative (OR = 5.5, P = 0.057) and absolute indication arm (OR = 5.231, P = 0.051) with a trend toward significance. Conclusions: Elective indication was associated with fewer complications than PN for relative or absolute indications.
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Comparison of sterile water irrigation versus intravesical mitomycin C in preventing recurrence of nonmuscle invasive bladder cancer after transurethral resection p. 144
Priyank Bijalwan, Ginil Kumar Pooleri, Appu Thomas
DOI:10.4103/iju.IJU_371_16  
Introduction: Early recurrence of nonmuscle invasive bladder cancer (NMIBC) following transurethral resection (TUR) remains relatively high. An immediate single instillation of mitomycin C (MMC) reduces the recurrence rates in the first 2 years but has not shown benefits in tumor progression or overall survival. Distilled water irrigation has shown to delay tumor recurrence by osmolysis of tumor cells. There are only limited clinical studies comparing the efficacy of MMC with continuous sterile water irrigation (CSWI) in preventing the recurrence of NMIBC after TUR in clinical setting.Materials and Methods: A prospective, randomized, open-label, two-arm, single-center, pilot study was conducted between December 2013 and September 2015 at a tertiary-care center in South India. Patients were randomized into CSWI group (n = 19) or single dose intravesical MMC group (n = 17) following TUR for NMIBC and analyzed. All patients were followed up with flexible cystoscopy and urine cytology at 3 months interval for 1 year. Recurrence-free rate was estimated as the primary criterion for outcome analysis.Results: At the end of 12 months, recurrence-free rates for MMC and CSWI groups were 47.1% and 52.6%, respectively. The mean recurrence-free interval for MMC and CSWI groups were 10.9 months and 9.8 months, respectively. The difference in recurrence-free rate or recurrence-free interval between two groups was statistically nonsignificant. Further, the complications in MMC group were significantly higher than that in CSWI group (P = 0.047).Conclusions: Continuous bladder irrigation with sterile water after TUR may be comparable to immediate single dose intravesical MMC in preventing tumor recurrence in NMIBC.
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Fosfomycin susceptibility among multidrug-resistant, extended-spectrum beta-lactamase-producing, carbapenem-resistant uropathogens p. 149
Sayantan Banerjee, Mallika Sengupta, Tanoy Kumer Sarker
DOI:10.4103/iju.IJU_285_16  
Introduction: Urinary tract infection (UTI) is one of the most common infectious diseases. With the emergence of multidrug resistance (MDR), therapeutic options for treatment of UTIs are becoming limited. Fosfomycin has emerged as a novel oral therapeutic option with bactericidal activity against the MDR uropathogens. We evaluated the susceptibility pattern of uropathogens to this antibiotic. Methods: A prospective study was conducted for 6 months in a tertiary care hospital in Eastern India to evaluate whether the common uropathogens were susceptible to fosfomycin. Identification of organisms causing significant bacteriuria was done by conventional biochemical and VITEK 2 Compact System™. Antimicrobial susceptibility testing was performed against these pathogens by Kirby-Bauer disc diffusion method. Minimum inhibitory concentrations were measured for certain drugs by E-strips and VITEK 2 Compact System. Results: A total of 2229 urine samples were referred for culture during the study period, which yielded 356 significant bacterial isolates. Among these isolates, 64.78% were extended-spectrum beta-lactamases producers, 15.97% were carbapenem-resistant Enterobacteriaceae, and 42.7% isolates were found to be MDR Enterobacteriaceae (MDRE). However, 95.18% of the total isolates and 95.93% of MDRE were found to be susceptible to fosfomycin. Conclusion: The common uropathogens, including MDR isolates, show high in vitro susceptibility to fosfomycin, which therefore has the potential to emerge as a promising alternative oral agent for outpatient therapy of UTIs.
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A novel composite two-stage urethroplasty for complex penile strictures: A multicenter experience p. 155
Pankaj M Joshi, Guido Barbagli, Vikram Batra, Sandesh Surana, Atef Hamouda, Salvatore Sansalone, Dimitris Costi, Massimo Lazzeri, Craig Hunter, Devang J Desai, Fabio Castiglione, Sanjay B Kulkarni
DOI:10.4103/0970-1591.203426  
Introduction: Complex penile strictures are usually repaired using a two-stage urethroplasty. Buccal mucosal graft (BMG) placed in the first stage can have a significant contraction rate, which may require a subsequent revision surgery. We describe a composite two-stage penile urethroplasty using BMG for patients of complex penile strictures who have some salvageable urethral plate. Methods: Within a multi-institutional cohort, 82 patients underwent a two-stage urethroplasty for complex stricture of the penile urethra. Of these 42 patients who underwent our composite two-stage penile urethroplasty using BMG implanted at the second-stage were included. Patients with genital lichen sclerosus or incomplete clinical records were excluded from this study. The primary outcome of the study was to evaluate stricture-free success rate. Results: Of total 42, 4 patients were lost to follow-up. 42% of stricture etiology was failed hypospadias repair. Mean stricture length was 4.5 cm (range 3–8 cm). Seventeen (44.7%) patients had undergone the previous urethroplasty. At a median follow-up of 44 months, of 38 patients, 34 (89.5%) were successful, and 4 (10.5%) had a recurrence. No patient required revision surgery before the second-stage and required redo buccal graft harvesting for subsequent urethroplasty. Conclusions: The composite two-stage technique in repairing complex penile urethral strictures is a valid and reproducible surgical treatment for complex penile stricture and it may reduce the rate of contraction of the transplanted BMG.
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Development and validation of Incontinence - Activity Participation Scale for spinal cord injury p. 159
Priya Walia, Jaskirat Kaur
DOI:10.4103/0970-1591.203413  
Introduction: We aimed to develop and validate an Incontinence - Activity Participation Scale (I-APS) for measurement of activity limitation and participation restriction due to bladder problems in spinal cord injury (SCI). Materials and Methods: The process of development was initiated by formation of open-ended questions after thorough review of literature which were then administered to SCI participants, caretakers, and professionals working with SCI. Items were generated based on their responses and initial draft of scale was formulated. This initial draft of the scale containing 77 items was then administered to 56 SCI participants for reduction of items using factor analysis, and a prefinal version of the scale was obtained containing thirty items only. Content validity and face validity was then established. Results: The I-APS is both health professional and self-administered questionnaire including two domains: Activities of daily living and occupation with 16 items having a content validity of 0.84. The overall internal consistency reliability was 0.86. Conclusion: The I-APS is a valid, comprehensive instrument that measures the activity limitation and participation restrictions due to bladder problems in SCI.
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CASE REPORTS Top

Silicate urolithiasis in a paediatric patient p. 165
Rajarajan Pichandi, Sathish Kumar Motilal Raamya
DOI:10.4103/iju.IJU_183_16  
Silicate urolithiasis is rare in humans (0.2%) but common in herbivorous animals. We report a previously unreported instance in India where a pediatric patient with renal pelvic calculus who underwent percutaneous nephrolithotomy was found to have silicate urolithiasis on stone analysis. Retrospective analysis did not reveal any risk factors associated with silicate stone formation.
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Primary intrarenal yolk sac tumor p. 167
Narasimhan Ragavan, P Dholakia Kunal, S Annapurneshwari
DOI:10.4103/0970-1591.203410  
Extragonadal germ cell tumors (EGGCTs) usually are not coexistent with a gonadal tumor, hence in a way, are primary and are rare. The origin of primary EGGCT is still a matter of debate. Herewith, we report a patient with primary intrarenal yolk sac tumor in a 43-year-old man. The purpose of this report is to add a rare tumor to the differential diagnosis of renal neoplasms.
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UROLOGICAL IMAGES Top

The negative pyelogram in urinary obstruction p. 169
Onkar Singh, Partho Mukherjee, Antony Devasia
DOI:10.4103/iju.IJU_395_16  
A case of chronic ureteral obstruction secondary to radiation-related ureteral stricture producing a classic “negative pyelogram” on intravenous urography is presented.
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A single left renal vein draining into the common iliac vein p. 171
Awad Bakhit Kaabneh, Sizeph Edward Haddad, Feras Ahmad Hammouri, Abdalla Yosef Omari, Mohammad K Abdadayem
DOI:10.4103/iju.IJU_356_16  
Several variations of the anatomy of the left renal vein have been reported. Rare variants are frequently overlooked in the preoperative assessment but can lead to complications during surgery. We describe a kidney donor with a rare anomaly of a single main left renal vein draining into the left common iliac vein.
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“Flying-saucer in the pelvis” sign: An equivalent of “pelvic Mickey mouse” sign p. 173
Onkar Singh, Nitin Sudhakar Kekre
DOI:10.4103/0970-1591.203423  
Isolated bilateral inguinal vesical hernia with urinary bladder as the only content is very rare. “Pelvic Mickey mouse” sign is a radiological sign described classically for bilateral inguinal vesical hernia on transverse axial imaging. Another imaging finding of a “Flying-saucer in the pelvis” sign seen on conventional intravenous urography is being presented.
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BOOK REVIEW Top

Reporting and publishing research in the biomedical sciences p. 175
Sanjay Sinha
DOI:10.4103/iju.IJU_72_17  
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LETTER TO EDITOR Top

Reply to: Biochemical failure after radical prostatectomy in intermediate-risk group men increases with the number of risk factors p. 176
Sohrab Arora
DOI:10.4103/iju.IJU_71_17  
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