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   Table of Contents - Current issue
Coverpage
January-March 2020
Volume 36 | Issue 1
Page Nos. 1-74

Online since Thursday, January 2, 2020

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EDITORIALS  

Robot-assisted surgery in India: A SWOT analysis Highly accessed article p. 1
Girdhar Singh Bora, Tushar Aditya Narain, Aditya Prakash Sharma, Ravimohan Suryanarayan Mavuduru, Sudheer K Devana, Shrawan K Singh, Arup Kumar Mandal
DOI:10.4103/iju.IJU_220_19  
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What's inside p. 4
Rajeev Kumar
DOI:10.4103/iju.IJU_357_19  
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Round up p. 6
Anil Mandhani
DOI:10.4103/iju.IJU_361_19  
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REVIEW ARTICLES Top

Management of clinically node-negative groin in patients with penile cancer Highly accessed article p. 8
Devayani Niyogi, Jarin Noronha, Mahendra Pal, Ganesh Bakshi, Gagan Prakash
DOI:10.4103/iju.IJU_221_19  
Malignant penile neoplasms are commonly squamous etiology, with the inguinal nodes being the first echelon of spread. The disease spreads to the pelvic lymph nodes only after metastases to the groin nodes, and this is the most important prognostic factor in penile carcinoma. While treatment of penile carcinoma with proven metastases to the inguinal lymph nodes mandates ilioinguinal lymph node dissection, the treatment of patients with impalpable nodes is more controversial. Overtreatment leads to excessive treatment-related morbidity in these patients, while a wait-and-see policy runs the risk of patients presenting with inguinal and distant metastases, which would have been curable at presentation. Unfortunately, no single imaging modality has been proved to be convincingly superior in the staging, and hence, management of the clinically negative groin has been subject to debate. While some high volume centers have promoted the use of dynamic sentinel lymph node biopsy, others advocate the use of the modified inguinal lymph node template to stage the groin adequately. Newer techniques such as video endoscopic inguinal lymph node dissection have been introduced as an alternative to the original radical inguinal lymphadenectomy to reduce morbidity.
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Robotic partial nephrectomy: The current status p. 16
Zeynep G Gul, Andrew Tam, Ketan K Badani
DOI:10.4103/iju.IJU_174_19  
Introduction: Since its introduction, robotic partial nephrectomy (RPN) has become increasingly popular, in part as a result of several advances in technique. The purpose of this paper is to review these techniques as well as the perioperative, functional, and oncologic outcomes after RPN and compare these outcomes to those after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN). Methods: A literature review was performed to identify papers and meta-analyses that compared outcomes after RPN to OPN or LPN. All meta-analyses were included in this review. Results: Technical advances that have contributed to improved outcomes after RPN include the first-assistant sparing technique, the sliding clip technique, early unclamping, and selective arterial clamping. All five meta-analyses that compared LPN to RPN found that RPN was associated with a shorter warm ischemia time (WIT), but that there were no differences in estimated blood loss (EBL) or operative times. Those meta-analyses that compared intraoperative and postoperative complications, conversion to open or radical nephrectomy, length of stay (LOS), and postoperative estimated glomerular filtration rate (eGFR) either found no difference or favored RPN. Four meta-analyses compared RPN to OPN. All four found that EBL, LOS, and postoperative complications favor RPN. There were no significant differences in intraoperative complications, conversion to radical nephrectomy, or positive surgical margin rates. One meta-analysis found that eGFR was better after RPN. Operative time and WIT generally favored OPN. Conclusions: Several techniques have been described to improve outcomes after RPN. We believe that the literature shows that RPN is as good if not better than both LPN and OPN and has become the preferred surgical approach.
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ORIGINAL ARTICLES Top

Open surgery for pheochromocytoma: Current indications and outcomes from a retrospective cohort p. 21
Pradeep Prakash, Rashmi Ramachandran, Nikhil Tandon, Rajeev Kumar
DOI:10.4103/iju.IJU_186_19  
Introduction: Minimally invasive approaches are the current standard of care for pheochromocytoma/paraganglioma (PC/PG) surgery. However, a number of patients still undergo open surgery for these tumors. We evaluated the current indications and outcomes of open surgery for PC/PG to define the role of this approach. Methods: Data of patients undergoing PC/PG surgery between July 2008 and July 2017 were retrieved from our prospectively maintained electronic database and hospital records. Tumor characteristics, operative and recovery parameters, and complications were evaluated for indications of open procedure and outcomes. Results: During the study period, 106 patients underwent 124 procedures for PC/PG, including 18 simultaneous bilateral procedures. Surgeries included 102 adrenalectomies, 18 PG excisions, one partial adrenalectomy, and three partial cystectomies. Twenty-five (23.6%) patients (mean age 38.2 ± 16.1 years) underwent an open procedure, including four bilateral procedures. This included 16 adrenalectomies and 9 PG excisions. The indications for open surgery were unilateral large tumours (5; size 8–16, mean 11 cm), bilateral large tumours (2; size 6–10, mean 8.2 cm), retrocaval tumour extension (4), inter aortocaval PGs (8), Retro-mesenteric PG (1), concomitant procedures (3), and conversion from laparoscopy (2). Mean operative time was 217 ± 63.8 min, blood loss was 868 ± 734.2 ml, 11 patients required blood transfusion, and hospital stay was 6.44 ± 2.4 days. All these parameters were higher than for minimally invasive surgery (MIS) in this cohort. Three patients (12%) suffered a postoperative complication, and the rate of complications was not higher than MIS cohort (16%). Conclusions: Open surgery was most often indicated for large tumors or those located in the inter-aortocaval region. Most such procedures require large incisions and possible hepatic mobilization on the right side. The procedures can be safely completed with few complications.
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Holmium: Yttrium-aluminum-garnet laser for endoscopic decompression of ureterocele in the first months of life: A comparison with electrosurgery p. 26
Dacia Di Renzo, Giada Pizzuti, Giuseppe Lauriti, Valentina Cascini, Pierluigi Lelli Chiesa
DOI:10.4103/iju.IJU_216_19  
Introduction: Few case series report the use of holmium: yttrium-aluminum-garnet (Ho:YAG) laser to decompress ureterocele (UC) in pediatric population, and only two studies compared its outcomes with electrosurgery. This study aims to compare outcomes of Ho:YAG laser transurethral endoscopic puncture (TUP) versus electrosurgery TUP of UC in the 1st month of life, analyzing incidence of secondary surgery, redo TUP, and iatrogenic vesicoureteral reflux (VUR). Patients and Methods: A retrospective study of patients treated by TUP of UC from 2008 to 2017 was performed. Those undergoing Ho:YAG laser TUP were included in Group A, those undergoing electrocautery TUP were included in Group B. Data were compared using Fisher's exact test. Results: Group A included seven patients (mean follow-up 4 years). Two required a redo TUP. Two had preoperative VUR, which resolved after TUP. Two developed VUR after TUP, which resolved spontaneously. No secondary surgery was required. Group B included nine patients (mean follow-up: 9.5 years). One required a redo TUP. Preoperative VUR was detected in 4/9 and persisted after TUP in 2. Three developed post-TUP VUR, which persisted. Five required further surgery because of persistent and symptomatic VUR. Secondary surgery was significantly lower after Ho:YAG laser compared to electrocautery TUP (P < 0.05). The incidences of both redo TUP and postoperative VUR were not significantly different between the two groups (P = ns). Conclusion: Ho:YAG laser TUP seems to be safe and effective in the decompression of obstructive UCs and maybe advantageous over electrocautery puncture. However, further studies with larger cohort are needed to corroborate our preliminary results.
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Immunocytochemical detection of minichromosome maintenance protein 2 as a potential urinary-based marker of bladder cancer: A prospective observational study p. 32
Kunal Kapoor, Chhanda Datta, Dilip Kumar Pal
DOI:10.4103/iju.IJU_128_19  
Introduction: Numerous biomarkers have been investigated for the diagnosis and follow-up of patients with bladder cancer, but none has achieved desirable acceptability. In the search of biomarkers, minichromosome maintenance protein 2 (MCM2), a cell cycle regulatory protein, was investigated and the preliminary results were promising. Hence, we conducted a study to investigate the role of immunocytochemical (ICC) detection of MCM2 in voided urinary samples of patients with bladder cancer in an Indian population. Materials and Methods: A prospective comparative observational study was performed. One hundred and fifty patients with a mass lesion in the bladder and 100 controls were enrolled in this prospective study from June 2017 to–December 2018. Fifty-milliliter of voided urine sample was collected and processed for ICC staining of MCM2. Results: Fifty, 100, and 200 positive MCM2 cells as a cutoff value has shown a sensitivity of 87.33% (80.93%–92.20%), 84.67% (77.89%–90.02%), and 80.67% (73.43%–86.65%), respectively. The specificity of 50, 100, and 200 positive MCM2 cells was 97% (91.48%–99.38%), 99% (94.55%–99.97%), and 100% (96.38%–100.0%), respectively. Conclusion: ICC detection of MCM2 in voided urinary samples has good sensitivity and specificity for the detection of bladder cancer. Hence, it can be used as a potential marker for the detection of bladder cancer.
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Implementation of ERAS protocol in robot-assisted radical cystectomy with intracorporeal ileal conduit urinary diversion: An outcome analysis beyond the learning curve p. 37
Ashwin Sunil Tamhankar, Puneet Ahluwalia, Saurabh Ramesh Patil, Sujata Nambiath, Gagan Gautam
DOI:10.4103/iju.IJU_207_19  
Introduction: The objective of this study was to evaluate the perioperative outcomes of patients undergoing robot-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (IIC) urinary diversion treated in line with the enhanced recovery after surgery (ERAS) protocol. Methods: After approval from the institutional ethics committee, we conducted an analysis of a prospectively maintained database of patients undergoing RARC + IIC using ERAS protocol by a single surgical team with the da Vinci Xi® system from March 2016 till December 2018. To minimize the effect of the learning curve of this complex procedure, we excluded the first thirty patients from analysis. Results: Thirty-five consecutive patients (33 males and 2 females) with a median age of 69 years (range: 50–82) were evaluated. The median total console time and console time for diversion were 253 min (range: 191–370) and 80 min (range: 65–90), respectively. The median estimated blood loss was 300 cc (range: 50–500). The median length of stay was 8 days (range: 4–30). Per-urethral pelvic drain was removed at a median of 2 days (range: 1–17). Overall, complications occurred in 16/35 (45.7%) patients, of which major complications (≥Grade 3) were seen in 5/35 (14.3%) patients, without any 90-day mortality. The median follow-up for the cohort was 14 months (1–34). Conclusions: While the initial outcomes of this combined treatment strategy appear promising in terms of complication rates and perioperative parameters, greater insight is required from multi-institutional data sets and prospective comparative studies to establish the true value of RARC + IIC and ERAS protocol for bladder cancer.
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Prophylaxis against renal ischemia-reperfusion injury in canine model: Stem cell approach p. 44
Yasser Osman, Sahar M Hamed, Nashwa M Barakat, Sherry Khater, Mahmoud Gabr, Ahmed Mosbah, Mohamed A Gaballah, Atallah Shaaban
DOI:10.4103/iju.IJU_114_19  
Introduction: Stem cell therapy at the time of ischemia/reperfusion (I/R) injury has been hypothesized to attenuate the severity of acute kidney injury and to accelerate the regeneration process in lower animal models. Data in higher animal models is limited and discordant. We aimed to explore the reno-protective effects of stem cells on I/R related renal injury in a canine model. Materials and Methods: Twenty-seven dogs that were treated with bone marrow-derived mesenchymal stem cells (BM-MSCs) were compared with another 27 dogs treated with adipose tissue-derived MSCs (AT-MSCs) following 90 min of warm ischemia to assess IR injury. Each group was divided into three subgroups (nine dogs each), according to the stem cell dose (5, 10, 15 × 106 in 500 μl volume) injected directly into the renal cortex after reperfusion. All dogs were re-evaluated by renogram, histopathology, and pro-inflammatory markers at 2 weeks, 2, and 3 months. Results: In Group I, there was a mean reduction of creatinine clearance by 78%, 64%, and 74% at the three used doses, respectively, at 2 weeks. At 3 months, these kidneys regained a mean of 84%, 92%, and 72%, respectively, of its basal function. In Group II, the reduction of clearance was much more modest with mean of 14%, 6%, and 24% respectively at 2 weeks with more intense recovery of renal function by mean of 90%, 100%, and 76%, respectively, at 3 months. Group I had significantly more tubular necrosis and delayed regeneration compared with the Group II. Expressions of pro-inflammatory markers were upregulated in both the groups with a higher and more sustained expression in Group I. Conclusion: Stem cells protected against ischemic reperfusion injury in a canine model. AT-MSCs provided better protection than BM-MSCs.
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Urinary prostate-specific antigen and microseminoprotein-beta levels in men with and without prostate cancer: A prospective cohort study p. 50
Prashant Shrivastava, Harshit Garg, Madhusudan Bhat, Amit Dinda, Rajeev Kumar
DOI:10.4103/iju.IJU_202_19  
Introduction: The role of urinary proteomics in the diagnosis of prostate cancer (PCa) is undefined. Levels of urinary biomarkers such as prostate-specific antigen (PSA) and microseminoprotein-beta (MSMB) may differ between men with and without PCa. We tested this hypothesis using urine samples before and after digital rectal examination (DRE) in men with an indication for prostate biopsy. Materials and Methods: In an institutional ethics committee approved prospective cohort study, men with elevated PSA or a nodule on DRE underwent a pre- and post-DRE urine sample examination for urinary PSA and MSMB levels. Levels were compared between men who had PCa diagnosed on biopsy (Group A) and those with a negative biopsy (Group B). Results: Seventy-seven patients were recruited of whom 32 had PCa (Group A) and 45 had no cancer (Group B) on biopsy. The median (interquartile range) serum PSA was 49.6 (0.2–254) ng/ml. The median urine PSA (29.5 vs. 26.4 mg/dl) and MSMB (1.7 vs. 2.4 mg/dl) were similar in both groups at baseline. However, post-DRE, both these metabolites rose in Group B but not in Group A, resulting in significantly higher post-to-pre values in Group B versus Group A. The post-DRE urine PSA/MSMB ratio was also significantly different between the groups. Conclusions: Urinary PSA and MSMB rose significantly after DRE only in men without PCa. Post-DRE urine PSA, MSMB, and PSA/MSMB ratio can differentiate PCa from benign pathology in men with an indication for prostate biopsy.
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CASE REPORTS Top

External iliac artery pseudoaneurysm following radical cystectomy: A report of two cases p. 56
Abhishek Laddha, Ginil Kumar Pooleri, Appu Thomas
DOI:10.4103/iju.IJU_240_19  
External iliac artery pseudoaneurysm is a rare complication following radical cystectomy and pelvic lymph node dissection. We report two cases that developed external iliac artery pseudoaneurysm following radical cystectomy and pelvic lymph node dissection with an ileal conduit. Survival in these patients is dependent on early diagnosis and prompt intervention. Mortality in such cases remains high even with aggressive management.
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Successful angioembolization for blunt adrenal gland trauma p. 59
Madhusudhanan Jegadeesan, A John Robert, Thodana Vadivelu Sekar
DOI:10.4103/iju.IJU_166_19  
Blunt adrenal gland trauma is an uncommon injury owing to the location of the adrenal gland in the retroperitoneum surrounded by major viscera and bony structures. We present a case of a 23-year-old male, who had sustained multiple injuries following a road traffic accident. Computed tomography scan revealed a large retroperitoneal hematoma, and active contrast extravasation was noted in the retroperitoneum adjacent to the bare area of the liver and right adrenal gland. After a trial of initial conservative management, he had expanding retroperitoneal hematoma with dropping hemoglobin. Angiography showed posttraumatic aneurysm from the adrenal artery that was successfully embolized with microcoils. As blunt adrenal gland trauma is rare, a high degree of clinical suspicion is required for the diagnosis, and multidisciplinary discussion is essential for the successful management of adrenal gland trauma.
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A novel approach to postrobot-assisted nephron-sparing surgery persistent urinary leak – Can we glue? p. 62
Ujjwal Gorsi, Santosh Kumar, Shantanu Tyagi, Anuj Sharma
DOI:10.4103/iju.IJU_209_19  
Urinary leak is a well known complication after partial nephrectomy. We describe a case of a persistent urinary leak after Robot assisted nephron sparing surgery that failed to resolve after conservative treatments and was subsequently managed with computed tomography (CT) guided percutaneous cynoacrylate glue injection.
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UROLOGICAL IMAGES Top

Arteriovenous malformation with a renal mass: A rare association p. 65
Aditya Prakash Sharma, Mukesh Kumar Gupta, Gopal Sharma, Ravimohan S Mavuduru
DOI:10.4103/iju.IJU_212_19  
Renal arteriovenous malformation can be rarely associated with a renal mass. A vigilant approach and careful planning is required to tackle both the pathologies in form of preoperative coil embolization followed by a minimally invasive radical nephrectomy.
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Gas-containing renal stones p. 67
John Peter, Suresh Bhat, Fredrick Paul
DOI:10.4103/iju.IJU_271_19  
Gas-containing renal stones is a rarely described complication of emphysematous pyelonephritis. Most of these patients are diabetic and almost all have urinary obstruction and stasis. Management of these patients may be associated with several complications.
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UROSCAN Top

The role of 225Ac-PSMA-617 in chemotherapy-naive patients with advanced prostate cancer: Is it the new beginning p. 69
Sumit Agrawal
DOI:10.4103/iju.IJU_266_19  
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LATITUDE: A landmark trial for high-risk metastatic castration-sensitive prostate cancer: Final overall survival analysis p. 71
Gautam Kumar
DOI:10.4103/iju.IJU_258_19  
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AWARDS Top

IJU Awards 2019 p. 73

DOI:10.4103/iju.IJU_352_19  
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