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   Table of Contents - Current issue
Coverpage
October-December 2018
Volume 34 | Issue 4
Page Nos. 237-309

Online since Monday, October 1, 2018

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EDITORIALS  

Health-care expenses – A need to be cautious p. 237
Santosh Kumar
DOI:10.4103/iju.IJU_297_18  PMID:30337775
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What's inside p. 239
Santosh Kumar
DOI:10.4103/iju.IJU_294_18  PMID:30337776
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Fertility preservation in men: Perspective p. 241
Aditya Prakash Sharma, Japleen Kaur, Ravimohan S Mavuduru, Girdhar S Bora, Sudheer K Devana, Shrawan K Singh, Arup K Mandal
DOI:10.4103/iju.IJU_279_18  PMID:30337777
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REVIEW ARTICLE Top

Simulation-based training in laparoscopic urology – Pros and cons p. 245
Abhishek Gajendra Singh
DOI:10.4103/iju.IJU_213_18  PMID:30337778
Surgery is traditionally taught by using Halsteadian principle, which includes “see one, do one, teach one”. This principle relies on sheer volume of surgical exposure rather than a specific course structure. Simulation in minimally invasive surgery allows the learner to practice new motor skills in a safe and stress free environment outside the operating room, thereby decreasing the learning curve. A non-structured exhaustive MEDLINE search was done using MeSH words: “Simulation, Urological Training, Training Models, Laparoscopy Urology, Laparoscopic Skill, Endotrainer, Surgical Simulators, Simulator Validation”. The “ Pros and Cons of simulation based training in laparoscopic urology” were studied. Results were discussed along the following lines : 1. How does skill acquisition occur? 2. Factors affecting simulator-based training. 3. Description of types of simulators and models. 4. Validating a simulator. 5. Task analysis after training on a simulator. 6. How effectively does simulation based training, translate into improved surgical performance in real time? Pros: Simulators have the ability to teach a novice basic psychomotor skills. Supervision and feedback enhance learning in a simulation-based training. They are supplements to and not a substitution for traditional method of teaching. These models can be used as a part of most of the surgical training curriculum. Cons: Cost and availability are the key issues. The cost will determine the availability of the simulators at a center and the availability in turn would determine whether a trainee will get the opportunity to use the simulator. Also, teacher training is an important aspect which would help teachers to understand the importance of simulation in student training. The domains in which it would improve and the extent to which simulation will improve surgical skills is dependent on various factors. Most simulators cannot train a surgeon to deal with anatomical and physiological variations. At present, it is not possible to re-validate all the surgeons in terms of their surgical skills, using simulators.
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TECHNOLOGY UPDATE Top

Laparoscopic nephrectomy simplified – A “two-window technique” for safer approach to hilum for a novice p. 254
Mallikarjuna Chiruvella, Ashwin Sunil Tamhankar, Syed Mohammed Ghouse, Mohammed Taif Bendigeri, Purna Chandra Reddy Kondakindi, Deepak Ragoori
DOI:10.4103/iju.IJU_231_18  PMID:30337779
Though the overall safety of laparoscopic nephrectomy (simple or radical) is well established, for a novice it remains a challenge. The classical description of laparoscopic nephrectomy entails dissection either from caudal to cephalad side or vice versa. Herein we describe our “two window technique” for managing renal hilum during laparoscopic (simple/radical) nephrectomy. Our main intention in description of this technique is to reduce the level of apprehension for a novice urologist for performing laparoscopic nephrectomy. After colon mobilization, sequential lower and upper windows are created around the hilum following which hilar vessels are dissected circumferentially when the hilum is at a stretch by traction from either of the window. There are multiple potential advantages of this method which includes easier and safer dissection especially for novice in this field by giving a safety window of application of vascular clamp in cases of vascular bleeds. Intrahilar dissection in stretched condition becomes safer with vision from all around 360° for safe application of Hem-o-lok® clips. Due to the widely exposed field, injuries to adrenal vein and lumbar veins would be minimized and the chances of missed accessory vessel would be minimized. En mass hilar control with vascular clamp in cases of partial nephrectomy is possible with same approach as well as the en block stapling is feasible in cases of nephrectomy. This needs a validation across multiple centers with comparative studies before considering it as a standard of practice. We sincerely believe that this is safe and easily reproducible by a novice.
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ORIGINAL ARTICLES Top

Pathological outcomes and biochemical recurrence-free survival after radical prostatectomy for high-risk prostate cancer in the Indian population p. 260
Priyank Bijalwan, Ginil Kumar Pooleri, Sanjeevan V Kalavampara, Sanjay Bhat, Appu Thomas, Praveen Sundar, Abhishek Laddha
DOI:10.4103/iju.IJU_65_18  PMID:30337780
Introduction: We analyzed the biochemical recurrence-free survival (BRFS) of patients with high-risk prostate cancer (HRCaP) as per the D'Amico classification undergoing radical prostatectomy (RP) at our center. We aimed to determine whether the number and type of risk factors (cT2c-T3b, prostate-specific antigen >20 ng/ml, Gleason score >7) are associated with biochemical recurrence (BCR) in HRCaP patients undergoing RP in the Indian population. Methods: Between 2006 and 2017, 192 patients underwent RP (open RP [ORP], laparoscopic RP [LRP], and robotic RP [RRP]) at our center, of which 109 had D'Amico HR disease. Preoperative, postoperative, and pathological outcome data were analyzed for patients with HR disease as per the D'Amico classification. Subgroups were formed to determine whether an increasing number of risk factors (1, 2, or 3) were associated with poorer oncological results and early BCR. The Kaplan–Meier method with log-rank test was used to test the difference in BRFS between the groups. Univariate and multivariate analyses were done to find significant variable against BCR. Results: According to the D'Amico criteria, 109 patients had HR, 63 patients had intermediate-risk, and 19 patients had low-risk disease. These 109 patients with HR disease were analyzed in our study (50 RRP, 33 ORP, and 26 LRP). A total of 59 (54.1%) patients had one HR factor (1HR), 44 (40%) had two HR factors (2HR), and 6 (5.5%) had three HR factors (3HR). The mean follow-up for our patient population was 21.5 ± 19 months (median 18 months; range, 0–108). Overall, the 2-year and 5-year BRFS was 45% and 35%, respectively (mean BRFS 46 ± 6 months). Two-year BRFS was 63%, 23%, and 22%, respectively, for 1HR, 2HR, and 3HR (logrank, P < 0.0001). The prognostic substratification based on the three risk factors was significantly predictive for adverse pathologic features and oncologic outcomes. Conclusion: Substratification based on the three well-defined criteria leads to a better identification of the more aggressive cancers and prediction of need for additional treatment modalities. Localized HRCaP includes a heterogeneous population of patients with variable oncological outcomes.
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Efficacy and role of Xpert® Mycobacterium tuberculosis/rifampicin assay in urinary tuberculosis p. 268
Benedict Paul Samuel, Joy Sarojini Michael, J Chandrasingh, Santosh Kumar, Antony Devasia, Nitin Sudhakar Kekre
DOI:10.4103/iju.IJU_189_18  PMID:30337781
Introduction: The aim was to study the accuracy of Xpert® (Cepheid Inc., Sunnyvale, CA, USA) Mycobacterium tuberculosis/rifampicin (MTB/RIF) assay as compared to a composite gold standard (urine culture, imaging, and biopsy) and to asses its utility as the initial test compared to smear microscopy to diagnose urinary tuberculosis. Methods: This prospective study included adult patients suspected to have urinary tuberculosis from March 2014 to December 2017. Three urine samples were collected from each patient and were subjected to Xpert MTB/RIF assay, acid-fast bacillus (AFB) smear microscopy, and liquid media (BACTEC Mycobacteria Growth Indicator Tube [MGIT] 960) culture. Imaging and tissue biopsies were performed as clinically indicated. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated using the bootstrap method for 95% confidence intervals for the Xpert assay. Results: Xpert MTB/RIF assay was found to be superior to the currently best available light-emitting diode fluorescent smear microscopy as the initial test for urinary tuberculosis (sensitivity of 69.09% vs. 32.72%). The Xpert MTB/RIF polymerase chain reaction test was found to have a moderate sensitivity (69.09%) and high specificity (100%) as compared to the composite reference standard. The sensitivity of liquid AFB culture MGIT 960 as compared to the reference standard was 90.32%. Conclusions: Xpert MTB/RIF assay on an early morning first void urine specimen can replace smear microscopy as the initial diagnostic test for urinary tuberculosis.
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Utility of restage transurethral resection of bladder tumor p. 273
Vignesh Manoharan, Ravimohan Suryanarayan Mavuduru, Santosh Kumar, Nandita Kakkar, Sudheer Kumar Devana, Girdhar Singh Bora, Shrawan Kumar Singh, Arup Kumar Mandal
DOI:10.4103/iju.IJU_218_17  PMID:30337782
Introduction: Transurethral resection of bladder tumor (TURBT) aims at complete resection of all the visible tumors. Existing guidelines recommend restage TURBT in all patients with T1 and high-grade tumors, to avoid under-staging. However, restage TURBT may not be plausible/feasible at all the times. This study was performed with an aim to better define the utility of restage TURBT in a tertiary care hospital of India. Methods: Patients with high grade/T1 tumors at the first TURBT were prospectively enrolled. Their demographic profile, previous cystoscopic findings, and histological reports were recorded. The primary objective was to assess the tumor detection and stage up-migration rates at restage TURBT. The secondary objectives was to identify factors predicting presence of tumor at restage TURBT. Patients were followed up to detect recurrence and progression for a minimum of 3 months. Results: Of 128 prospective patients' enrolled, 29 patients were lost to follow-up and 11 patients did not undergo restage. A total of eighty-eight patients underwent restage TURBT of which twenty-eight patients (31.8%) had tumor at their second TURBT with five of these patients being upstaged to T2. The risk of having a tumor at restage was significantly higher in patients with solid tumors (56.2% vs. 26.4%, P = 0.02, 95% confidence interval: 0.035–0.024) but was independent of the tumor size (P = 0.472), number of growths (P = 0.267), grade of tumor (P = 0.441), presence or absence of muscle at the initial TURBT (P = 0.371) and place of initial TURBT (P = 0.289). There was a significant difference in the recurrence and progression rates in patients who had tumor at restage as compared to those who did not (recurrence; 33.3% and 23.8%, P = 0.022, respectively vs. progression; 11.1% and 3.7% respectively, P = 0.07; mean follow-up = 10.8 months). Conclusions: We conclude that restage TURBT is necessary in patients with solid looking tumors and the presence of tumor at restage confers a higher risk of recurrence and progression.
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Urodynamic profile in posterior urethral valve patients following fulguration: Does age at fulguration matter? p. 278
Ashwin Mallya, Vilvapathy Senguttuvan Karthikeyan, Sundaramoorthy Vijayganapathy, Ali Poonawala, Ramaiah Keshavamurthy
DOI:10.4103/iju.IJU_148_17  PMID:30337783
Introduction: Children with posterior urethral valve (PUV) may develop urinary bladder (UB) dysfunction even after valve fulguration (VF). Using Urodynamics (UDS), we sought to identify whether age at VF and time elapsed since VF contributed to UB dysfunction. Materials and Methods: Between January 2009 and July 2016, 39 PUV patients referred to a tertiary care center for UDS were classified into Groups A and B (based on age if <2 or ≥2 years at VF) and subclassified into Group A1/A2 and B1/B2 depending on time duration after VF (TVU). A1 and B1 constituted TVU ≤4 years and A2 and B2 constituted TVU >4 years, respectively. Results: Median (range) ages at VF and UDS were 18 (1–108) months and 9 (1–19) years. Median (range) time between VF and UDS was 60 (6–164) months. Reduced compliance was seen in 67%, detrusor overactivity in 38.5%, and leak in 15.4% boys, respectively. Median (range) Qmaxwas 8 (0–28) ml/s and 25% boys had hypocontractile detrusor at voiding. Statistically significant reduction was found in compliance when comparing Group B versus Group A (P = 0.037) and in bladder capacity (P = 0.002) and compliance (P = 0.043) in Group A2 versus A1. Conclusions: Boys with VF at <2 years had better urodynamic profiles than those with fulguration over 2 years of age. As the time period since fulguration increased, there was a higher incidence of bladder dysfunction in both the groups.
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A novel technique for direct visualization of reservoir placement for penoscrotal inflatable penile prostheses using a single incision p. 283
Joshua D Roth, M Francesca Monn, Thomas M Shelton, Matthew J Mellon
DOI:10.4103/iju.IJU_219_18  PMID:30337784
Introduction: We aim to present a modified technique and outcomes of a novel method allowing for direct visualization of the reservoir placement during a penoscrotal inflatable penile prosthesis (IPP). Methods: Out of165 patients who underwent IPP placement from August 2012 to March 2015, 157 underwent a modified technique and comprised the cohort of this study. A Deaver's retractor was placed lateral to the penis and over the pubic bone to allow for direct visualization of the tissues overlying the lower abdomen. After dissecting through the superficial layers, the Deaver's was slowly advanced, allowing for visualization of the fascia, which was incised. Using blunt dissection, a space for the reservoir was created between the bladder and the pubic bone. The reservoir was then placed safely into this space and the Deaver's retractor was removed. Results: The causes of ED in the study cohort included postprostatectomy ED (n = 107), organic impotence (n = 40), Peyronie's disease (n = 3), ED following cystoprostatectomy (n = 2), ED due to spinal cord injury (n = 2), ED resulting from priapism (n = 2), and ED after pelvic injury (n = 1); all of which were refractory to medical management. The median age of study population was 66 years and the mean (standard deviation) operative time was 72.8 (14.7) min. Eighty percent of the procedures were performed on outpatient basis. Complication rates were low (<5%), with four infections, one proximal pump migration, one scrotal hematoma, and one urinary tract infection. Conclusion: The modified technique for placement of the IPP's spherical reservoir under direct visualization through a penoscrotal incision is quick, safe, and effective.
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The effect of phosphodiesterase-5 inhibitor, tadalafil, on in vitro potassium chloride-induced contractions of isolated human ureteral tissue p. 287
MS Sakthivel, Ratna Prabha, Onkar Singh, Nitin S Kekre, Santosh Kumar
DOI:10.4103/iju.IJU_107_18  PMID:30337785
Introduction: Drugs causing ureteral relaxation are used for medical expulsive therapy (MET) for stones. We investigated the in vitro ability of tadalafil to cause relaxation of potassium chloride (KCl)-induced contractions of isolated human ureteral tissue. Materials and Methods: Eight grossly normal proximal ureteral tissues were collected from the radical and donor nephrectomy specimen. The standard organ bath protocol was followed. Ureteral contractions were induced with 80 mM KCl before and after exposure to tadalafil. Results: The median amplitude and frequency of KCl-induced contractions and the median area under the contractility curve (AUCC) after exposure to 20 μM tadalafil showed significant reductions compared to that of before exposure to tadalafil (7.87 cm, 3.79/min, and 2.98 cm2, respectively, versus 9.37 cm, 4.48/min, and 4.50 cm2, respectively; P = 0,026, 0.008, and 0.008, respectively). After exposure to 40 μM tadalafil, the median amplitude and frequency of KCl-induced contractions and AUCC (4.50 cm, 2.56/min, and 0.92 cm2, respectively) showed significant reductions compared to that of before exposure to tadalafil (7.62 cm, 3.88/min, and 3.32 cm2, respectively; P = 0.008, 0.016, and 0.008, respectively). However, reductions in the parameters after exposure to 20 μM and 40 μM tadalafil were similar (P = 0.065, 0.195, and 0.130, respectively, for median amplitude, frequency, and AUCC). Conclusion: Tadalafil reduces KCl-induced contractions of isolated human ureteral tissue in vitro. No incremental relaxations in contractions occurred by increasing the dose of tadalafil from 20 μM to 40 μM.
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CASE REPORTS Top

Brachial plexopathy in carcinoma of the prostate: An uncommon presentation of a common malignancy Highly accessed article p. 292
C Danny Darlington
DOI:10.4103/iju.IJU_143_18  PMID:30337786
Neurological presentation is rare in carcinoma prostate. Brachial plexopathy as the only manifestation of carcinoma prostate is very rare and has not been previously reported. We report an 88-year-old man who presented with new-onset paralysis of the right hand. Digital rectal examination revealed a hard, enlarged prostate and biopsy revealed adenocarcinoma of the prostate with a Gleason score of 7 (4 + 3) with perineural invasion. Computed tomography of the neck showed osteoblastic secondaries involving C6, C7, and T1 vertebrae with a paravertebral soft-tissue mass involving the right foramina of C6, C7, and T1 vertebra. The patient succumbed to the disease despite complete androgen blockade.
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Giant peritoneal mouse: A rare case presenting with lower urinary tract symptoms p. 295
Shailesh Chandra Sahay, Pawan Kesarwani, Ajay Jain
DOI:10.4103/iju.IJU_87_18  PMID:30337787
Peritoneal loose bodies called ‘peritoneal mice' are rare entities that can grow to large sizes and produce lower urinary tract symptoms due to a mass effect. We describe a case that was managed with laparoscopic removal of the mass with complete resolution of symptoms.
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Extranodal Richter's syndrome of the urinary bladder p. 297
Almudena Carrión-Valencia, Jonathan Rodríguez-Talavera, Begoña Ballesta-Martínez
DOI:10.4103/iju.IJU_45_18  PMID:30337788
Lymphomas of the urinary bladder are rare and can be primary or secondary. The latter group includes Richter's Syndrome-which is a transformation of a chronic low-grade lymphoproliferative syndrome into a common type of non-Hodgkin lymphoma, most commonly localized in the lymph nodes. We report a case of an 84-year-old male, former-smoker with a history of low-grade chronic lymphocytic leukemia, treated with chemotherapy, with a recurrence of the disease to retroperitoneal and iliac lymph nodes, splenomegaly, and thickening of the bladder wall. The hematologist consulted us because of hematuria with coexistent bilateral obstructive uropathy. We performed transurethral resection of the bladder which revealed secondary lymphoma in the bladder, probably the result of a high-grade transformation from chronic leukemia, a very rare location of this transformation.
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Primary bilateral non-Hodgkin's lymphoma of the adrenal gland p. 300
Mohammad Raoofziaee, Aliasghar Yarmohamadi, Hassan Ahmadnia
DOI:10.4103/iju.IJU_113_18  PMID:30337789
Primary bilateral non-Hodgkin's lymphoma (NHL) of the adrenal gland is very rare. Herein, we report the case of a high-grade lymphoma of both adrenal glands that was found in a 38-year-old patient. The patient was admitted because of an ultrasound which demonstrated large bilateral adrenal masses. The computed tomography scan-guided biopsy of both adrenal glands suggested the diagnosis of bilateral adrenal NHL. Primary bilateral adrenal NHL should be considered as the differential diagnosis of adrenal masses, especially if they are bilateral and well defined with rapid growth in imaging. Early diagnosis and treatment might dramatically affect the clinical outcome.
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UROLOGICAL IMAGES Top

Renal hydatid cyst presenting as an intrarenal-pelvic mass p. 303
Arshed Hussain Parry, Abdul Haseeb Wani, Imza Feroz
DOI:10.4103/iju.IJU_138_18  PMID:30337790
Intra-renal-pelvic hydatid cyst is a rare manifestation of renal hydatid disease, as most of the renal hydatid cysts are based in the renal cortex. We present and discuss the clinical and radiological findings of a 55-year-old woman who presented with left flank pain, frequency, dysuria, and hydatiduria. She was thoroughly investigated radiologically, and the diagnosis of intra-renal-pelvic hydatid cyst was confirmed surgically.
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UROSCAN Top

Apalutamide: A novel therapy for non metastatic castration-resistant carcinoma prostate p. 305
Sudhindra Jayasimha
DOI:10.4103/iju.IJU_152_18  PMID:30337791
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LETTERS TO EDITOR Top

Re: Kumar M, Batra G, Maletha M, Malhotra A. Hirschsprung's disease in a child with posterior urethral valve: An unwanted association. Indian J Urol 2018;34:223-5 p. 307
Sachit Anand, Anjan Kumar Dhua
DOI:10.4103/iju.IJU_228_18  PMID:30337792
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Urethral caruncle in a perimenopausal female: Dramatic response to topical estrogen cream p. 308
Manisha Balai, Lalit Kumar Gupta, Asha Kumari
DOI:10.4103/iju.IJU_200_18  PMID:30337793
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