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   Table of Contents - Current issue
January-March 2018
Volume 34 | Issue 1
Page Nos. 1-94

Online since Friday, December 29, 2017

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Whose evidence do we follow? p. 1
Rajeev Kumar
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Medical Council of India's amended qualifications for Indian medical teachers: Well intended, yet half-hearted p. 3
Sunita V. S. Bandewar, Amita Aggarwal, Rajeev Kumar, Rakesh Aggarwal, Peush Sahni, Sanjay A Pai
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What's inside p. 7
Rajeev Kumar
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Round up p. 9
Anil Mandhani
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New therapies in nonmuscle invasive bladder cancer treatment p. 11
Kareem N Rayn, Graham R Hale, Gustavo Pena-La Grave, Piyush K Agarwal
Introduction: Nonmuscle invasive bladder cancer (NMIBC) remains a very challenging disease to treat with high rates of recurrence and progression associated with current therapies. Recent technological and biological advances have led to the development of novel agents in NMIBC therapy. Methods: We reviewed existing literature as well as currently active and recently completed clinical trials in NMIBC by querying and Results: A wide variety of new therapies in NMIBC treatment are currently being developed, utilizing recent developments in the understanding of immune therapies and cancer biology. Conclusion: The ongoing efforts to develop new therapeutic approaches for NMIBC look very promising and are continuing to evolve.
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PET-CT and PET-MR in urological cancers other than prostate cancer: An update on state of the art p. 20
Abdul Razik, Chandan Jyoti Das, Sanjay Sharma
Hybrid positron emission tomography with computed tomography (PET/CT) and magnetic resonance imaging (PET/MRI) have enabled the combination of morphologic and functional imaging with the promise of providing better information in guiding therapy. Further advance has been made in the past decade with the development of newer radiotracers and optimization of the technical aspects. We performed a search in PubMed, Scopus, and Google Scholar for peer-reviewed literature concerning the advances and newer developments in the imaging of nonprostate urologic cancers between 2005 and 2017. This review aims at summarizing the current evidence on PET imaging in nonprostate urologic cancers and their impact on the diagnosis, staging, prognostication, response assessment, and restaging of these malignancies. However, much of the evidence is still in infancy and has not been incorporated into routine management or the practice guidelines of National Comprehensive Cancer Network or European Society for Medical Oncology (ESMO).
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Decline in semen parameters from 2000 to 2016 among Bangladeshi men attending a tertiary care hospital p. 28
Nusrat Mahmud, Eshita Sharmin, Md. Arif Mamun, Zayan Shamayeen, Natalie Rivadeneira, Roger Rochat, Akanksha Mehta
Introduction: The objective of this study was to analyze longitudinal changes in sperm parameters of Bangladeshi men. We hypothesized that semen parameters declined for this population. Methods: We retrospectively analyzed semen data from men aged 18-64 years who sought care for general sperm quality or updates on fertility status at an infertility clinic in Dhaka, Bangladesh, from January 2000 to June 2016 (n = 13,953). Samples with incomplete data were excluded (n = 143). The WHO normal criteria and semen analysis procedures were used to evaluate parameters of the remaining 13,810 specimens. Samples with missing values on sperm concentration (n = 6187) were excluded from concentration analyses. Age and duration of abstinence at testing were recorded and adjusted for. Data were imported into SAS® 9.4 statistical software. Temporal significance was investigated using one-way ANOVA for motility parameters and Chi-square test for raw concentration. Logistic regression analyzed the effects of confounders on azoospermia and raw concentration, while median regression modeling adjusted confounders for concentration, total motility, and rapid linear (RL) motility. Results: Age distribution was significantly correlated with annual parameter changes (concentration, total motility, and RL motility [P < 0.0001]). Adjusted total motility and RL motility declined by 20% from their maximum values to end of the study (P < 0.0001). Raw concentration lacked clear trends and was unaffected by adjustment. Azoospermia increased by 18% between the 2000–2010 and 2011–2016 participants (odds ratio = 0.16 [0.14–0.16]). Conclusion: In agreement with the hypothesis, Bangladeshi males attending this clinic have experienced decline in semen parameters (total motility and RL motility) and increased frequency of azoospermia.
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Urodynamic outcomes of tamsulosin in the treatment of primary bladder neck obstruction in men p. 34
Manoj K Sudrania, Anuj Deep Dangi, Santosh Kumar, Barath Kumar, Nitin S Kekre
Introduction: Alpha blockers are widely used in the treatment of primary bladder neck obstruction; however, evidence for objective urodynamic efficacy is scarce. We studied the effect of the uroselective α1-blocker tamsulosin on urodynamic parameters in male patients with type I primary bladder neck obstruction. Methods: A single center prospective observational study was carried out from July 2013 to February 2015. Male patients (18–50 years) with type 1 primary bladder neck obstruction were recruited. Selected patients were started on tablet tamsulosin 0.4 mg once daily for 3 months. International prostate symptom score (IPSS), uroflow and urodynamic studies were done pre- and post-treatment. Primary outcome was decreased in minimum detrusor pressure at maximum flow rate by 15%. Wilcoxon-matched pair signed-rank test was used. Results: Of 39 patients recruited, 21 patients completed the follow-up as per protocol and were analyzed. Mean age was 41 years. 57% patients achieved the primary outcome (median detrusor pressure pre- and post-treatment were 71 and 56 cm of water, P < 0.001). Similarly, median values for bladder outlet obstruction index (BOOI) and IPSS decreased from 59 to 38 (P < 0.001) and 22 to 12 (P < 0.001), respectively. Median maximum flow rate increased from 8 to 10 ml (P = 0.05). Pretreatment BOOI of >60 was associated with poor outcomes. Conclusions: Tamsulosin 0.4 mg once a day is effective in reducing bladder outlet obstruction on pressure flow studies in patients with primary bladder neck obstruction type 1.
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Oncologic outcomes in patients with nonurothelial bladder cancer p. 39
Sanjay G Patel, Adam Benjamin Weiner, Kirk Keegan, Todd Morgan
Introduction: We aimed to evaluate the relative prognostic impact of the most common variant histologies on disease-specific survival (DSS) in patients undergoing radical cystectomy. Materials and Methods: The Surveillance, Epidemiology, and End Result database was used to identify patients who underwent radical cystectomy for bladder cancer from 1990 to 2007. Patients with urothelial cell carcinoma (UCC), squamous cell carcinoma (SCC), adenocarcinoma (AC), sarcoma, small cell carcinoma, signet ring carcinoma, and spindle cell carcinoma were included in the study. Multivariable analysis was performed using Cox proportional hazards model to assess independent predictors of disease-specific survival (DSS). Mortality rates were estimated using Kaplan–Meier analyses. Results: A total of 14,130 patients met inclusion criteria with the following histologies: UCC (90.1%), SCC (4.6%), AC, (2.3%), sarcoma (0.8%), small cell carcinoma (0.8%), signet ring carcinoma (0.5%), and spindle cell carcinoma (0.9%). Three-year DSS was most favorable in patients with UCC (63.7%; 95% confidence interval [62.9%–64.8%]) and AC (65.3% [59.3%–70.6%]), whereas 3-year DSS was the least favorable for small cell carcinoma (41.6% [31.3%–51.6%]) and sarcoma (45.4% [35.1%–55.1%]). In the multivariable analysis, independent predictors of DSS were age, marital status, grade, T-stage, N-stage, and variant histology. With respect to UCC, there was an increased risk of disease-specific death associated with all variants except AC. Sarcoma and spindle cell carcinoma were associated with the highest risk of death. Conclusions: With the exception of AC, the most common variant bladder cancer histologies are all independently associated with worse DSS relative to UCC in patients undergoing radical cystectomy.
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Lateral percutaneous nephrolithotomy: A safe and effective surgical approach p. 45
Jonathan Jian Wei Gan, Jaslyn Ju Lia Gan, Jasmine Ju Hsien Gan, Kim Tiong Lee
Introduction: Percutaneous nephrolithotomy (PCNL) is traditionally performed with the patient in the prone position for large renal calculi. However, anesthetic limitations exist with the prone position. Similarly, the supine position is associated with poorer ergonomics due to the awkward downward position of the renal tract, a smaller window for percutaneous puncture, and a higher risk of anterior calyx puncture. This study aimed to demonstrate the feasibility and safety of lateral-PCNL in managing large renal calculi without the disadvantages of prone and supine positions. Methods: Retrospectively, 347 lateral-PCNL cases performed from July 2001 to July 2015 were examined. the patient's thorax, abdomen, and pelvis were positioned over a bridge perpendicular to a “broken” table, creating an extended lumbodorsal space. The procedure was evaluated in terms of stone clearance at 3 months' postprocedure, operative time, and complications. Results: Primary stone clearance was achieved in 82.7% of patients. The mean operating time was 97 min. The average time taken to establish the tract and mean radiation time were 4.5 min and 6.93 min, respectively. In total, 2.3% of patients required postoperative transfusion, and 13.5% of patients had postoperative fever. There was one case of hydrothorax, but no bowel perforation. Conclusions: Our lateral-PCNL technique allows for effective stone clearance due to good stone ergonomics and it should be considered as a safe alternative even in the most routine procedures.
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Comparison of RENAL, PADUA, and C-index scoring systems in predicting perioperative outcomes after nephron sparing surgery p. 51
Aditya P Sharma, Ravimohan Suryanarayana Mavuduru, Girdhar Singh Bora, Sudheer K Devana, Kiruthika Palani, Anupam Lal, Nandita Kakkar, Shrawan K Singh, Arup K Mandal
Introduction and Objective: The RENAL, PADUA and centrality index (C-index) nephrometry scoring systems (SS) have been individually evaluated for their role in predicting trifecta outcomes after nephron-sparing surgery (NSS). However, there is little data on their comparative superiority. The present study was designed to evaluate the predictive value of three SS and to assess interobserver reliability. Materials and Methods: Fifty patients undergoing NSS at our center between January 2014 and April 2016 were included in the study. The demographic details were noted. Images (computed tomography [CT] scans or magnetic resonance imaging) were reviewed by a urologist and a radiologist independently and RENAL, PADUA, and C-index were calculated. The correlation between these scoring system and trifecta outcomes were calculated. Results: The RENAL and PADUA score did not correlate with any of the perioperative parameters. However, C-index had a significant correlation with operative time (OT) (P = 0.02) and trifecta outcomes (P < 0.05). There was an excellent concordance between the two observers in scoring the RENAL score (α = 0.915; intraclass correlation coefficient [ICC] = 0.814) and PADUA score (α = 0.816; ICC = 0.689 [P < 0.001]). There was lesser although acceptable concordance in the calculation of C-index (ICC −0.552; α −0.711). Conclusions: There is good correlation among all the 3 SS. C-index has lower reproducibility due to difficult mathematical calculation but correlated best with trifecta outcomes.
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Symptomatic lower urinary tract dysfunction in sacral agenesis: Potentially high risk? p. 56
Sanjay Sinha, Mehul A Shah, Dilip M Babu
Introduction: Sacral agenesis (SA) is a caudal regression anomaly that can cause neurogenic bladder but is not generally recognized as high risk. We studied the clinical presentation, upper urinary tract, bone and spine abnormalities, and urodynamic findings in patients with SA and compared them with related high-risk conditions, anorectal malformation (ARM), and cloacal malformation. Materials and Methods: Patient records between May 2011 and December 2015 were identified and grouped into isolated SA without an overt anomaly (Group I), SA with overt caudal regression anomalies (Group II), and ARM or cloacal malformation without the SA (Group III). Distribution of clinical and urodynamic findings and factors associated with reduced eGFR were tested with rank sum test, t-test, and unadjusted odds (P < 0.05 significant) using R statistical program (version 3.1.3). Results: Of 605 neurogenic bladder patients treated in the study period, 39 fulfilled the inclusion criteria. 12 were Group I, 5 Group II, and 22 Group III. Long-standing lower urinary symptoms were noted in all SA patients. Group I patients were older (14.5 years vs. 6 years and 5 years for II and III). Patients with SA (Group I and II) had poor compliance (6.7 ml/cmH2O, interquartile range [IQR] 4–13.6 ml/cmH2O), reduced age-adjusted bladder capacity (59%, IQR 22–85%), elevated end-fill pressure (22 cmH2O, IQR 11–28 cmH2O), hydronephrosis (88%), and reduction in eGFR (29%), all comparable to Group III. Most had Renshaw type II SA and tethered spinal cord rather than wedge-shaped termination. Limitations include small numbers and significant selection bias. Conclusions: Symptomatic neurogenic bladder due to SA may cause renal damage similar to ARM but often eludes diagnosis.
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Impact of learning curve on the perioperative outcomes following robot-assisted partial nephrectomy for renal tumors Highly accessed article p. 62
Brendan Hermenigildo Dias, Mohammed Shahid Ali, Shiv Dubey, Srinivas Arkalgud Krishnaswamy, Amrith Raj Rao, Deepak Dubey
Introduction: Robot-assisted partial nephrectomy (RAPN) is an established, minimally invasive technique to treat patients with renal masses. The aim of this study was to assess the learning curve (LC) of RAPN, evaluate its impact on perioperative outcomes following RAPN and to study the role of surgeon experience in achieving “trifecta” outcomes following RAPN. Methods: We prospectively analyzed the clinical and pathological outcomes of 108 consecutive patients who underwent RAPN for renal tumors from January 2012 to December 2016 by a laparoscopy trained surgeon with no prior robotic experience. We used warm ischemia time (WIT) <20 min, operative time <120 min, and blood loss <100 ml as endpoints for plotting the LCs. Trifecta was analyzed in relation to our LC. Results: Surgeon experience was found to correlate with WIT, operative time, and blood loss. Overall 18.5% of patients developed complications. Complication rate reduced with increasing surgeon experience. LC was 44 cases for WIT ≤20 min, 44 cases for operative time <120 min, and 54 cases for blood loss <100 ml. Trifecta outcome was achieved in 67.6% patients overall and was found to correlate with increasing surgeon experience. Improvement in trifecta outcomes continued to occur beyond the LC. Conclusions: RAPN is a viable option for nephron-sparing surgery in patients with renal carcinoma. For a surgeon trained in laparoscopy, acceptable perioperative outcomes following RAPN can be achieved after an LC of about 44 cases. Increasing surgeon experience was associated with improved “trifecta” achievement following RAPN.
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Effects of tumor size and location on survival in upper tract urothelial carcinoma after nephroureterectomy p. 68
Shreyas S Joshi, Laura L Quast, Sam S Chang, Sanjay G Patel
Introduction: Upper Tract Urothelial Carcinoma (UTUC) is a rare disease with few prognostic determinants. We sought to evaluate the impact of tumor size and location on patient survival following nephroureterectomy for UTUC. Materials and Methods: Data on 8284 patients treated with radical nephroureterectomy for UTUC in the United States between 1998 and 2011 were analyzed from the National Cancer Data Base. Univariable survivorship curves were generated based on pT stage, pN stage, grade, tumor size, and tumor site (renal pelvis vs. ureter). A Cox proportional hazards model was used to evaluate the effect of age, comorbidity, T stage, lymph node involvement, tumor site, and tumor size on survival. Results: The median follow-up time was 46 months. A majority of the patients were male (55.4%) with a tumor size of ≥3.5 cm (52.0%) and pT stage P = 0.023). Conclusions: Using the largest series of patients with UTUC undergoing nephroureterectomy, we demonstrated a worse survival in patients with larger tumor sizes (≥3.5 cm) but no difference in survival based on tumor location while controlling for other pathologic characteristics. Incorporation of tumor size into perioperative risk modeling may help with patient stratification and provide further prognostic information for patient counseling.
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Editorial comment on “Effects of tumor size and location on survival in upper tract urothelial carcinoma after nephroureterectomy” p. 74
Gagan Prakash, Gagan Gautam
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Pediatric pelvic fracture urethral distraction defect causing complete urethrovaginal avulsion p. 76
Ritesh Kumar Singh, Devashish Kaushal, Nikhil Khattar, Rishi Nayyar, T Manasa, Rajeev Sood
Pelvic fracture with urethral injury in girls is an uncommon entity that is usually associated with concomitant vaginal lacerations. Management options vary from immediate exploration and urethral anastomosis to delayed urethroplasty. We report our experience of managing a 10-year old girl presenting 6 months after a pelvic fracture with urethrovaginal injury and a completely obliterated urethral meatus managed successfully with a single-stage bladder tube repair.
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Papillary renal cell carcinoma with abscess formation: A report of three cases p. 79
Girdhar Singh Bora, Pankaj Panwar, Ravimohan S Mavuduru, Nandita Kakkar
We report three cases of renal cell carcinoma (RCC) associated with abscess formation. Such association has been reported uncommonly in literature. Our cases were unique in that final histopathological report was papillary RCC in all of the patients.
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Extrarenal retroperitoneal angiomyolipoma with oncocytoma p. 82
Amir Mahmud Ali, Syed Jamal Rizvi, Kamal V Kanodia
The simultaneous presence of renal angiomyolipoma and oncocytoma is a rare occurrence. Extrarenal retroperitoneal angiomyolipoma is an even more rare neoplasm, and its simultaneous presence with renal oncocytoma has not been documented. We present herein the first case to be reported in English literature.
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Ureteropelvic junction obstruction - mimicking an “elephant head” on magnetic resonance imaging p. 85
Sony Bhaskar Mehta, Hariharan Krishnamoorthy, Biju Pillai
Ureteropelvic junction obstruction (UPJO) with giant hydronephrosis is relatively rare in adults as compared to children. Most of the UPJO reported or seen in daily practice have a distinct hydronephrosis with a narrow ureteropelvic junction and a collapsed ureter distally. We present images a case of an adult female with Left UPJO, which on MRI mimicked an 'elephant head'.
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Periureteral inferior vena caval venous ring presenting as urinary obstruction p. 87
Suprava Naik, Arashdeep Singh, Sudipta Mohakud, Nerbadyswari Deep
The embryological development of the inferior vena cava (IVC) is complex, and thus the vena cava may undergo a large number of congenital anomalies. Periureteric venous ring is a rare developmental anomaly of IVC where the right ureter passes through a slit-like opening in a partially duplicated infrarenal IVC, resulting in dilatation of upper urinary tract. Split-bolus multidetector computed tomography technique is useful in detecting such vascular anomaly causing ureteric obstruction as it can clearly show the vascular and ureteric phase in a single acquisition.
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Re: Goel A. Research training during residency. Indian J Urol 2017;33:257-8 p. 89
Sohrab Arora
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Author Reply Re: Goel A. Research training during residency. Indian J Urol 2017;33:257-8 p. 90
Apul Goel
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Re: Singh A et al. Robot-assisted retroperitoneal lymph node dissection: Feasibility and outcome in postchemotherapy residual mass in testicular cancer. Indian J Urol 2017;33:304-9 p. 91
Mustafa Zafer Temiz, Omer Onur Cakir, Engin Kandirali, Atilla Semercioz
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IJU Awards 2017 p. 93

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