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   Table of Contents - Current issue
Coverpage
July-September 2017
Volume 33 | Issue 3
Page Nos. 179-256

Online since Friday, June 30, 2017

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EDITORIALS  

On generic prescriptions and live surgeries p. 179
Rajeev Kumar
DOI:10.4103/iju.IJU_145_17  
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What's inside p. 181
Rajeev Kumar
DOI:10.4103/iju.IJU_192_17  
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Round-up p. 183
Apul Goel
DOI:10.4103/iju.IJU_186_17  
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GUEST EDITORIAL Top

Clinical andrology: The missing jigsaw pieces p. 186
Ashok Agarwal, Chak-Lam Cho
DOI:10.4103/iju.IJU_172_17  
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REVIEW ARTICLES Top

Semen culture and the assessment of genitourinary tract infections p. 188
Michael Solomon, Ralf Henkel
DOI:10.4103/iju.IJU_407_16  
The male factor contributes approximately 50% to infertility-related cases in couples with an estimated 12%–35% of these cases attributable to male genital tract infections. Depending on the nature of the infection, testicular sperm production, sperm transport, and sperm function can be compromised. Yet, infections are potentially treatable causes of infertility. Male genital tract infections are increasingly difficult to detect. Moreover, they often remain asymptomatic (“silent”) with the result that they are then passed on to the relevant sexual partner leading to fertilization and pregnancy failure as well as illness of the offspring. With the worldwide increasing problem of antibiotic resistance of pathogens, proper diagnosis and therapy of the patient is important. This testing, however, should include not only aerobic microbes but also anaerobic as these can be found in almost all ejaculates with about 71% being potentially pathogenic. Therefore, in cases of any indication of a male genital tract infection, a semen culture should be carried out, particularly in patients with questionable semen quality. Globally, an estimate of 340 million new infections with sexually transmitted pathogens is recorded annually. Among these, the most prevalent pathogens including Chlamydia trachomatis, Ureaplasma urealyticum, Neisseria gonorrhoeae, and Mycoplasma hominis. Escherichia coli are considered the most common nonsexually transmitted urogenital tract microbes. These pathogens cause epididymitis, epididymo-orchitis, or prostatitis and contribute to increased seminal leukocyte concentrations.
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Empiric medical therapy with hormonal agents for idiopathic male infertility p. 194
Nicholas N Tadros, Edmund S Sabanegh
DOI:10.4103/iju.IJU_368_16  
Introduction: Infertility affects approximately 15% of all couples, and male factor contribute to up to 50% of cases. Unfortunately, the cause of male infertility is unknown in about 30% of these cases. Infertility of unknown origin is classified as idiopathic male infertility when abnormal semen parameters are present. Despite not having a definable cause, these men may respond to treatment. This review focuses on the use of empiric hormonal therapies for idiopathic male infertility. Methods: A detailed PubMed/MEDLINE search was conducted to identify all publications pertaining to empiric use of hormonal therapies in the treatment of idiopathic male infertility using the keywords “idiopathic,” “male infertility,” “empiric treatment,” “clomiphene,” “SERM,” “gonadotropin,” “aromatase inhibitor,” and “androgen.” These manuscripts were reviewed to identify treatment modalities and results. Results: Gonadotropins, androgens, aromatase inhibitors, and selective estrogen receptor modulators (SERMs) have all been used with varying results. The studies on these treatments are of variable quality. The most well-studied agents are the SERMs which show a modest increase in semen parameters and pregnancy rates. Aromatase inhibitors are most effective in non-idiopathic patients. Gonadotropin treatment is limited by their inconvenience and relative ineffectiveness in this population. Testosterone suppresses spermatogenesis and should not be used to treat infertility. Conclusion: Gonadotropins, SERMs, and aromatase inhibitors may improve semen parameters and hormone levels in men with idiopathic infertility with the best results from SERMs. Testosterone should never be used to treat infertility. Large multicenter randomized controlled studies are needed to better determine the success of empiric use of hormonal therapy on pregnancy rates.
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Laboratory tests for oxidative stress p. 199
Ashok Agarwal, Ahmad Majzoub
DOI:10.4103/iju.IJU_9_17  
Introduction: Oxidative stress (OS) is considered a significant contributor to male infertility. A number of laboratory techniques have been developed to evaluate oxidative stress in the semen. We review these tests and their current use. Methods: A literature review was performed utilizing the PubMed search engine for articles studying OS etiology and impact on male fertility, and the laboratory tests used in its assessment. Results: The state of OS results from exaggerated production of oxygen-derived free radicals, also known as reactive oxygen species, to an extent overwhelming the body's antioxidant defense mechanisms. Several laboratory tests have been utilized in OS measurement during male fertility evaluation. These tests are classified into direct assays which measure the degree of oxidation within a sperm cell and indirect assays which estimate the detrimental effects of OS. The chemiluminescence assay, flow cytometry, nitroblue tetrazolium assay, and cytochrome c reduction are examples of direct assays while the myeloperoxidase test and measurements of lipid peroxidation, oxidation-reduction potential, and total antioxidant capacity are examples of the indirect assays. Conclusion: OS measurement is an important tool that may help in understanding the pathophysiology of male infertility and provide valuable information that would guide treatment decisions and patient follow-up.
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Antioxidant therapy in idiopathic oligoasthenoteratozoospermia p. 207
Ahmad Majzoub, Ashok Agarwal
DOI:10.4103/iju.IJU_15_17  
Introduction: Idiopathic oligoasthenoteratozoospermia (iOAT) is commonly encountered during the evaluation of men with infertility. Antioxidants have been utilized empirically in the treatment of iOAT based on their ability to reverse oxidative stress (OS)-induced sperm dysfunction often encountered in this patient population. Methods: A literature search was performed using MEDLINE/PubMed, focusing on publications of antioxidant therapies for iOAT. The main objective of our review article was to report the rationale and available evidence supporting the use of antioxidants. Results: Antioxidants such as glutathione, vitamins E and C, carnitines, coenzyme-Q10, N-acetylcysteine, selenium, zinc, folic acid, and lycopene have been shown to reduce OS-induced sperm damage. While rigorous scientific evidence in the form of double-blind, placebo-controlled clinical trials is limited, recent systematic reviews and meta-analyses have reported a beneficial effect of antioxidants on semen parameters and live birth rates. Conclusion: Additional randomized controlled studies are required to confirm the efficacy and safety of antioxidant supplementation in the medical treatment of idiopathic male infertility as well as the dosage required to improve semen parameters, fertilization rates, and pregnancy outcomes in iOAT.
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OPINION Top

Vitamins and antioxidants in the management of male fertility p. 215
Jason R Kovac
DOI:10.4103/iju.IJU_188_17  
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ORIGINAL ARTICLES Top

Have we overcome the complications of laparoscopic nephrectomy? A prospective, cohort study using the modified Clavien–Dindo scale p. 216
Tapan Agrawal, Rajeev Kumar, Prabhjot Singh, Ashish Saini, Amlesh Seth, Premnath Dogra
DOI:10.4103/iju.IJU_47_17  
Introduction: Apart from the complexity of procedure and surgeon's experience, surgical complication rates depend on case definition and method of recording data. We prospectively evaluated the complications of laparoscopic nephrectomy (LN) in a current cohort of patients, graded on the modified Clavien–Dindo (CD) scale and compared them with historical cohorts. Methods: In the Institutional Review Board approved protocol, all patients undergoing LN over a 30-month were enrolled in the study. Clinical parameters, operative data, inhospital course, and 30-day follow-up were recorded prospectively in an electronic database by a resident who did not perform any of the surgeries. The complications were analyzed using the CD scale. Results: A total of 103 patients (age 14–80 years) underwent LN (30 radical, 73 simple) during the study period. Forty-three of these procedures were for inflammatory conditions (stone disease or tuberculosis). Six procedures were converted to open surgery due to vascular injury (2), bowel injury (1), and adhesions (3). There were 45 (46%) complications in the 97 procedures completed laparoscopically including 34 low-grade (CD grade 1, 2) and 11 high-grade (CD grade 3, 4) complications. There was no mortality. Complications were similar in patients undergoing surgery for inflammatory or noninflammatory conditions. Conclusions: LN continues to be associated with postoperative complications in 46% of cases. However, the complication rates appear to be higher than historical series, possibly due to the more rigorous case-definition and prospective recording.
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Outcome and complications of living donor pediatric renal transplantation: Experience from a tertiary care center p. 221
Priyank Bijalwan, Kalavampara V Sanjeevan, Anil Mathew, T Balagopal Nair
DOI:10.4103/iju.IJU_382_16  
Introduction: We retrospectively reviewed the patient characteristics, outcome, and complications of renal transplantation in pediatric age group performed at our center and compared the results with various centers in India and other developed countries. Materials and Methods: Patients younger than eighteen years of age who underwent renal transplantation from 2003 to 2014 at our institute were reviewed. Demographic data of the transplant recipients and donors, etiology of ESRD, mode of dialysis, surgical details of renal transplantation, immunosuppression, medical and surgical complications, and post-transplant follow-up were assessed. Graft survival was determined at 1, 3 and 5 years post-transplant. All data collected were entered into Microsoft excel program and analyzed using SPSS 20. Kaplan–Meier method was applied to determine the graft survival at 1, 3, and 5 years. The log-rank test was applied to test the statistical significance of the difference in survival between groups. Results: Thirty-two children underwent transplantation comprising of 18 females and 14 males. The mean age was 14.5 years (range 10–17 years). The primary cause of renal failure was glomerular diseases in 53% (17/32) of patients. Seventeen postsurgical complications were noted in our series. Two grafts were lost over a follow-up of 5 years. The 1, 3, and 5 year graft survival rates were 96.7%, 92.9%, and 85%, respectively. There was no mortality. Conclusion: The etiology of ESRD in our region is different from that of developed countries. The mean age at which children undergo renal transplantation is higher. Graft survival at our center is comparable to that of developed nations. Renal transplantation can be safely performed in children with ESRD.
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Three-dimensional versus two-dimensional laparoscopy in urology: A randomized study p. 226
Suresh B Patankar, Gururaj R Padasalagi
DOI:10.4103/iju.IJU_418_16  
Introduction: Conventional two-dimensional (2D) laparoscopy systems have the drawback of poor depth perception and spatial orientation. Three-dimensional (3D) laparoscopic systems have stereoscopic vision in which depth perception is achieved by different unique images received by each eye. We evaluated 3D laparoscopy in comparison with conventional 2D laparoscopy in urological procedures in a prospective randomized study. Materials and Methods: Over a 19 month study period, 108 patients scheduled to undergo various urological procedures were randomized to either conventional 2D or 3D laparoscopy (2D n = 53; 3D n = 55). A single senior surgeon performed all the surgeries. Parameters such as total operative time, dissection and suturing time, blood loss, hospital stay, complications (Clavien-Dindo), and visual analog scale (VAS) score for pain were assessed. The subjective assessment of the operating surgeon of superiority and inferiority of either technology on parameters defining surgical skills was recorded using a Likert scale. Results: The total operative time (P < 0.0003), blood loss (P < 0.028), dissection, suturing and stenting time (P < 0.0001), and the State-Trait Anxiety Inventory for Adults score (P < 0.0001) was significantly in favor of 3D laparoscopy. Post operative pain, hospital stay, and complications after surgery were similar in both groups. The subjective assessment of the operating surgeon also favored the 3D system. Conclusion: Our study showed significant advantages of the 3D system over 2D laparoscopy. These advantages include enhanced operative performance and greater surgeon comfort.
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Initial experience of robotic nephron sparing surgery in cases of high renal nephrometry scores p. 230
Girdhar S Bora, Ravimohan S Mavuduru, Aditya P Sharma, Sudheer K Devana, Nandita Kakkar, Anupam Lal, Shrawan K Singh, Arup K Mandal
DOI:10.4103/iju.IJU_331_16  
Introduction: The renal nephrometry scoring (RNS) system enables prediction the feasibility of nephron-sparing surgery (NSS) in renal masses. There is insufficient data regarding the outcome of robot-assisted NSS in tumors with RNS ≥10. We reviewed the trifecta outcomes of patients undergoing robotic NSS with high RNS and compare it with tumors of low and intermediate RNS. Materials and Methods: Our prospectively maintained data of all robot-assisted NSS were reviewed, and those with RNS of ≥10 were identified. Patient data, outcomes and postoperative estimated glomerular filtration rate were compared between high, intermediate and low RNS patients. Results: In high RNS group, the mean age of the patients was 53 years (male:female = 15:3). Mean diameter of tumors was 6.28 cm (3.0–10.5 cm). Mean operative time was 173.61 ± 52.66 min and mean warm ischemia time was 27.85 ± 5.27 min. Mean estimated blood loss (EBL) was 363.89 ± 296.45 ml. Mean hospital length of stay was 5.39 ± 1.91 days (3–9 days). When compared with low and intermediate RNS, only EBL and need for pelvicalyceal system repair was significantly higher in high RNS group. Postoperative complications, renal function preservation and oncological outcomes at 3 months were comparable in all the three groups. Conclusion: Robot-assisted NSS is feasible with comparable outcomes in tumors with high RNS.
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Testosterone versus clomiphene citrate in managing symptoms of hypogonadism in men Highly accessed article p. 236
Pranav Dadhich, Ranjith Ramasamy, Jason Scovell, Nathan Wilken, Larry Lipshultz
DOI:10.4103/iju.IJU_372_16  
Introduction: Both clomiphene citrate (CC) and testosterone supplementation therapy (TST) are effective treatments for men with hypogonadism. We sought to compare changes in symptoms and treatment efficacy in hypogonadal men before and after receiving CC and TST. Patients and Methods: 52 men who received TST and 23 men who received CC for symptomatic hypogonadism were prospectively followed for change in hormone levels and symptoms after treatment. These men were also compared to eugonadal men who were not on CC or TST during the same period. Comparisons were made between baseline and posttreatment hormone levels and symptoms. Symptoms were evaluated using the androgen deficiency in aging male (ADAM) and quantitative ADAM (qADAM) questionnaires. Results: Serum total testosterone increased from pretreatment levels in all men (P < 0.05), regardless of therapy type (TST: 281–541 ng/dL, CC: 235.5–438 ng/dL). Men taking TST reported fewer ADAM symptoms after treatment (5–2, P < 0.05). Similarly, men taking CC reported fewer ADAM symptoms after treatment (3.5–1.5, P < 0.05). Conversely, eugonadal men had similar T levels (352 vs. 364 ng/dL) and hypogonadal symptoms (1.5 vs. 1.4) before and after follow-up. When we evaluated individual symptoms, men treated with TST showed significant increases in qADAM scores in libido, erectile function, and sports performance. However, among the men who received CC, qADAM subscore for libido was lower following treatment (3.75–3.2, P = 0.04), indicating that CC could have an adverse effect on libido in hypogonadal men. Conclusions: Both TST and CC are effective medications in treating hypogonadism; however, our study indicates that TST is more effective in raising serum testosterone levels and improving hypogonadal symptoms. CC remains a viable treatment modality for hypogonadal men but its adverse effect on libido warrant further study.
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Contrast-induced nephropathy in urological imaging: A comparison with cardiology interventions p. 241
Manas Babu, Devesh Bansal, Sony Bhaskar Mehta, Biju Pillai, Hariharan Krishnamoorthy, Thankachan Attacharil
DOI:10.4103/iju.IJU_328_16  
Introduction: Published studies about contrast-induced nephropathy (CIN) mainly focus on cardiac intervention and rarely focus on patients undergoing urological contrast investigations. We aimed to determine the association and effect of intravenous (IV) iodinated contrast material on the incidence of CIN in a group of patients undergoing urology investigation and compare the results with that of cardiology interventions. Methods: This prospective study was performed in patients undergoing IV contrast studies in Urology and those undergoing coronary interventions, in our institution for 1 year. Association between the occurrence of CIN and the risk factors such as age (≥60 years), sex, diabetes mellitus, hypertension, anemia, left ventricular ejection fraction <40%, estimated glomerular filtration rate (eGFR), and volume of contrast used were studied using Chi-square tests or Fisher exact test and Student's t-test. Results: A total of 339 cases (168 urology and 171 cardiology) were studied. CIN was noted in 8.3% of urology patients whereas it was 29.8% in cardiology patients. In urology patients, statistically significant association was noted between CIN and eGFR <60 ml/min/1.73 m2 and volume of contrast used. In cardiology patients, statistically significant association (P < 0.05) was noted for diabetes, hypertension, eGFR <60 ml/min/1.73 m2, volume of contrast used. Conclusion: Although CIN was found to occur with contrast studies, the deleterious effects of contrast in urological procedures were lower than cardiology patients. The association between the occurrence of CIN and patient factors were also different in the two groups.
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CASE REPORTS Top

Dihydroxyadenine stone with adenine phosphoribosyltransferase deficiency: A case report p. 246
Pramod Krishnappa, Venkatesh Krishnamoorthy, Kiran Krishne Gowda
DOI:10.4103/iju.IJU_419_16  
Adenine phosphoribosyltransferase (APRT) deficiency is a rare autosomal recessive error of purine metabolism resulting in the generation of 2,8-dihydroxyadenine (DHA), a highly insoluble metabolite of adenine, which can cause radiolucent urolithiasis. This is the second case of DHA stone being reported in India and the first case in India to document the mutation of the APRT gene on blood DNA analysis.
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Cystitis glandularis: Management and challenges in a renal transplant recipient p. 249
Himanshu Agarwal, Mukund G Andankar, Viswanath Billa
DOI:10.4103/iju.IJU_35_17  
Cystitis cystica or glandularis is a clinical and pathological entity of the bladder mucosa occurring secondary to inflammation or chronic obstruction. Its premalignant nature remains controversial, especially in an immunocompromised transplant recipient. We present a rare case where a chronic kidney disease patient was found to have cystitis glandularis while being worked up for living-related donor renal transplant and describe its subsequent management.
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Priapism with penile gangrene: An unusual presentation of multiple myeloma p. 251
Vikas Kumar Panwar, Ravimohan S Mavuduru, Sudheer Kumar Devana, Kim Vaiphei, Girdhar Singh Bora
DOI:10.4103/iju.IJU_41_17  
Penile gangrene is very rare sequel of ischemic priapism. Previous published reports have shown its occurrence in patients with sickle cell disease, urethral carcinoma, bladder carcinoma, thrombotic thrombocytopenic purpura, idiopathic, traumatic, etc. Ischemic priapism with penile gangrene as an initial presentation of multiple myeloma has not been reported. We present a 44-year-old patient of multiple myeloma presenting with ischemic priapism and penile gangrene requiring partial penectomy.
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SURGICAL CRAFT Top

Cystoscopic stent removal using a guidewire loop p. 253
Ajay T Oswal, Pankaj N Maheshwari, Dhruti Amlani
DOI:10.4103/iju.IJU_88_17  
Stent removal is a simple procedure performed with a rigid cystoscope and a stent removal forceps. In the rare event when the stent removal forceps does not work or breaks down, a guidewire loop can be used to remove the stent.
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LETTER TO EDITOR Top

Re: Silicate urolithiasis in a pediatric patient p. 255
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/iju.IJU_116_17  
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BOOK REVIEW Top

Under the knife: Surgical stories from around the world p. 256
Sanjay A Pai
DOI:10.4103/iju.IJU_157_17  
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