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   2004| January-June  | Volume 20 | Issue 2  
 
 
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REVIEW ARTICLES
Chyluria - a clinical and diagnostic stepladder algorithm with review of literature
Igbal Singh, P Dargan, N Sharma
January-June 2004, 20(2):79-85
Objectives: Chyluria is an infrequently discussed urological problem and a rare urological manifestation of filariasis. Apart from few isolated case reports the lit­erature regarding the etiology, diagnostic approach and management of chyluria is grossly inadequate. We un­dertook the present study to review chyluria in its entirety so as to have a broader insight in to its etiopathogenesis and to suggest the clinician with a proposed stepladder protocol approach (algorithm) towards its management. Methods: We made a detailed systematic data search for the period covering the last 37 years on the "Pubmed" for published English literature using the key words 'chy­luria', `milky urine' and 'hematochyluria'. The signifi­cant findings and recent advances on chyluria were reviewed. Results: About 250 articles were found; these were analyzed, tabulated and reviewed for their clinical ap­proach and management of chyluria. Conclusions: Though generally a harmless condition in a majority, chyluria should not be ignored, instead all cases must be aggressively investigated to arrive at a cause. These should then be managed on the lines similar to as proposed in our 10-stepladder protocol.
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RESEARCH ARTICLES
Sexual function status before and after transurethral resection of prostate (TURP) in Indian patients with benign hyperplasia of prostate
Narmada P Gupta, Daresh D Doddamani, Rajeev Kumar
January-June 2004, 20(2):86-89
Objectives : To evaluate the change in sexual function status after TURP in a select population of Indian elderly males presenting with benign prostatic hyperplasia (BPH). Methods : One hundred and thirty-six patients present­ing with BPH and treated with transurethral resection of prostate (TURP) during the period from August 1999 to July 2001 were evaluated for pre and postoperative sexual function using a 10-question proforma. Results : The mean age of the patients was 64.9 years while the mean duration of lower urinary tract symptoms was 1.9 years. Of the 109 patients with a living wife/part­ner, 54 (49.54%) had active sex lives with coital frequency ranging from once a week to less than once a fortnight. Preoperatively, 48 of these patients had good erections whereas 6 had weak erections though they were able to have satisfactory penetration. All 54 had normal ejacu­lation prior to TURP. In the postoperative follow up, 10 (18.5%) of these 54 patients reported an improvement in their sex life in terms of increased libido and improved erections. Twenty-six (48.1 %) had no change in their sta­tus after TURP, but were satisfied with their sex life. Out of these 36 patients, 4 patients had preserved ante grade ejaculation. The remaining 18 (33.33%) had deteriora­tion in their status in terms of decreased libido and poor erections. None of our patients who were sexually inac­tive before TURP regained sexual activity. Conclusions: About 50% of patients with a living spouse/partner are sexually active at the time of undergo­ing TURP for BPH. TURF leads to a deterioration of sexual function in up to 33% of these patients. This in­cludes both loss of libido and erections. It is also associ­ated with a loss of ante grade ejaculation in over 85% patients. Very few patients who are sexually inactive pre-operatively recover sexual function after surgery. This study suggests that sexual counseling during informed consent should be a regular feature prior to TURP.
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Penile fractures: Results of delayed repair
Manohar Shetty, RB Nerli, Shailesh Kamat, Abhinandan Sadalge, Vinay K Patil, Shrishailesh Amarkhed
January-June 2004, 20(2):123-125
Objectives : To assess the results of delayed repair of penile fractures. Methods: The patients presenting with penile fractures constituted study group. Those who have come after 24 hours of sustaining , penile injury are considered as de­layed presentation. Five of the total 7 patients were in delayed group. All the patients were treated by surgical correction. Results: Except for mild wound infection in 2 patients, there were no bothersome complications. The results were as good as with early repair and there was no increased risk of erectile dysfunction in penile fractures. Conclusions: The surgical correction need not be de­ferred in delayed presentation of penile fractures.
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CASE REPORTS
"Snapped in" penis: An unusual presentation of degloving injury of the penis
YK Sarin, Arvind Sinha, Sunita Ojha
July-December 2004, 20(2):56-57
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Trans-sexualism and sex reassignment surgery: Case report of two patients
Manohar Shetty, RB Nerli, Rajesh Powar, Shailesh Kamat
January-June 2004, 20(2):185-186
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RESEARCH ARTICLES
A simple modification of the free hand technique of circumcision
GR Sharma, Anshu Sharma
January-June 2004, 20(2):126-129
Objective : To evaluate a modification of the free hand technique of circumcision for achieving better cosmetic results Methods : The prepuce is first divided at the 12 o'clock and then at 6 o'clock. Two preputial flaps are thus ob­tained which are then divided from ventral, i. e., 6 o'clock to dorsal i.e. 12 o'clock aspect from below upwards. The mucosal collar is thus cut under vision and a good cos­metic result is obtained. Circumcision was done in 126 cases using this modification of the free hand technique. Results : Good cosmetic result was obtained in all cases. No complications were seen Conclusions: The modification described makes the free-hand technique of circumcision a simpler and safe operation that gives very good functional and cosmetic results.
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Assessment of the utility of testicular FNAC in infertile males with special reference to differential counts
Madhu S Agarwal, Atul Gupta, Kiran Chaturvedi, Prashant Lavania
January-June 2004, 20(2):148-153
Objectives: This study was conducted to make morpho­logical assessment of spermatogenesis on testicular FNAC in infertile males, along with quantitative analysis of cy­tological smears using various cell indices, and to corre­late the cytological findings with histology. Methods: Testicular FNAC was performed in 155 azoospermic and oligozoospermic patients, and smears were examined qualitatively and quantitatively. Various cell indices including `Spermatic index', 'Sertoli cell in­dex' and 'sperm-Sertoli cell index' were studied in these smears, and correlation made with histology. Results: On the basis of morphological assessment and differential cell counts, the cases were classified as 'nor­mal spermatogenesis' in 54 cases, `hypospermatogenesis' in 37 cases, `maturation arrest' in 18 cases, 'Sertoli cell only' syndrome in 33 cases, `scanty aspirate /absence of spermatogenesis' in 10 cases, and discordant results in bilateral testicular aspirates in 3 patients. 'Sertoli cell index' was found to be the most important index in dis­tinguishing hypospermatogenesis from normal sperma­togenesis. The differences between the indices in normal spermatogenesis and other cytological categories were statistically significant. In most cases, complete agree­ment was found between cytological and histological find­ings. Conclusions : Fine needle aspiration cytology of the tes­tis is a safe, reliable and minimally invasive modality for evaluation of spermatogenic activity in infertile males, with excellent correlation with histology. Use of quantitative studies accurately and reproducibly segregate the cases into clinically and therapeutically useful groups.
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Giant hydronephrosis: What is the ideal treatment?
Shailesh A Shah, Prakash Ranka, Sharad Dodiya, Rajesh Jain, Gaurang Kadam
January-June 2004, 20(2):118-122
Objectives : To formulate a strategic approach for the treatment of giant hydronephrosis based upon anatomi­cal and functional status of renal units in the individual patient. Methods : We have treated ten cases of giant hydrone­phrosis between November 1997 and December 2002. Age of the patients was in the range of 14 to 42 years. Seven were males and 3 were females. IVU revealed non-visu­alized unit of the affected side in 9 patients. One patient had bilateral hydronephrosis with azotemia. Percutane­ous nephrostomy was done in all patients as a primary procedure. The quantity of urine drained instantaneously was between 1.2 litres to 2.5 litres. Antegrade study and creatinine clearance of the affected unit was done in all. Four patients were subjected to nephrectomy. Two pa­tients underwent reduction pyeloplasty with nephropexy and 1 patient underwent primary calycoureterostomy. In two patients primary Boari flap calycovesicostomy was performed and in one patient with obstructed megaureter ureteroneocystostomy with tapering was done. Results : Two patients, in whom Boariflap ealycovesico­stomy was done, have refluxing units. They have been advised double voiding. Follow-up IVU, in 6 patients who underwent reconstructive procedure, demonstrated rea­sonable function and optimal drainage. Follow-up range is 4 months to 5 years. Conclusions: In very poorly fimctioning unit with gross infection nephrectomy is the procedure of choice. In salvageable unit, anatomical configuration should dictate the type of reconstructive procedure. In a moderately dilated extra renal system, reduction pyeloplasty with nephropexy is a reasonable option. The entirely intrarenal dilated col­lecting system is an ideal situation for calycoureterostomy. In patients with enormous calyceal dilatation Boari flap; cahvcovesicostomy ensures wide, patent, dependent drain­age.
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CASE REPORTS
Adult wilms' tumor : Three case reports with review of literature
Subroto Ranjan Poddar, Sudip C Chakraborty, RK Das, Uttara Chatterjee, Srikrishna Mondol, Anup Kumar Kundu, Prabhas Kumar Sarkar
July-December 2004, 20(2):60-62
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Spontaneous bacterial abscess of corpus cavernosum
Santosh Kumar, SK Sharma, AK Goswami
July-December 2004, 20(2):66-67
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RESEARCH ARTICLES
Retroperitoneal laparoscopic ureterolithotomy - our experience
Tejanshu P Shah, Kirtipal Vishana, Prakash Ranka, Manish Patel, Rajesh Chaudhary
January-June 2004, 20(2):101-105
Objectives : Appraisal of indications for laparoscopic ureterolithotomy, its results and advantages in the current era of minimally invasive surgery. Methods : We performed 56 laparoscopic uretero­lithotomy in 54 patients, all by extraperitoneal approach. Out of 56 stones, 34 were located in the upper ureter, 18 in the mid-ureter and 4 in the lower ureter Main indica­tion was large (1.5 to 3.5 cm) impacted stone in 50 cases (89%). Other indications were failed ESWL and a failed attempt at ureteroscopy. Results : There were no major complications. The pro­cedure failed in two patients. Average duration of hospi­tal stay was 2-4 days. During follow-up 3 months later IVU revealed normal ureter in all cases. Conclusions : In selected patients with large, hard, impacted ureteral stones, which are likely to cause diffi­culty in endourological procedures due to its large size and distance from pelviureteral junction or ureterovesi­cal junction, laparoscopic ureterolithotomy is a reason­able treatment option in lieu of open surgery. It offers stone free status by a single procedure with serendipitous ad­vantage of maintaining laparoscopic skill among general urologic community who do not have flexible uretero­scopies and holmium laser facilities.
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Renal cell carcinoma with tumor thrombus extension to inferior vena cava: SGPGIMS experience
Vishwajeet Singh, Wahid Zaman, Anant Kumar, Rakesh Kapoor, Aneesh Srivastava
January-June 2004, 20(2):90-94
Objectives : Renal cell carcinoma with tumor thrombus extension to inferior vena cava is found in 4-10% of pa­tients. We evaluated the surgical techniques of thrombec­tomy for different levels of the tumor thrombus in inferior vena cava and overall surgical outcome in these patients. Methods : We retrospectively reviewed the records of 17 patients operated between 1994 and 2001. Eleven pa­tients had Infrahepatic (level I) thrombus, retrohepatic (level II) thrombus in two patients and four had supra­diaphragmatic (level III) thrombus without intra-a trial extension. All patients underwent radical nephrectomy and vena caval thrombectomy. The retrohepatic and supradia­phragmatic thrombectomies were done under venovenous bypass. Results : The patients with infrahepatic and retrohepatic thrombectomies recovered without any major post opera­tive complication. Two patients with supradiaphragmatic thrombectomy died in postoperative period. The overall 2-year and 5-year survivals were 64.9% and 29.5% respectively. Conclusions: Radical nephrectomy and vena caval thrombectomy is the best treatment option in renal call carcinoma with tumor thrombus extending to inferior vena cava. The retrohepatic and supradiaphragmatic thrombec­tomies can be done with the help of venovenous bypass in select group of patients.
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Effect of tropical vaginal hydroceles on testicular morphology and histology
C Srinath, N Ananthakrishnan, S Lakshmanan, Vikram Kate
January-June 2004, 20(2):109-112
Objectives : Currently data on the effect of long stand­ing hydrocele on the testis is contradictory. A study was carried out to evaluate whether vaginal hydroceles affect testicular morphology andd histology. Methods : Twenty-five patients with unilateral vaginal hydroceles were prospectively studied. The morphology and histology of the affected testis was studied and com­pared with the opposite unaffected testis. Results : It was found that unilateral hydroceles did not affect ipsilateral scrotal temperature or the ipsilateral testicular volume. Histologically there was marked thick­ening of the tunica albugenia and the basement membrane on the affected side. There was distortion of the seminifer­ous tubules arrangement with marked intertubular edema. There was also significant reduction in the total seminif­erous cell count on the affected side due primarily to a decrease in spermatids. There was premature sloughing of the spermatogenic cells into the lumen of the tubules. .None of these changes correlated with the duration of the hydrocele, volume of the hydrocele fluid or intratunica vaginalis pressure. Conclusions : It is concluded that vaginal hydroceles significantly affect the morphology of the testis by caus­ing reduction in the number of seminiferous tubules pri­marily spermatids besides producing changes in the structure and arrangement of the seminiferous tubules. It is not known whether these changes are reversible with treatment of the hydrocele.
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Causes of lower urinary tract symptoms (LUTS) in adult Indian males
C Nageswara Rao, Mithilesh K Singh, T Shekhar, K Venugopal, M Rama Prasad, K Lily Saleem, U Satyanarayana
January-June 2004, 20(2):95-100
Objectives : Evaluation of causes of lower urinary tract symptoms in adult Indian males. Methods : In this study, 1329 men above the age of 40 years from Krishna District of Andhra Pradesh attending the clinics for lower urinary tract symptoms (LUTS) were subjected to detailed physical examination and were given IPSS questionnaire for evaluating LUTS. Special atten­tion was paid to nocturia, as it behaved differently from other LUTS. Results : Of the 1329 men, 480 had specific diseases (i.e. 36%) responsible for occurrence of LUTS (stricture urethra 43%, prostatic enlargement 40%, neurogenic blad­der 8.8%, miscellaneous 8.2%). About 14% of the total subjects (192/1329) had benign prostatic enlargement. Among the 849 men who had some degree of LUTS, no specific disease was found responsible for these symptoms. Nocturia was the most predominant among the symptoms in both groups of subjects and it had a significant impact on IPSS. If nocturia is eliminated, IPSS gets drastically lowered for each age group irrespective of the presence or absence of disease. Conclusions: The study indicated that lower urinary tract symptoms are not just confined to the prostatic en­largement. There could be contribution of several urological and non-urological factors in the etiopatho­genesis of LUTS. The relevance of nocturia in IPSS re­quires careful reconsideration. Thus patients with LUTS need a well-planned assessment of disease process and a clear cut understanding of the relevant pathophysiology and an orderly approach to diagnosis and therapy.
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Multiple vessel renal transplant - army hospital (research and referral) experience
Rajesh Khanna, R Sood, P Madhusoodanan, T Sinha, AS Sandhu, SK Gupta, AA Pradhan, A Kumar, GS Sethi, A Srivastava
January-June 2004, 20(2):130-133
Objectives: Over the past three decades graft and pa­tient outcomes in kidney transplantation have improved dramatically. The aim of our study was to measure the prevalence of multiple artery renal transplants, and to analyze the rates of vascular and urologic complications in these recipients. Methods: Between July 1991 andAugust 2003 the trans­plantation team at our hospital performed 340 kidney transplantations. Twenty-nine patients (8.53%) who un­derwent multiple-artery anastomosis were compared with 311 patients (91.47%) with single-artery anastomosis. Of the 29 grafts with multiple arteries, 23 (79.3%) had dou­ble arteries and 5 (17.2%) had 3 arteries. The solitary patient with quadruple arteries (3.5%) underwent a suc­cessful double pyjama anastomosis. Postoperatively all patients were placed on immunosuppression and graft outcomes assessed. Results: Multiple vessel transplantation was attended by minimal postoperative complications. There was no significant different in graft function, assessed by the in­cidence of acute tubular necrosis (ATN) and post-trans­plantation hypertension. The patient survival rates were comparable and none of the patients who received multi­ple renal artery grafts developed vascular or urologic com­plications. Conclusions: Transplantation of kidneys with multiple renal arteries is generally avoided. However, shortage of organs continues to be critical. Our results confirm that multiple artery grafts can be successfully transplanted with results similar to single vessel kidney grafts.
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Measurement of serum PSA in benign and malignant enlargements of prostate in Indian population: Relevance of PSAD in intermediate range PSA
Madhu S Agarwal, Sumit Sinha, Sanjay Juyal, AK Gupta
January-June 2004, 20(2):138-143
Objectives : PSA has revolutionized the diagnosis and management of men with prostate cancer. However as PSA is organ-specific but not cancer-specific, its useful­ness is somewhat limited due to high false-positive and false-negative results. This study assesses the PSA levels in benign and malignant enlargements of prostate and evaluates the advantages of PSA density (PSAD) over PSA in early diagnosis of carcinoma of the prostate. Methods : This study was conducted on 184 cases of prostatic enlargement presenting with symptoms of out­flow obstruction. One hundred sixty of these patients had BPH and 24 were histologically proven carcinoma. Se­rum PSA and prostate volume using TRUS was measured in all patients. Results : In BPH, there was a statistically significant correlation of PSA with age and volume of the gland. In carcinoma of the prostate there was no correlation of a age and volume with PSA, but there was moderate correlation of PSA with clinical stage and significant correlation with Gleason scoring. PSAD was better correlated with the clinical stage and Gleason scoring as compared to PSA. PSAD demonstrated better specificity as compared to PSA in diagnosis of carci­noma, especially in the intermediate range (4-10 ng/ml). The construction of receiver operating characteristic (ROC) curves demonstrated the most appropriate cut-off value of PSAD to be 0.3 (at which level the sensitivity and specificity were 75% and 84.4% respectively), a level higher than those reported in American, European and Japanese literature. Conclusions: In this study, in northern Indian popula­tion, baseline values of PSA and PSAD in BPH patients were found to be higher than those reported in western literature. PSAD demonstrated better specificity as compared to PSA in diagnosis of carcinoma, especially in the intermediate range (4-10 ng/ml).
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Endoscopic intervention in obstructive renal papillary necrosis
V Chandrashekar Rao, Soumya S Bhat, Padmanabha Vijayan, Shankar Ramamurthy
July-December 2004, 20(2):29-32
To evaluate the usefulness of ultrasonography, endoscopic retrieval, and the outcome of patients with diabetes mellitus presenting with ureteric obstruction caused by necrosed renal papillae. Material And Methods: Eleven seriously ill patients with diabetes mellitus, admitted into medical wards, were found to have ureteric obstruction complicated by urinary infection. The diagnosis was made by ultrasonography alone. Prompt relief followed endoscopic extraction of the offending necrosed papillae. Results: Ten patients improved dramatically. One patient died from septicemia. Conclusions: Ultrasonography appears to be a useful diagnostic method to diagnose ureteric obstruction. It is cheap, fast, and extremely reliable. Endoscopic extraction of the obstructing papilla offers the best chance for successful outcome.
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Diagnosing bladder outlet obstruction can we do away with pressureflow studies?
Abraham Vinod Peedikayil, NK Shyamkumar, Nitin Kekre
July-December 2004, 20(2):36-41
Objective: To compare pressure-flow study on one hand with BWT, prostate volume, urine flow rate PVR and IPSS index in the other arm for diagnosis of BOO. Materials and methods: A prospective cross-sectional study was carried out in 48 men with lower urinary tract symptoms (LUTS). International prostate symptom score was completed by the patient who then underwent free urine flow study. Pressure-Flow study was performed as per recommendations of International continence Society. Abrams-Griffiths nomogram and number were used to diagnose BOO. Patients with diabetes, neurovesical dysfunction, acute urinary retention, prior pelvic surgery and known prostate cancer were excluded. Suprapubic ultrasonography was performed independently by a consultant radiologist, who was blinded to findings of Pressure-Flow study. Prevoid bladder volume, postvoid residue (PVR), prostate volume and bladder wall thickness (BWT) were noted. Results: Based on objective evidence from Pressure-Flow study, 35 patients were obstructed, 13 were not. Multivariate analysis was performed using Backward Stepwise Logistic Regression Model. Bladder wall thickness, prostate volume and urine flow rate had statistically significant relationship with BOO. Their coefficients of correlation were +0.794, +0.084 and 0.393 respectively. Bladder outlet obstruction could be defined by using a mathematical formula as detailed in the text (Positive Predictive Value 96.97%). Post-void residue and IPSS index were statistically insignificant. Conclusion: In a select group of patients presenting with LUTS, it should be possible to diagnose BOO without the use of Pressure-Flow study.
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Ureterocalycostomy: A salvage procedure for complex ureteropelvic junction strictures
Tejanshu P Shah, Kirtipal Vishana, Rohit N Joshi, Gaurang Kadam, Manish Dhawan
January-June 2004, 20(2):144-147
Objectives: To report our experience with Ureterocaly­costomy for treating complex ureteropelvic junction stric­tures, to salvage a renal unit. Methods: Twenty-five patients were subjected to ure­terocalycostomy between year 1992 and 2002. Nineteen patients had UPJ obstruction; 7 had primary UPJ obstruc­tion with 3 having horseshoe anomaly and 4 having intrarenal pelvis, while 12 had secondary UPJ obstruc­tion following pyeloplasty (5), endopyelotomy (2) and pyelolithotomy (5). Six patients had long proximal ureteric strictures; 5 tuberculous and 1 following blunt abdominal trauma. Five patients had solitary units. Preliminary nephrostomy drainage was provided in all secondary cases and in solitary units. A wide spatulated anastomosis was performed after amputating lower pole parenchyma and further length was achieved by renal descensus in indi­cated cases. Results: Follow-up evaluation included ultrasonogra­phy, intravenous urography and renal scan. Twenty two patients improved and are still doing well. Two patients failed to show radiographic improvement although being asymptomatic. One patient presented with restricture and pyonephrosis and warranted nephrectomy. Conclusions: Ureterocalycostomy is a viable alterna­tive for salvaging a renal unit jeopardized by complex UPJ strictures. This procedure is a versatile one which can be done without any extra preparation even in unexpected situations.
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CASE REPORTS
Seminoma arising in a true hermaph­rodite with normal male external genitalia
Abraham Kurien, Kim Mammen, Sunitha Jacob
January-June 2004, 20(2):180-181
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RESEARCH ARTICLES
Single stage substitution urethroplasty using buccal mucosa graft in management of stricture urethra
MC Songra, Arun Kerketta, Rakesh Dua
July-December 2004, 20(2):47-51
Buccal mucosa graft and the Berbaglis technique are recent development in treatment of urethral stricture. We report results of 14 patients who were managed by single stage substitution urethroplasty using buccal mucosa graft. Patients and Methods: From July 2002 to June 2004, 14 patients of mean age 27.02yrs (range 20 to 54) underwent dorsal onlay graft urethroplasty (Simple onlay in 12 patients and augmented type in 2 patients). All patients were evaluated preoperatively and postoperatively with uroflowmetry, retrograde and voiding urethrogram. Results: Overall success rate was 85.71% and only 2 patients had restricture. Out of 14 patients 3 patients had leak at repair site which was managed conservatively. Conclusion: Dorsal onlay graft urethroplasty is a versatile technique. The intrinsic properties of buccal mucosa also make it a better substitute for urethroplasty.
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Gastrointestinal complications in renal transplantation
Kamal Jeet Singh, Aneesh Srivastava, Amit Suri, Avinash Srivastava, Deepak Dubey, Rakesh Kapoor, Anant Kumar
July-December 2004, 20(2):33-35
Objective: Gastrointestinal complications are responsible for substantial morbidity and mortality among renal allograft recipients. We retrospectively analyzed incidence of these complications and their impact on the patient outcome. Materials & Methods: Between 1998 to Aug 2002, 558 live related renal transplants were performed at our center. The immunosuppression used consisted mainly of cyclosporine, azathioprine and prednisolone, though varied in some patients. These patients were followed for any occurrence of significant gastrointestinal problems. Results: Out of the of 538 renal transplant recipients studied, gastro esophageal ulcerations were seen in 3% patients. Acute pancreatitis was observed in twelve (2.2%) patients and four patients had acute intestinal obstruction secondary to fecal impaction. Infectious complications included acute diarrheas in 18% of patients. Three patients developed abdominal tuberculosis. Acute rejection episodes were encountered in 26% of the patients. During these episodes, 58% of patients experienced prolonged ileus. Most of these complications (66%) occurred within first one-year post transplant. Three patients presenting with acute intestinal obstruction required laparotomy (two- bands, one­intussusception). There were four mortalities -two patients had severe pancreatitis, one patient had massive upper GI bleed and one succumbed due to perforation peritonitis. Conclusions: Gastrointestinal complications account for significant morbidity and mortality in renal transplant recipients. Paralytic ileus secondary to acute vascular rejection is quite common and resolves spontaneously with recovery of renal function.
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CASE REPORTS
Hematemesis and malena as the initial presentations of metastatic germ cell tumor of the testis: A case report
Vishwajeet Singh, Devendra Kumar, Aneesh Srivastava
July-December 2004, 20(2):54-55
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RESEARCH ARTICLES
Delayed cystectomy for T 1 G 3 TCC of urinary bladder managed initially by TURBT & intravesical immunotherapy (BCG + interferon) rationale & our result
NK Mohanty, Sunita Saxena, Neeraj K Goyal, Uday Pratap Singh, RP Arora
July-December 2004, 20(2):24-28
Objectives: Management of pT 1 G 3 TCC of urinary bladder is always a dilemma for urologists due to its high recurrence & disease progression rate. We evaluated the role of conservative management for this subgroup with TURBT and intravesical immunotherapy; and delayed cystectomy for progressive disease with an aim to salvage bladder. Patients & Methods: Between Jan.1996 to Dec.2002, 66 patients (15%) of pT 1 G 3 , out of a total 440 patients of superficial bladder cancer treated in this department were subjected to low dose BCG (40mg) and Interferon 3 million IU intravesically with maintenance therapy after complete TURBT and followed up for average 60 months. The mean tumor free interval was 26 months & 18 months in superficial recurrences & muscle progression disease respectively. Delayed cystectomy being preserved only for disease progression patients and the mean period of delayed cystectomy was 24 months (18-30 months). Results: 19 patients (29%) had no tumor recurrence, 35 patients (53%) showed superficial recurrence and 12 patients (18%) progressed to higher stage at end of five year follow up thereby giving a disease progression free interval of 60 months in 82% of our patients. Five patients of disease progression group died due to metastatic disease process and 7 patients are alive after delayed cystectomy at the end of follow up. Side effects from intravesical therapy were confined to local irritative symptoms only. Conclusion: Our data only confirms the benefit of adjuvant intravesical low dose immunotherapy in management of pT 1 G 3 tumor after TURBT with bladder salvage in 82% of patients, simultaneously not compromising the survival rate.
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Laparoscopic radical nephrectomy: Our initial experience
Pradeep Bansal, Anant Kumar, Aneesh Shrivastava, Devendra Kumar, Anil Mandhani, Mahendra Bhandari
January-June 2004, 20(2):154-159
Objectives: The objective of the current study was to report our initial experience of transperitoneal laparoscopic radical nephrectomy with intact specimen extraction and to compare it with a similar cohort of pa­tients who underwent conventional open surgical proce­dure to assess the feasibility and advantage of laparoscopy in renal tumor surgery. Methods: Twenty patients (13 men and 7 women) with mean age of 55 years underwent transperitoneal laparo­scopic radical nephrectomy. The kidney was dissected laparoscopically together with the adrenal gland, perire­nal fat and Gerota's fascia. Intact specimen was removed through a small incision. Intra-operative and postopera­tive problems were analyzed and compared with the 16 comparable renal tumors operated by open procedures during the same period. Results: Of the 20 patients, 16 kidneys could be suc­cessfully removed laparoscopically. Four patients needed early conversion to open either due to technical problem in dissecting the hilar area because of larger tumor size or due to bleeding. Mean operating time was 3.5 hours and mean estimated blood loss was 290 ml. Two had intraoperative complications, one with splenic tear due to retraction injury and the other with bleeding from ad­renal vein avulsion. Laparoscopy costed about rupees 4.5 to 5 thousand more than open surgery while the incision length was 5 to 11 cm depending on the tumor size (mean 7 cm) as compared to 20-28 cm (mean 25 cm) in open surgery. Pathological tumor stage was T1NOMO in 16, T2NOMO in 1 patient treated laparoscopically, which were comparable to that of the conventional open group. Post­operative hospital stay was 3-7 days (mean 5 days) when compared to 5-12 days (mean 7 days) in the open group. Convalescence period was between 12 and 34 days (mean 19 days). No metastatic disease, local recurrence and seed­ing at the port site were observed during the follow-up period of 1-23 months (mean 12 months). Conclusions: Laparoscopic radical nephrectomy, al­though technically demanding and more expensive, is a viable option for managing localized renal tumors. It im­parts lesser morbidity, better cosmesis and early conva­lescence to the patient.
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Evaluation of renal donors with helical CT angiography - our experience
N Upendra Kumar, PVLN Murty, Nand Kumar, Ram Reddy, Ramamurthy , Jyotsna , KV Dakshina Murthy
January-June 2004, 20(2):134-137
Objectives: To compare the findings of helical com­puted tomography (CT) angiography and the intraopera­tive findings in voluntary kidney donors. Methods: This was a prospective study evaluating 28 voluntary kidney donors from January 2001 to December 2002 who underwent a preoperative CT angiography with a 20 minute intravenous urogram film and was compared with intraoperative findings during nephrectomy to de­termine the accuracy of CT angiography. Donors consti­tuted 21 females and 7 males and all were related donors with mean age of 35.5 years (19 to 55 years). Results: Intraoperative findings correlated in 25 out of 28 patients (88.75%). Among those 3 patients, one pa­tient had an upper polar accessory artery, another had a lower polar artery and the third patient had an early branching respectively. Conclusions: Helical CT and 3-D reformatting allowed improved vascular imaging and has the potential for fu­ture single imaging method for donor evaluation. It has been cost effective also. It needs a dedicated radiologist for interpretation. About 10% of renal arteries are not seen on helical CT renal arteriograms when compared with findings at surgery.
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Review of 48 consecutive cases of renal injury: Outcome of management by conservative vs operative approach
RS Rai, SK Singh, AK Mandal, UK Mete, AK Goswami, SK Sharma
January-June 2004, 20(2):113-117
Objectives : To analyse the outcome of conservative and surgical management of renal injuries in terms of renal salvage and complications. Methods: Medical records of 48 consecutive patients of renal injury occurring in isolation or in association with polytrauma, managed during January 2000 to April 2002 were reviewed. After initial clinical evaluation and re­suscitation, patients were evaluated by abdominal ultra­sound followed by computerized tomography to stage the injury. The patients were classified into group 1 compris­ing of 29 patients having renal injuries of grade 1-III and group 2 consisting of 19 patients of grade IV, V and pen­etrating injuries. Initially, all patients in group 1 and 9 of group 2 were managed conservatively. Follow up evalu­ation included blood pressure monitoring, urinalysis and estimation of serum creatinine at each visit and intrave­nous urography after 6-8 weeks. Outcome in terms of re­nal salvage was evaluated in two subsets of patients in accordance with management adopted for renal injury (conservative vs operative) as well as severity of renal injure and the significance of difference between two pa­tient groups was assessed statistically by Chi-square test. Results : There were 37 males and 11 females in the age group of 11-70 years (mean 28 years). Blunt abdomi­nal trauma accounted for renal injury in 85.4% (41/48) patients. Flank pain (43/48; 89.5%) and haematuria (40/ 48; 85.4%) were the common presenting symptoms. Thirty four (70.8%) patients had associated one or more organ injuries. In group 1, all renal units were salvaged except one, who underwent nephrectomy for massive secondary haemorrhage. In group 2, half of the patients (5/10) man­aged surgically (]for haemodynamic instability, 3 for non­salvageable kidney and ]for secondary haemorrhage after repair of renal laceration) lost their injured kidney. Dur­ing follow-up, 2 patients in group 2 managed conserva­tively lost their kidney. In one patient, the kidney became non-functioning due to renovascular injury and one pa­tient of stab injury managed earlier by angioembolisation underwent nephrectomy for recurrent haematuria due to pseudoaneurysm of intrarenal artery. The renal loss was significantly more in cases with severe renal injury (7/19 vs 1/29, χ2 = 9.22, p < 0.01) and in cases who underwent operative management (5/10 vs 3/38, χ2 = 10.105, p < 0.01). Conclusions : The data in this study suggest that con­servative management of renal injuries yields more favour­able results with high renal salvage rate, low morbidity and minimal complications when compared with immedi­ate renal exploration. However, in this retrospective study, the decision of conservativs vs operative management was influenced by several factors. Therefore, a randomized prospective study including those cases in whom both the options are feasible would be helpful to derive a definite conclusion.
  3,301 0 -
REVIEW ARTICLES
Molecular biology in urology
Rajeev Kumar
January-June 2004, 20(2):75-78
Introduction: Molecular biologic techniques form the cornerstone of progress in the field of medicine in the next millennium. These techniques are useful in diagnosis, prog­nosis, management and follow-up of patients. Methods: Recent publications in the field of molecular biology and its use in urology were reviewed. The mate­rial was then edited to produce this article. Results: There has been a tremendous interest in this field in the last decade. Over 50 articles in indexed jour­nals and edited text books were found. Literature relating to its use in urology is less common but seems to be in­creasing in the last few years. Conclusions: Molecular diagnosis is the identification of presence of disease or susceptibility to disease based on the presence of abnormal genes or their products. Mo­lecular therapy is the development of rational therapeutic strategies aimed at correcting the basic genomic abnor­mality using molecular biologic techniques. These two applications of molecular biology shall be the focus of advance in urology in the next millennium.
  3,294 0 -
CASE REPORTS
Case report: Penile horn overlying condylomata acuminata
Vivek Singla, Rohit Ajmera, BL Laddha
January-June 2004, 20(2):175-176
  3,152 0 -
RESEARCH ARTICLES
Management of testicular tumors- SGPGIMS experience
Vishwajeet Singh, Aneesh Srivastava, Avinash Srivastava, Anant Kumar, Rakesh Kapoor, Anil Mandhani
January-June 2004, 20(2):160-163
Objectives : To assess the single centre experience of multimodality treatment approaches and overall outcome in testicular tumor patients. Methods : In a retrospective study, records of 70 pa­tients were analysed. Seminoma was present in 21 cases, non seminomatous germ cell tumour (NSGCT) in 48 pa­tients and Leydig cell tumor in 1 patient. The clinical stag­ing in seminoma of the testis were stage I in 6 cases, stage IIA in 4 cases, the stage JIB in 2 cases, stage HC in 2 cases and stage III in 7 cases. In the NSGCT group stage I tumor was present in 3 cases, stage IIA in I case, stage IIB in 4 cases, stage IIC in 4 cases and stage III in 36 cases. Adjuvant radiotherapy to retroperitoneum was given in stage I and IIA of seminoma. Primary retroperitoneal lympho node dissection (RPLND) was done in 4 cases of NSGCT and biopsy of lymph nodes was positive for ma­lignant cells in one case. Cisplatinum based chemotherapy was given in stage IIB, JIC and stage III of seminoma and NSGCT Secondary RPLND was done in 2 cases and ex­cision of postchemotherapy residual masses in 14 cases. Results : The patients of stage I NSGCT tumors had recurrence free mean follow-up of 9 years while 1 case of stage IIA was disease free at 1 year of follow-up. All cases of stage IIA, IIB,IIC seminoma and NSGCT patients were alive and doing well on follow-up. In advanced and meta­static tumors, 75% of seminoma and 60% of NSGCT pa­tients were alive and disease free with mean follow-up period of 5 years and 4 years respectively. Conclusions: Excellent prognosis was seen in early stages of testicular germ cell tumors. Advanced and metastatic seminoma showed good prognosis whereas only 60% of such NSGCT are disease free and alive on long-term follow-up.
  2,886 0 -
CASE REPORTS
A rare presentation of posterior urethral valves in adults
Nagesh Kamat
January-June 2004, 20(2):182-183
  2,848 0 -
Leiomyoma of ureter - a rare cause of intractable hematuria and clot retention
Shailesh A Shah, Prakash Ranka, Sharad Dodiya, Rajesh Jain, Gaurang Kadam
January-June 2004, 20(2):181-182
  2,837 0 -
RESEARCH ARTICLES
Is contralateral renal involvement in genitourinary tuberculosis primary?
H Chaudhary, A Mandhani, D Dubey, M Jain, A Srivastava, R Kapoor, A Kumar, M Bhandari
July-December 2004, 20(2):19-23
Objective: To know whether contralateral involvement in genitourinary tuberculosis is primary or sequential to the involvement of the bladder. Methods: Retrospectively from June 1989 to Jan 1998 and then prospectively till Dec 2002, patients of genitourinary tuberculosis were reviewed. Of 147 patients complete record with follow up was available in 117. Diagnosis was considered proven only on the presence of one major and or two minor criteria. Major criteria were granulomatous lesion on histopathology, AFB positivity in urine or histopathology and a positive PCR. Minor criteria were changes suggestive of tuberculosis on intravenous urography, hematuria, raised ESR and or pulmonary changes of old Koch's lesion. Patients were grouped as group 1 (N=64) with renal involvement only, Group 2 (N=20) with renal and reversible bladder involvement and group 3 (N=33) with tubercular contracted bladder (capacity <250m1). Laterality and degree of involvement (grade I, single calyceal involvement, grade II more than one and grade 3, involvement of the ureter on intravenous urogram or Nephrostogram) were recorded. Results: There was no difference in patient age, symptoms, positive urine culture for Acid fast bacilli in all 3 groups. Bilateral involvement was present in 23 (19.6%) patients and all the cases were in group 3. Of these, contra lateral lower ureteric stricture was present in 12 and vesico­ureteric reflux in 11 patients. None of these 23 patients on imaging showed calyceal changes in contra lateral kidney suggestive of primary hematogenous involvement. The only finding was pelvicalyceal dilatation, which was a consequence of reflux or backpressure changes. At a mean follow up 46.8±34.2 months no patient developed complication in the contra lateral kidney in terms of calyceal deformity and ureteric stricture. Conclusions: As the involvement of the contralateral ureter is through the bladder, diagnosis of bilateral lower ureteric tubercular stricture in absence of contracted bladder should be made with caution. This fact would help in minimizing intervention on the contra lateral low grade reflux and prognosticating the reversibility of function in patients with renal impairment.
  2,834 0 -
Tubularized incised plate urethroplasty (TIP) for distal and midshaft hypospadias a preliminary experience
GR Sharma
July-December 2004, 20(2):15-18
Objective: To describe the tubularized incised plate (TIP) urethroplasty for distal and midshaft hypospadias. To describe certain technical aspects to decrease the incidence of meatal stenosis and urethrocutaneous fistula. Methods: TIP urethroplasty was undertaken in 35 patients in the last three years. The age ranged from two to 26 years. Nineteen cases were distal penile and 16 were midshaft hypospadias. Five cases had undergone a repair previously. Certain technical points were strictly adhered to during the TIP urethroplasty so as to achieve a normal slit like meatus and to decrease the incidence of meatal stenosis and urethrocutaneous fistula. Results: The catheter was removed after 10 days. Average follow up was six months. There was complete dehiscence of the repair in one patient. One patient had superficial extravasation of urine. Meatal stenosis was seen in the first two cases. Fistula was seen in three patients. The patients with a successful repair voided with a single straight urinary stream in a forward direction and had a normally situated slit like glanular meatus. Conclusions: TIP urethroplasty is a versatile, simple operation with good cosmetic results. Certain technical considerations if strictly adhered to help in preventing complications and achieve a satisfactory result.
  2,804 0 -
A study on the correlation between clinical outcome and residual prostatic weight ratio after transurethral resection of the prostate for benign prostatic hyperplasia
MC Songra, Rajiv Kumar
July-December 2004, 20(2):42-46
Objective: A prospective trial to determine the effect of the extent of tissue resection on symptom improvement after transurethral resection of the prostate in men with symptomatic benign prostatic enlargement and to evaluate any potential correlation between prostate size and outcome, a new variable the residual prostatic weight ratio (RPWR) Patients and Methods: From October 2002 to November 2003, a total of 50 patients (mean age 62.6 yrs., range 50-91) with symptomatic benign prostatic enlargement who underwent TURP participated in this prospective study. Patients were assessed preoperatively with the American Urological Association symptom Score, Urinary flow rate measurements (Qmax and Qavg) as well as prostate volumes by transabdominal ultrasound. The amount of tissue resected was weighted. RPWR was derived by dividing the weight afterTURP by the initial weight. Clinical outcome was evaluated by the difference in AUA score, Qmax and Qavg before and 2 months after Surgery. Results: There was a significant improvement in AUA score, Qmax and Qavg postoperatively. Maximum numbers of patients undergoing TURP had RPWR in the range of 51­60% (mean RPWR 49.9%). Mean overall change in AUA Score (DAUA), D Qmax and D Qavg was 12.04, 8.27 ml/sec and 6.64 ml/sec respectively. Smaller the RPWR larger is the DAUA, DQmax, DQavg and vice versa. There was negative correlation between the RPWR and the DAUA, DQmax and DQavg (r = -0.42, -0.067, and -0.09 respectively). Conclusion: Symptomatic improvement after TU RP will depend on the amount of tissue removed and the smaller the RPWR after TU RP the better the clinical outcome.
  2,667 0 -
CASE REPORTS
Mesothelioma of tunica vaginalis
Dilip Kumar Pal, Mallika Basuroy, Manoj Kumar Chowdhury
July-December 2004, 20(2):67-68
  2,572 0 -
RESEARCH ARTICLES
Interpretation of prostatic biopsies: A review (for practicing urologists)
A Chitale, S Khubchandani
July-December 2004, 20(2):3-10
  2,379 0 -
CASE REPORTS
Presacral dermoid cyst presenting as acute retention of urine
Justin Stephen, TV Haridas, PA Thomas, Sreekumar Ramachandran, Joy Jyothis
January-June 2004, 20(2):177-178
  2,346 0 -
Renal and ureteral arteriovenous malformation
Kamal Jeet Singh, M Raghvendran, Amit Suri, Anil Mandhani
July-December 2004, 20(2):69-70
  2,337 0 -
Sacro-coccygeal chordoma: An unusual cause of retention of urine
Dilip Kumar Pal, Manoj Kumar Chowdhury
January-June 2004, 20(2):170-171
  2,299 0 -
Cystectomy with orthotopic neobladder ; an option for giant leiomyoma of urinary bladder : A case report and the review of literature
Kamal Jeet Singh, Amit Suri, Prashant Lavania, Anil Mandhani
July-December 2004, 20(2):63-66
  2,298 0 -
Leydig cell tumor of the testis - a case report
Vishwajeet Singh, Himanshu Chaudhary, Aneesh Srivastava
January-June 2004, 20(2):166-166
  2,263 0 -
Asymptomatic large prostatic utricle
Anjali Bhosle, Snehal Patel, Mahesh Desai
January-June 2004, 20(2):184-185
  2,238 0 -
Vaginal metastasis from renal cell carcinoma - a case report
Pranjal Ramanlal Modi, P Jacob John, Deepak Pravinbhai Joshi, Rohit Naranbhai Joshi
January-June 2004, 20(2):169-170
  2,228 0 -
RESEARCH ARTICLES
Modified anterior vaginal wall sling for SUI
AS Sawant, VD Trivedi, SA Salve, V Upadhaye, P Dangle
January-June 2004, 20(2):106-108
Objectives : Bladder neck suspension using autologous tissue is an established technique for SUI. We report 12 cases of anterior vaginal wall sling for patients with ana­tomical incontinence and modification of standard proce­dure by anchoring the sling to Cooper's ligament. Methods : Twelve patients with anatomical incontinence were operated by our technique. Detailed preoperative evaluation was done and patients with only anatomical incontinence were selected, patients with intrinsic sphinc­ter deficiency (ISD) were excluded. The surgical tech­nique included suspension of rectangular strip of anterior vaginal wall overlying proximal urethra and bladder neck with number 1 polypropylene to Cooper's ligament. Results : The follow-up period ranged from 6 months to 3 years and all patients were continent. Conclusions : Cooper's ligament provides a good an­choring system and avoids the use of expensive bone an­choring systems.
  2,197 0 -
Ureteric complications in live related donor renal transplantation - impact on graft and patient survival
A Srivastava, H Chaudhary, A Sehgal, D Dubey, R Kapoor, A Kumar
July-December 2004, 20(2):11-14
Objective : The study was performed with an aim to determine the incidence of ureteric complications in live related donor renal transplantation, and to study the effect of ureteric complications on long term graft and patient survival. Patients And Methods: Records of 1200 consecutive live related renal transplants done from 1989-2002 were reviewed. Twenty-six ureteric complications were noted to occur and treatment modalities employed were documented. In the non complication group sufficient data for evaluation was available in 867 patients. Survival analysis were performed using Kaplan-Meier techniques. Results: The overall incidence of urological complications is 2.9%. Complications occurred at a mean interval of 31.9 days after renal transplantation. Ureteric complications occurred in 2% patients with stented and 7.7% patients with non stented anastomosis (p=0.001). Mean follow up following renal transplantation was 37.4 months. Survival analysis showed that ureteric complications did not increase the risk of graft fai lu re or patient death. Conclusions: Ureteric complications in live related donor renal transplantation occurred in 2.9 % patients and did not impair graft and patient survival.
  2,092 0 -
CASE REPORTS
Management of a ureteral stone following a forgotten stent after transuretero- ureterostomy
Nagesh Kamat
January-June 2004, 20(2):174-175
  2,089 0 -
Virilising tumor of testis - a case report
L Sudhakar, C Anand, K Sri Ram, G Sivasankar, N Muthulatha, MG Rajamanickam
January-June 2004, 20(2):164-165
  2,015 0 -
Basketing the Basket
P Vijayan
July-December 2004, 20(2):68-69
  1,757 0 -
Ectopic prostatic tissue presenting as a bladder mass
VD Trivedi, SA Salve, P Dangle, A Sawant, Gadgil , G Nelivegi
January-June 2004, 20(2):167-168
  1,743 0 -
Tuberculous pyonephrosis of native kidney in a transplant recipient 16 years after the ligation of the native ureter
PVLN Murthy, Surya Prakash, Nandkumar , Ram Reddy, KV Dakshina Murthy
January-June 2004, 20(2):176-177
  1,741 0 -
Carcinoma of the prostate presenting as IVC obstruction
Maneesh Sinha, Nitin S Kekre, Ganesh Gopalakrishnan
January-June 2004, 20(2):186-187
  1,731 0 -
Duplicate exstrophy of bladder with squamous cell carcinoma : A case report
C Anand, L Sudhakar, R Jayaganesh, M Iiangovan, MG Rajamanickam
July-December 2004, 20(2):52-53
  1,729 0 -
Congenital vasocutaneous fistula
Dilip Kumar Pal, Mallika Basuroy
July-December 2004, 20(2):62-63
  1,686 0 -
Mucinous cystadenocarcinoma of renal pelvis - a case report
Vinay A Chougule, KR Babli, Mukund G Andankar, Sandhya R Rao, Hemant R Pathak
January-June 2004, 20(2):172-174
  1,680 0 -
Cutaneous mucormycosis in a cadaveric renal allograft recipient - a case report
VD Trivedi, HD Trivedi, P Dangle, SA Salve, U Tendolkar
January-June 2004, 20(2):168-169
  1,668 0 -
Extrinsic ureteral obstruction due to retroperitoneal Kimura's disease
KV Vinod, AS Albert, S Sankar
January-June 2004, 20(2):179-180
  1,640 0 -
Iatrogenic secondary urolithiasis: A case report
Rajesh Khanna, SK Gupta, P Madhusoodanan, AS Sandhu, T Sinha, A Kumar, GS Sethi, A Srivastava
January-June 2004, 20(2):187-188
  1,619 0 -
Squamous cell carcinoma of prostate - a case report
L Sudhakar, C Anand, G Sivasankar, N Muthulatha, MG Rajamanickam
July-December 2004, 20(2):53-54
  1,489 0 -
Renal cell carcinoma in autosomal dominant polycystic kidney disease: A case report
Subroto Ranjan Poddar, Sujit Kumar Sinha, Uttara Chatterjee, Anup Kumar Kundu
July-December 2004, 20(2):58-59
  1,464 0 -
Metastatic mucinous cystadenocarcinoma in solitary kidney- A rare presentation of occult ovarian primary
Vishwajeet Singh, Aneesh Srivastava
July-December 2004, 20(2):57-58
  1,402 0 -
Pyeloduodenal fistula - a case report
Nebu Issac Mammen
January-June 2004, 20(2):171-172
  1,283 0 -
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