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   2008| October-December  | Volume 24 | Issue 4  
    Online since November 28, 2008

 
 
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REVIEW ARTICLES
Emergency management of ureteral stones: Recent advances
Luis Osorio, Estevao Lima, Riccardo Autorino, Filinto Marcelo
October-December 2008, 24(4):461-466
DOI:10.4103/0970-1591.44248  PMID:19468497
Most ureteral stones can be observed with reasonable expectation of uneventful stone passage. When an active ureteral stone treatment is warranted, the best procedure to choose is dependent on several factors, besides stone size and location, including operators' experience, patients' preference, available equipment and related costs. Placement of double-J stent or nephrostomy tube represents the classical procedures performed in a renal colic due to acute ureteral obstruction when the conservative drug therapy does not resolve the symptoms. These maneuvers are usually followed by ureteroscopy or extracorporeal shockwave lithotripsy, which currently represent the mainstay of treatment for ureteral stones. In this review paper a literature search was performed to identify reports dealing with emergency management of renal colic due to ureteral stones. The main aspects related to this debated issue are analyzed and the advantages and disadvantages of each treatment option are carefully discussed.
  14,948 592 8
Raman spectroscopy and its urological applications
Vishwanath S Hanchanale, Amrith R Rao, Sakti Das
October-December 2008, 24(4):444-450
DOI:10.4103/0970-1591.39550  PMID:19468494
Purpose: The Raman spectroscopic technology can be utilized for the detection of changes occurring at the molecular level during the pathological transformation of the tissue. The potential of its use in urology is still in its infancy and increasing utility of this technology will transform noninvasive tissue diagnosis. The Nobel laureate, Sir C.V. Raman is credited for the discovery of the principles of Raman spectroscopy. Materials and Methods: Applications of Raman spectroscopy in the bladder, renal, prostate, and other urological disorders were gathered from Medline and abstracts from recent international urological meetings. Current status and future directions of Raman spectroscopy in urology were also reviewed. Results: Raman spectroscopic technology is used to interrogate biological tissues. The potential use of this technology in urology has shown encouraging results in the in vitro diagnosis and grading of cancers of the bladder and the prostate. Raman microprobes have been used for the characterization and identification of renal lithiasis. Technology may be available for the urologists to determine the margin status intraoperatively during partial nephrectomy and radical prostatectomy. The future would see the development of optical fiber probes to incorporate them into catheters, endoscopes, and laparoscopes that will enable the urologist to obtain information during the operation. Conclusion: Raman spectroscopy is an exciting tool for real-time diagnosis and in vivo evaluation of living tissue. The potential applications of Raman spectroscopy may herald a new future in the management of various malignant, premalignant, and other benign conditions in urology.
  13,949 434 3
SYMPOSIUM
Flexible ureteroscopy update: indications, instrumentation and technical advances
Srinivas Rajamahanty, Michael Grasso
October-December 2008, 24(4):532-537
DOI:10.4103/0970-1591.44263  PMID:19468513
Retrograde ureteroscopy has recently gained a broadened indication for use from diagnostic to a variety of complex minimally invasive therapies. This review aims to look at the recent advances in the instrumentation and accessories, the widened indications of its use, surgical techniques and complications. With minimization of ureteroscopic instruments manufacturers are challenged to develop new, smaller and sturdier instruments that all will also survive the rigors of surgical therapy.
  12,791 442 8
SURGICAL CRAFT
Laparoscopic adrenalectomy: Surgical techniques
Matthew J Mellon, Amanjot Sethi, Chandru P Sundaram
October-December 2008, 24(4):583-589
DOI:10.4103/0970-1591.44277  PMID:19468527
Since its first description in 1992, laparoscopic adrenalectomy has become the gold standard for the surgical treatment of most adrenal conditions. The benefits of a minimally invasive approach to adrenal resection such as decreased hospital stay, shorter recovery time and improved patient satisfaction are widely accepted. However, as this procedure becomes more widespread, critical steps of the operation must be maintained to ensure expected outcomes and success. This article reviews the surgical techniques for the laparoscopic adrenalectomy.
  12,535 334 2
SYMPOSIUM
Extracorporeal shockwave lithotripsy for lower pole calculi smaller than one centimeter
Christian Chaussy, Thorsten Bergsdorf
October-December 2008, 24(4):517-520
DOI:10.4103/0970-1591.44260  PMID:19468510
Extracorporeal shockwave lithotripsy (ESWL) has revolutionized the treatment of urinary calculi and became the accepted standard therapy for the majority of stone patients. Only for stones located in the lower calix, ESWL displayed a limited efficacy. Since the stone-free rate seemed to be preferential, endoscopic maneuvers like percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) have been proposed as the primary approach for this stone localization. Stone size seems to be the most important parameter in regard to the stone-free rate, whereas anatomical characteristics of the lower pole collecting system are discussed controversial. Various studies show a good stone clearance between 70-84% for stones up to 1 cm in diameter. Additional physical and medical measures are suitable to improve treatment results. Stone remnants after ESWL, defined as clinical insignificant residual fragments (CIRF) will not cause problems in every case and will pass until up to 24 months after treatment; in total 80-90% of all patients will become stone-free or at least symptom-free. When complete stone-free status is the primary goal , follow-up examinations with new radiological technologies like spiral CT show that the stone-free rate of ESWL and endoscopically treated patients (RIRS) does not differ significantly. However, in comparison to endoscopic stone removal, shockwave therapy is noninvasive, anesthesia-free and can be performed in an outpatient setup. Therefore, ESWL remains the first choice option for the treatment of lower caliceal stones up to 1 cm. The patient will definitely favour this procedure.
  11,235 269 6
Retrograde intrarenal surgery for lower pole renal calculi smaller than one centimeter
Hemendra Navinchandra Shah
October-December 2008, 24(4):544-550
DOI:10.4103/0970-1591.44265  PMID:19468515
Objectives: Recently there has been an increasing interest in the application of retrograde intrarenal surgery (RIRS) for managing renal calculi. In this review we discuss its application for the management of lower calyceal (LC) stones less than 10 mm in maximum dimension. Materials and Methods: Literature was reviewed to summarize the technical development in flexible ureterorenoscopy and its accessories. Further, the indications, outcome and limitations of RIRS for LC calculi < 1 cm were reviewed. Results: Use of access sheath and displacement of LC stone to a more favorable location is increasingly employed during RIRS. Patients who are anticoagulated or obese; those with adverse stone composition and those with concomitant ureteral calculi are ideally suited for RIRS. It is used as a salvage therapy for shock wave lithotripsy (SWL) refractory calculi but with a lower success rate (46-62%). It is also increasingly being used as a primary modality for treating LC calculi, with a stone-free rate ranging from 50-90.9%. However, the criteria for defining stone-free status are not uniform in the literature. The impact of intrarenal anatomy on stone-free rates after RIRS is unclear; however, unfavorable lower calyceal anatomy may hamper the efficacy of the procedure. The durability of flexible ureteroscopes remains an important issue. Conclusions: RIRS continues to undergo significant advancements and is emerging as a first-line procedure for challenging stone cases. The treatment of choice for LC calculi < 1 cm depends on patient's preference and the individual surgeon's preference and level of expertise.
  10,883 314 7
UROPATHOLOGY
Multicentric small cell neuroendocrine neoplasm of the renal pelvis and ureter with concomitant focal high-grade urothelial carcinoma of the ureter: A case report
John S Banerji, Anila Korula, Jayalakshmi B Panicker
October-December 2008, 24(4):571-574
DOI:10.4103/0970-1591.44273  PMID:19468523
Malignant small cell neuroendocrine tumors of the pelvi-calyceal system are rare, and even more uncommon is their occurrence with concomitant transitional cell carcinoma, in the same renal unit. We present such a case for its unique presentation.
  11,028 125 3
SYMPOSIUM
Percutaneous nephrolithotomy for 1-2 cm lower-pole renal calculi
Percy Jal Chibber
October-December 2008, 24(4):538-543
DOI:10.4103/0970-1591.44264  PMID:19468514
Objectives: The most appropriate management of patients with lower-pole calyceal (LC) stones remains controversial. In this review we discuss the role of percutaneous nephrolithotomy (PCNL) in the management of LC stones 1-2 cm in maximum dimension. Materials and Methods: A detailed literature review was performed to summarize the recent technical developments and controversies in PCNL. The results of PCNL for 1-2 cm LC calculi were reviewed. Results: PCNL is increasingly employed as a primary modality in the treatment of LC calculi. It has a high success rate and acceptably low percentage of major complications in experienced hands. Supine position is found to be as safe and effective as prone position. Urologist-acquired access is associated with fewer access-related complications and better stone-free rates. Ultrasound is increasingly employed as an imaging modality for obtaining access. There have been increasing reports of tubeless PCNL in the literature. Most patients undergoing tubeless PCNL do not need hemostatic agents as an adjuvant for hemostasis. Non-contrast computed tomography does not yield statistically valuable increase in the diagnosis of significant residual stones compared with that of plain X-ray and linear tomography. Comprehensive metabolic evaluation and aggressive medical management can control new stone recurrences and growth of residual fragments following PCNL. Conclusions: PCNL is a highly effective procedure with consistently high stone-free rates when compared with extracorporeal shockwave lithotripsy or retrograde intrarenal surgery. The results also do not depend on anatomic factors and stone size. It is associated with low morbidity in experienced hands.
  10,610 332 6
CASE REPORTS
Ectopic prostate presenting as a mass in bladder
Filiz Eren, Muhammet Guzelsoy, Bulent Eren, Ovgu Aydyn
October-December 2008, 24(4):564-565
DOI:10.4103/0970-1591.44270  PMID:19468520
A 24-year-old man presented with dysuria and voiding frequency. Cystoscopy revealed a smooth surfaced nodular mass in the trigonal region. Transurethral insisional biopsy of the mass was done. Histopathological and immunohistochemical examination revealed benign prostatic tissue situated ectopically.
  10,780 118 1
ORIGINAL ARTICLES
Y chromosome microdeletions in sperm DNA of infertile patients from Tamil Nadu, south India
Poongothai J Sakthivel, Manonayaki Swaminathan
October-December 2008, 24(4):480-485
DOI:10.4103/0970-1591.44252  PMID:19468501
Context: Y chromosome microdeletions in infertile men of Tamil Nadu, South India. Aim: The paper assesses the association of Y chromosome microdeletions among infertile patients using several STS markers from each AZF (AZoospermic Factor) region and also aspires to determine whether the blood DNA microdeletion picture matches the semen DNA Yq microdeletion map. Materials and Methods: A total of 287 men, including 147 infertile men and 140 normozoospermic fertile controls were included for the study. Results: Screening 72 semen samples with the STS markers specific to AZF (a,b,c) regions showed Y chromosome microdeletions in 19 (12.9%) individuals. No deletion was observed in all the three AZF regions by screening 45 blood and 30 paired samples. None of the control men showed deletion for the 28 STS markers, which were used for the primary screening of the deletion of AZF a,b,c regions. Conclusion: Germ cell DNA can be analyzed for Yq microdeletions rather than blood DNA.
  10,580 228 4
REVIEW ARTICLES
Testis-sparing surgery for benign and malignant tumors: A critical analysis of the literature
Gianluca Giannarini, Andrea Mogorovich, Irene Bardelli, Francesca Manassero, Cesare Selli
October-December 2008, 24(4):467-474
DOI:10.4103/0970-1591.44249  PMID:19468498
In order to explore the latest advances in organ-sparing treatment of testicular tumors, a literature search of the Medline/PubMed database was carried out for published data in the English language up to 2007. In the recent past the management of testicular tumors has evolved in favor of a testis-sparing approach in selected cases, both in the adult and pediatric population. The widespread use of high-frequency testicular ultrasound has led to detecting an increasing number of asymptomatic, non-palpable, small-volume masses. A higher proportion of testicular lesions of benign nature than previously reported has now been documented. The high accuracy of frozen section examination and the increasing interest in the potential functional, psychological and cosmetic advantages related to preserved testicular parenchyma are other arguments currently favoring the adoption of an organ-sparing policy for most testicular masses. Greater experience has been gained in also managing conservatively malignant tumors. Patients with germ-cell cancer in solitary testis or bilateral tumors can be submitted to testis-sparing surgery, provided that the maximum size of the lesion is <2 cm, preoperative testosterone is normal and adjuvant radiotherapy of the residual parenchyma is delivered. Cancer-specific survival is excellent, local recurrence rate very low and androgen supplementation unlikely.
  10,325 357 8
CASE REPORTS
Severe acute tumor lysis syndrome in patients with germ-cell tumors
Guilherme Alvarenga Feres, Jorge Ibrain Figueira Salluh, Carlos Gil Ferreira, Marcio Soares
October-December 2008, 24(4):555-557
DOI:10.4103/0970-1591.44267  PMID:19468517
Germ-cell tumors are a high-proliferative type of cancer that may evolve to significant bulky disease. Tumor lysis syndrome is rarely reported in this setting. The reports of three patients with germ-cell tumors who developed severe acute tumor lysis syndrome following the start of their anticancer therapy are presented. All patients developed renal dysfunction and multiorgan failure. Patients with extensive germ-cell tumors should be kept on close clinical and laboratory monitoring. Physicians should be aware of this uncommon but severe complication and consider early admission to the intensive care unit for the institution of measures to prevent acute renal failure.
  10,518 117 5
POINT-COUNTER-POINT
Endoscopic management is the preferred treatment modality for a Grade III vesicoureteric reflux with breakthrough infections in a young girl
SS Joshi
October-December 2008, 24(4):478-479
DOI:10.4103/0970-1591.44251  PMID:19468500
Endoscopic injection treatment for VUR appears to have less success rate than open surgical treatment, even in Gr 3 VUR. Economics of use of deflux injection and its success rate do not suit Indian milieu. To achieve high success rate of Atlanta group in endoscopic injection treatmnent , requires a longer learning curve and yet it has not achieved success rate of 96-98% achieved by open surgical techniques. Recent addition of modified extravesical reimplantation technique has reduced significantly the post operative pain and patient can be discharged within 2 days from the hospital.
  10,443 161 -
SYMPOSIUM
Combined electrohydraulic and holmium: YAG laser ureteroscopic nephrolithotripsy of large (>2 cm) renal calculi
Albert J Mariani
October-December 2008, 24(4):521-525
DOI:10.4103/0970-1591.44261  PMID:19468511
Percutaneous nephrolithotripsy (PCL) is a standard treatment for renal calculi >2 cm. Modern flexible ureteroscopes and accessories employing the complementary effects of electrohydraulic lithotripsy (EHL) and Ho:YAG laser lithotrites can treat these renal calculi in a minimally invasive fashion with similar or superior results. Objective: To assess the safety and efficacy of ureteroscopic nephrolithotripsy monotherapy for the management of >2 cm renal calculi in the community setting. Materials and Methods: Fifty nine patients with 63 renal calculi ranging from 20 to 97 mm (mean 44 mm) in length and 175 to 3300 mm2 (mean 728 mm2) area underwent staged ureteroscopic nephrolithotripsy monotherapy. Obesity (BMI > 30) was present in 54% and 19% were morbidly obese (BMI > 40). An infectious etiology was present in 49% and hard stone components in 89%. All patients presented with hematuria, pain, and/or recurrent urinary tract infection (UTI). Lithotripsy was performed with a single deflection flexible ureteroscope and predominantly EHL. Laser drilling was employed (n = 6) to weaken very hard stones prior to EHL. Low intrarenal pressure was maintained by continuous bladder drainage and placement of a stiff safety wire. Visibility was maintained using manual pulsatile irrigation. Results: All patients were rendered pain and infection-free. No patient required a blood transfusion and there was no change in serum creatinine. Mobile stone-free status was achieved in 60/63 (95%) with a mean of 1.7 nephrolithotripsy stages and 0.38 secondary or ancillary procedures. Outpatient management was sufficient for 121/131 (92%) of the procedures. Operative time averaged 46 min/stage and 79 min/calculus. Complications included endotoxic shock (3), fever (5), ureteral fragments requiring treatment (11), delayed extubation (2), delayed pneumonia (1), and urinary retention (1). Conclusion: Staged ureteroscopic nephrolithotripsy of large renal calculi is feasible with low morbidity and stone clearance rates that compare favorably with PCL. It has largely replaced PCL at this institution.
  10,352 172 9
CASE REPORTS
Posterior urethral valve associated with orthotopic ureterocele
Arun Chawla, Sreedhar Reddy, K Natarajan, Joseph Thomas, K Sasidharan
October-December 2008, 24(4):569-570
DOI:10.4103/0970-1591.44272  PMID:19468522
Symptomatic presentation of orthotopic ureterocele in infancy is very rare and its association with posterior urethral valves has not been reported till date. The first such case and a review of the literature on anomalies in association with posterior urethral valves is presented.
  10,379 132 1
ORIGINAL ARTICLES
Epidemiological differences of lower urinary tract symptoms among female subpopulations and group level interventions
Avasarala Atchuta Kameswararao, Syed Meraj Ahmed, Sujatha Nandagiri, Swati Tadisetty
October-December 2008, 24(4):498-503
DOI:10.4103/0970-1591.44256  PMID:19468505
Objectives: 1) To study the risk factor profiles of lower urinary tract symptoms (LUTS) among adolescent girls, housewives and working women and its socioeconomic and quality of life losses. 2) To undertake risk factor modifications using the adolescent girls. Design and Setting: Cross-sectional descriptive study followed by educational intervention. Statistical Methods: Cluster sampling, Proportions, confidence intervals, Chi square and t-Tests and Logistic regression. Materials and Methods: House to house survey was done in two villages and one urban ward. Seventy-five housewives, 75 working women and 180 adolescent girls were asked about the risk factors and losses due to LUTS. Three teams of adolescent girls were utilized to bring about behavioral modifications. Impact was measured through user perspectives obtained from the participants. Results: Risk factors, social, economic and quality of life losses were different among the three female populations. Overall prevalence of LUTS among the three groups is 61(18.5%). Improper anal washing technique, malnutrition, presence of vaginal discharge, use of unsanitary menstrual pads, pinworm infestation and use of bad toilets were the significant causes among girls. Presence of sexually transmitted diseases was a contributing factor among housewives and working women. Prolonged sitting the posture was also contributing to LUTS among working women. Seventy-four per cent of beneficiaries expressed that intervention is useful. Conclusions: The causes for LUTS and their consequences were differing among the three female subpopulations. Specific group level interventions using trained girls were successful.
  10,173 195 1
Small cell cancer of the bladder: The Leon-Berard cancer centre experience
Nabil Ismaili, Fadi Elkarak, Pierre Etienne Heudel, Aude Flechon, Jean Pierre Droz
October-December 2008, 24(4):494-497
DOI:10.4103/0970-1591.44255  PMID:19468504
Background: Small cell bladder carcinoma is an uncommon tumor. In this retrospective study we report our experience dealing with this disease at the Leon-Berard Cancer Centre. Materials and Methods: We retrospectively analyzed various characteristics of small cell bladder carcinoma: patient demographics, histological diagnosis, disease stage, treatment effects and outcome, in 14 non-metastatic small cell bladder carcinoma patients treated at our institution between 1995 and 2006. Results: The mean age at diagnosis was 60 years (range, 45-77). All patients were male. Seventy-five per cent were smokers. All had locally advanced disease. Ten patients (71.4%) were treated by cystoprostatectomy and bilateral pelvic lymph node resection, one by cystoprostatectomy alone. Two patients received neoadjuvant chemotherapy and four received adjuvant chemotherapy. One patient was treated by radiotherapy with concomitant cisplatin after transurethral resection of bladder tumor (TURBT). One patient refused surgery and was treated by chemotherapy alone. One patient was lost to follow-up after TURBT. After 49-month median follow-up, 12 patients had relapsed. Disease-free survival was 5.7 months. The most frequent sites of relapse were the retroperitoneal lymph node (seven patients) and the liver (three patients). Nine patients died of metastasis. Median overall survival was 29.5 months. Survival probability at two years was 58%. Median overall survival was 34 months in the mixed small carcinoma group, as compared with 9.5 months in the pure small cell carcinoma group (P=0.01). Mean overall survival was 27.2 months for all patients and 38.6 months for patients treated with cystectomy and adjuvant chemotherapy. Conclusion: To date, the optimal treatment for locally advanced small cell bladder carcinoma is not clear. Cystectomy with neoadjuvant or adjuvant chemotherapy appears as a viable option.
  10,096 255 19
SYMPOSIUM
Should flexible ureteroscope be added to our armamentarium to treat stone disease?
Anand Dharaskar, Anil Mandhani
October-December 2008, 24(4):513-516
DOI:10.4103/0970-1591.44259  PMID:19468509
The field of Urology in Medicine has witnessed tremendous advancement in technology and in accordance with it. Endourology has taken a leap ahead in terms of stone management. Most of the stones could be treated with semi-rigid ureteroscopy, percutaneous nephrolithotomy (PNL) and ESWL and some would need Flexible ureteroscopy. Flexible ureteroscopy has been primarily indicated to treat ESWL resistant renal stones but with changes in the technology of incorporating secondary active deflection and availability of laser fibres, its horizon for indications to treat stones is being widened. Though Flexible ureteroscopy is being used to treat stones of various sizes and locations, its cost effectiveness is debatable. Should it be used ubiquitously to treat stones amenable to PNL or ESWL is a big question we need to answer. As of now true indications of Flexible ureteroscopy are limited and there is an urgent need for a randomized trial to compare its efficacy with ESWL and PNL for renal and upper ureteric stones.
  10,049 260 1
REVIEW ARTICLES
What every urologist should know about surgical trials Part II: What are the results and should I apply them to patient care?
Sohail Bajammal, Mohit Bhandari, Philipp Dahm
October-December 2008, 24(4):437-443
DOI:10.4103/0970-1591.44245  PMID:19468493
Surgical interventions have inherent benefits and associated risks. Before implementing a new therapy, we should ascertain the benefits and risks of the therapy, and assure ourselves that the resources consumed in the intervention will not be exorbitant. Materials and Methods: We suggest a three-step approach to the critical appraisal of a clinical research study that addresses a question of therapy. Readers should ask themselves the three following questions: Are the study results valid, what are the results and can I apply them to the care of an individual patient. This second review article on surgical trials will address the questions of how to interpret the results and whether to apply them to patient care. Results: Once a study has been determined to be valid, one should determine how effective an intervention is using either relative (i.e. risk ratio, relative risk reduction) or absolute measures (i.e. absolute risk reduction, number-needed to treat) of effect size. The reader should then determine the range within which the true treatment effect lies (95% confidence intervals). Having found the results to be of a magnitude that is clinically relevant, one must then consider if the result can be generalized to one's own patient, and whether the investigators have provided information about all clinically important outcomes. Then, it is necessary to compare the relative benefits of the intervention with its risks. If one perceives the benefits to outweigh the risks, then the intervention may be of use to one's patient. Conclusion: Given the time constraints of a busy urological practice, applying this three-tiered approach to every article will be challenging. However, knowledge of the critical steps to assess the validity, impact and applicability of study results can provide important guidance to clinical decision-making and ultimately result in a more evidence-based practice of urology.
  10,075 225 -
URORADIOLOGY
Left renal vein hypertension as a cause of occult hematuria: Multi-detector computed tomography demonstration
Nitin P Ghonge, Bharat Aggarwal
October-December 2008, 24(4):575-578
DOI:10.4103/0970-1591.44274  PMID:19468524
  10,097 145 1
CASE REPORTS
Triad of bladder agenesis with solitary kidney and ectopic ureter
Sajni I Khemchandani
October-December 2008, 24(4):566-568
DOI:10.4103/0970-1591.44271  PMID:19468521
The bladder agenesis is an extremely rare congenital genitourinary anomaly; only 60 cases have been reported in the English literature and only 19 of these were noted in viable neonates. [1] Our case represents the 20th live birth with bladder agenesis. The triad of bladder agenesis with solitary kidney and ectopic ureter is seldom compatible with life due to associated anomalies. [2,3] Successful treatment and the long-term prognosis are usually poor because of the associated abnormalities. In our case, function of left solitary kidney was good and child did not have associated life-threatening disorder. Hence child was successfully managed with continent urinary diversion with good quality of life.
  9,793 131 6
REVIEW ARTICLES
Single access laparoscopic nephrectomy
Jay D Raman, Jeffrey A Cadeddu
October-December 2008, 24(4):457-460
DOI:10.4103/0970-1591.44247  PMID:19468496
Laparoscopic nephrectomy has assumed a central role in the management of benign and malignant kidney diseases. While laparoscopy is less morbid than open surgery, it still requires several incisions each at least 1-2 cm in length. Each incision carries morbidity risks of bleeding, hernia and/or internal organ damage, and incrementally decreases cosmesis. An alternative to conventional laparoscopy is single access or keyhole surgery, which utilizes magnetic anchoring and guidance system (MAGS) technology or articulating laparoscopic instruments. These technical innovations obviate the need to externally space trocars for triangulation, thus allowing for the creation of a small, solitary portal of entry into the abdomen. Laboratory and early clinical series demonstrate feasibility as well as safe and successful completion of keyhole nephrectomy. Future work is necessary to improve existing instrumentation, increase clinical experience, assess benefits of this surgical approach, and explore other potential applications for this technique.
  9,558 327 8
SYMPOSIUM
Accessory instrumentation in flexible ureteroscopy: Evidence-based recommendation
Timothy Holden, Renato Nardi Pedro, Manoj Monga
October-December 2008, 24(4):510-512
DOI:10.4103/0970-1591.39548  PMID:19468508
Instrumentation is the key to success in endourology. Indeed, endourology could be redefined as "enginurology" as the marriage between engineering and urology to develop instrumentation to improve patient outcomes is the key facilitator in the advancement of minimally invasive techniques. This review article will identify the evidence-base that supports our current recommendations for equipment used during ureteroscopy.
  9,502 308 1
GUEST EDITORIAL
Retrograde intra-renal surgery: Where are we today?
Percy Jal Chibber
October-December 2008, 24(4):509-509
DOI:10.4103/0970-1591.44258  PMID:19468507
  9,435 241 -
REVIEW ARTICLES
The sentinel node concept in prostate cancer: Present reality and future prospects
M Egawa, M Fukuda, H Takashima, T Misaki, K Kinuya, S Terahata
October-December 2008, 24(4):451-456
DOI:10.4103/0970-1591.44246  PMID:19468495
A sentinel node (SN) is defined as the first site where cancer cells are carried by lymph flow from a tumor. If this definition (SN concept) correctly reflects the clinical reality, intraoperative SN biopsy would facilitate precise nodal staging. In malignant melanoma, a prolonged survival has been evidenced by a large-scale randomized controlled study. On the contrary, research on SN concept in deeply located cancers including prostate cancer, is still investigative, and no concrete data from clinical trials are yet available. Since 1993, several investigators have demonstrated that the SN concept could be applied in prostate cancer patients as well with high accuracy. Although promising and technically feasible in pre-clinical settings, many hurdles remain to be cleared before clinical application can be recommended. This review addresses the current status and related issues of the SN concept in prostate cancer, and discusses the future directions.
  9,198 312 2
ORIGINAL ARTICLES
Primary cryoablation for Gleason 8, 9, or 10 localized prostate cancer: Biochemical and local control outcomes from the Cryo OnLine database registry
J Stephen Jones, John C Rewcastle
October-December 2008, 24(4):490-493
DOI:10.4103/0970-1591.44254  PMID:19468503
Introduction and Objective: The increased use of cryoablation as an initial treatment for localized high-grade prostate cancer has been due to many factors including reports that cell kill from exposure to cryogenic temperatures is independent of cellular dedifferentiation and Gleason score. The objective of this study is to report the outcomes of primary cryoablation when used to treat Gleason 8, 9, or 10 localized prostate cancer at a large number of centers. Materials and Methods: Data from 1608 patients who underwent primary cryoablation at 27 centers were collected using the Cryo OnLine Database (COLD) registry. This analysis considers only the 77 patients who had a Gleason score of at least 8 and a minimum of 24 months of follow-up. Biochemical failure was defined according to both the original ASTRO definition (three rises) and the 2006 updated ASTRO (Phoenix) definition of nadir + 2. Biopsy was performed at the physician's discretion, but most commonly if a patient had a rising or suspicious prostate specific antigen (PSA). Results: The average age at treatment was 69.6 8.2 years. Pretreatment PSA was 16.2 17.9 ng/ml and the average Gleason was 8.5 0.6. Patients were followed for 39.0 18.8 months (range: 24-120 months) and 5-year follow-up was available for 12 patients. Eight-seven percent of the patients achieved a PSA nadir < 0.4 ng/ml. Five-year actuarial biochemical survivals was 64.4 6.0% and 44.6 8.0% for the ASTRO and Phoenix definitions, respectively. A total of 47 underwent posttreatment biopsy. Of these, 12 showed evidence of disease resulting in a positive biopsy rate for those who underwent biopsy of 25.5%. This yields a positive biopsy rate of the entire population of 15.6% (12/77). Conclusions: Cryoablation, as a primary treatment for high-grade Gleason prostate cancer practiced over a wide spectrum of users provides definable biochemical and local control for a hard to manage patient population with aggressive disease.
  9,266 144 1
Shock wave lithotripsy as a primary modality for treating upper ureteric stones: A 10-year experience
Abhijit S Padhye, Pushkaraj B Yadav, Pratikshit M Mahajan, Ashish A Bhave, Yogesh B Kshirsagar, Yogesh B Sovani, Shivadeo S Bapat
October-December 2008, 24(4):486-489
DOI:10.4103/0970-1591.44253  PMID:19468502
Aims and Objectives: Shock wave lithotripsy (SWL) has been recommended as a first-line treatment for upper ureteric calculi in several studies with a success rate of 80-90%. Our aim is to present our retrospective data of treatment of upper ureteric stones with SWL as primary modality over a 10-year period and evaluate the factors affecting fragmentation and clearance. Materials and Methods: From February 1997 to March 2007, 846 patients with upper ureteric stones were treated with SWL as the primary modality. Age: 9-69 years, 546 males and 300 females, stone size: 7-22 mm. Pyuria in 132/846 with clinical infection 40/132, pre-SWL JJ stenting: 40/846 and anesthesia in 41/846 patients. Duration of symptoms: <4 weeks- 780/846, >4 weeks- 66/846. Stone size: <1 cm- 513/846, >1 cm-333/846. Workup: X-Ray KUB, Urine and Uro-USG. Intravenous urogram (IVU): 130/846. Intraoperative (C-arm) fluoroscopic imaging was used. Presentation: colic-801/846, incidental-45/846. Criteria for clearance: symptomatic relief, X-ray and USG confirmation. Results: Clearance rate: <1cm- 95.91% (492/513), >1 cm- 85.29% (284/333). Overall clearance rate: 91.73% (776/846). No clearance: 70/846 (8.27 %). In these, 59/70 underwent ureteroscopy, 8/70 percutaneous nephrolithotomy and 3/70 open ureterolithotomy for clearance. Post SWL complications were seen in 25 (3%) cases with septicemia in nine and stein strasse in 16 cases. Duration of symptoms <4 weeks - 93.7% success (731/780), >4 weeks - 68.1% (45/66). Non-stented - 92% (744/806) success. Stented group-80% (32/40). Conclusions: Best results with SWL as monotherapy for upper ureteric stones are achieved when stones are less than 1 cm in size, of short duration history and without indwelling stents. Overall success rate - 91.73%.
  9,076 185 2
CASE REPORTS
Cystitis glandularis forming a tumorous lesion in the urinary bladder: A rare appearance of disease
Kazuyoshi Shigehara, Tohru Miyagi, Takao Nakashima, Masayoshi Shimamura
October-December 2008, 24(4):558-560
DOI:10.4103/0970-1591.44268  PMID:19468518
We report a rare appearance of cystitis glandularis forming a tumorous lesion with blueberry spots in the urinary bladder. A 49-year-old woman was admitted to our hospital with pollakisuria and recurrent gross hematuria. Urine examination showed no pyuria. Computed tomography (CT) scan showed an extravesical invasive mass and cystoscopy revealed a non-papillary tumor with blueberry spots in the bladder. Transurethral resection (TUR) was performed. Histopathological examination revealed cystitis glandularis with cystitis cystica in the part. Postoperative CT scan and cystoscopy showed reduction of the mass in the bladder without any treatments. She is currently well with no evidence of tumor growth three months after TUR.
  9,023 198 2
UROSCAN
Survival following primary androgen deprivation therapy among men with localized prostate cancer
Pawan Vasudeva, Apul Goel, Divakar Dalela
October-December 2008, 24(4):590-591
PMID:19468528
  9,103 109 -
POINT-COUNTER-POINT
Endoscopic management is the preferred "treatment" modality for grade III vesicoureteric reflux with breakthrough infections in a young girl
RB Nerli
October-December 2008, 24(4):475-477
DOI:10.4103/0970-1591.44250  PMID:19468499
Endoscopic subureteric injection of tissue-augmenting substances has become an alternative to long-term antibiotic prophylaxis and open surgery, in the treatment of children with vesicoureteric reflux (VUR). Successful elimination of reflux in about 80% of patients after a single injection (and in 90% after a repeat) has been achieved using non-degradable substances. young girl with grade III VUR and breakthrough infections would definitely need to undergo antireflux procedure. Endoscopic treatment would be an ideal procedure as it is a one-day surgery, with over 80% success rate, low morbidity and no long-term complications. Moreover, this form of surgery is appealing to, as well as the choice of the majority of parents.
  8,814 181 2
CASE REPORTS
Ureteric valve: Case report with an insight into anatomy, embryology, presentation and management
Rahul K Gupta, SS Borwankar, Sandesh V Parelkar
October-December 2008, 24(4):561-563
DOI:10.4103/0970-1591.44269  PMID:19468519
Congenital ureteric obstruction caused by a ureteric valve is an exceedingly rare entity. Our patient, a nine-year-old male, had undergone evaluation for recurrent pain in the abdomen and was diagnosed as a case of left hydronephrosis on ultrasound abdomen. Intravenous urography and magnetic resonance urography showed incomplete duplex system on the right side along with left hydronephrosis and hydroureter. Cystoscopy with left ascending gram followed by excision of lower third of ureter along with valve and Cohen's ureteroneocystostomy was done. Histopathology revealed Type II ureteric valve. A high index of suspicion is required to make a correct preoperative diagnosis.
  8,799 142 1
LETTER TO EDITOR
Impaired detrusor contractility due to venlafaxine use
J Torgovnick, NK Sethi, PK Sethi, E Arsura
October-December 2008, 24(4):581-582
DOI:10.4103/0970-1591.44276  PMID:19468526
  8,434 96 -
UROSCAN
Intravesical real-time imaging and staging of bladder cancer: Use of optical coherence tomography
Vengetesh K Sengottayan, Pawan Vasudeva, Divakar Dalela
October-December 2008, 24(4):592-593
PMID:19468530
  8,313 160 2
Is lap nephrectomy superior to open? A randomized trial
Anup Kumar, Rajeev Kumar
October-December 2008, 24(4):591-592
PMID:19468529
  7,950 125 -
SYMPOSIUM
Ureteroscopic management of upper tract transitional cell carcinoma and ureteropelvic obstruction
Sebastien Crouzet, Andre Berger, Manoj Monga, Mihir Desai
October-December 2008, 24(4):526-531
DOI:10.4103/0970-1591.44262  PMID:19468512
Introduction: Technological advances have increased the application of the endoscopic management of upper tract transitional cell carcinoma (TCC) and ureteropelvic junction obstruction (UPJO). Materials and Methods: Published, peer-reviewed articles on endoscopic treatment of upper tract TCC and UPJO were identified using the MEDLINE database. Results: Although nephroureterectomy remains the gold standard for upper tract TCC treatment, low-grade, low-stage and small tumors, especially in patients with solitary kidneys or poor renal function can be managed with encouraging success rates, despite the considerable recurrence rate. Endoscopic alternatives to pyeloplasty for UPJO can be used especially in cases with absence of crossing vessels, stricture length less than 1.5 cm, severe hydronephrosis and renal function less than 30%. Conclusion: Proper patient selection is critical for the successful endoscopic management of treatment of upper tract TCC and UPJO.
  7,776 200 -
EDITORIAL
Published evidence: How good?
Nitin S Kekre
October-December 2008, 24(4):433-433
DOI:10.4103/0970-1591.44243  PMID:19468491
  7,795 155 -
ORIGINAL ARTICLES
Histopathological analysis of T1 renal cell carcinoma: Does presentation matter?
Gaurav Gupta, Samiran Das Adhikary, Santosh Kumar, Ninan K Chacko, Nitin S Kekre, Ganesh Gopalakrishnan
October-December 2008, 24(4):504-507
DOI:10.4103/0970-1591.44257  PMID:19468506
Objectives: To study the differences in the clinico-pathological features of incidental and symptomatic T1 renal cell carcinoma (RCC) and to see, particularly in T1b RCC, if symptomatic presentation has adverse pathological features concerning the oncological safety of elective nephron-sparing surgery (NSS) in this subgroup. Materials and Methods: Of 278 patients who underwent radical nephrectomy for RCC from January 1995 to January 2005, 70 had tumor size up to 7 cm (T1). They were categorized as incidental or symptomatic and as T1a or T1b tumors. Clinico-pathological features were compared between incidental (IRCC) and symptomatic (SRCC) groups. Tumors were analyzed using the 1997 TNM staging and Fuhrman's grade. Results: Of the 70 with T1 tumors, 24 had T1a (IRCC, 12 and SRCC, 12) and 46 had T1b tumors (IRCC, 27 and SRCC, 19). Clear cell was the commonest histology. In T1a cancers, though no significant difference in histopathological pattern and grade was seen between the incidental and symptomatic groups, symptomatic tumors had more papillary, mixed histopathological pattern and higher nuclear grade. Among T1b tumors, 14 had papillary and mixed histology, 12 (86%) of which were symptomatic (P= <0.0001). In T1b, 15 (79%) symptomatic had higher nuclear grade (G2-3) while 22 (81%) incidental had lower Fuhrman's grade (P= <0.0001). Conclusion: Symptomatic T1b RCCs had higher nuclear grade and papillary histology. This difference was statistically significant. This may be relevant when considering elective NSS in symptomatic T1b disease.
  7,460 165 2
SYMPOSIUM
Lower pole calculi larger than one centimeter: Retrograde intrarenal surgery
Andreas J Gross, Thorsten Bach
October-December 2008, 24(4):551-554
DOI:10.4103/0970-1591.44266  PMID:19468516
Controversy remains on how to treat lower pole calculi between 1 and 2 cm of size. Treatment options like shock wave lithotripsy (SWL) or percutaneous stone treatment (PCNL) are associated with poor stone-free rates or high morbidity. Due to the ongoing development in endourologic technology, especially in flexible renoscopy, laser technique and grasping devices (tipless Nitinol baskets) retrograde intrarenal surgery (RIRS) has become an option in treating these patients. Based on personal experience and an overview of the published literature we discuss RIRS as a valuable alternative to PCNL in treating patients with larger calculi of the lower pole. The technical developments in laser technology as well as significant improvement in flexible renoscopes have made RIRS for larger lower pole stones possible. The low complication rate gives RIRS for lower pole stones superiority over the invasive percutaneous approach, which is associated with significant morbidity, even in experienced hands.
  7,267 280 2
LEGENDS IN UROLOGY
Hattangadi Shashidhar Bhat - "Guru"
Ganesh Gopalakrishnan
October-December 2008, 24(4):434-436
DOI:10.4103/0970-1591.44244  PMID:19468492
  6,647 215 -
EVIDENCE BASED UROLOGY
Is laparoscopic approach safe for radical nephrectomy for tumors larger than 7 cm?
Paresh Jain, Anil Mandhani
October-December 2008, 24(4):579-580
DOI:10.4103/0970-1591.44275  PMID:19468525
  6,210 125 -
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