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   2011| October-December  | Volume 27 | Issue 4  
    Online since January 4, 2012

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Dysfunctional voiding: A review of the terminology, presentation, evaluation and management in children and adults
Sanjay Sinha
October-December 2011, 27(4):437-447
DOI:10.4103/0970-1591.91429  PMID:22279306
Dysfunctional voiding (DV) is a voiding disorder characterized by dyssynergic striated sphincteric activity in the absence of a proven neurological etiology. It can present at any age with a spectrum of storage and voiding symptoms that may resemble florid neurogenic bladder. There is a striking lack of clarity regarding what this entity represents, the diagnostic methodology and treatment. The limitations of existing guideline documents are analyzed. Specifically, use of the term "habitual", the assumption that bladder changes are secondary to the outlet, the emphasis on "staccato" voiding and the implication of striated urethral sphincter are discussed. Literature shows that DV may also present with continuous slow flow or normal flow. Dyssynergia may be at the level of the striated urethral sphincter, the pelvic floor or both, better termed "striated urethral sphincter-pelvic floor complex" (SUS-PFC).A diagnostic algorithm is provided so that patients are evaluated on merit rather than on the basis of different philosophies of individual centers. High-risk markers such as hydronephrosis, vesicoureteral reflux, renal failure or marked voiding difficulty should prompt a formal urodynamics evaluation and imaging for neurological etiology. Patients with predominantly storage symptoms with incidental staccato voiding can be managed initially, on the basis of non-invasive evaluation. Conservative urotherapy including biofeedback is appropriate initial management for patients without high risk factors. Treatment and evaluation should be escalated based on response. Patients with severe DV will need treatment similar to neurogenic bladder including clean intermittent catheterization and measures to control storage pressures.
  7 9,729 665
Oxidative and antioxidative defense system in testicular torsion/detorsion
FA Elshaari, RI Elfagih, DS Sheriff, IF Barassi
October-December 2011, 27(4):479-484
DOI:10.4103/0970-1591.91436  PMID:22279313
Aim: The present study was aimed to assess the early effects of ischemia/reperfusion injury on the oxidants and anti-oxidant defense status in rat testicular tissue by measuring MDA, glucose-6-phosphte dehydrogenase activity and reduced glutathione levels in a designated time frame sequel to reperfusion. Animals were divided randomly into six groups (12 animals per group) in the following order: Group I: Sham-operated control group (Cso) without the application of the torsion. Group 2: Torsion-induced ischemia group (T30 m): Ischemia was induced through the torsion of spermatic cord for a period of 30 min. Group 3: One hour reperfusion group after detorsion (T30 mR1 h). Group 4: Twenty-four hour reperfusion group after detorsion (T30 mR24 h). Group 5: Forty-eight hours reperfusion group after detorsion (T30mR48h). Group 6: One week reperfusion group after detorsion (T30mR1wk). Results and Discussion: The oxidant-antioxidant system of the testicular tissue is altered during torsion as well as detorsion which results in the altered activities involved in the key enzyme of hexose monophosphate shunt pathway, glucose 6 phosphate dehydrogenase activity along with a reduction of glutathione (G.SH) content. The increase in G6PDH activity during torsion and followed by an increase in detorsion indicates the tissue's response to counter the oxidant stress caused by reduced blood supply. Continued exposure to such oxidant stressed physiological state of a tissue may lead to decreased capacity of the tissue to perform its physiological function such as testicular steroidogenesis and spermiogenesis shown in the present study.
  6 3,455 57
Laparoscopic reconstruction of iatrogenic-induced lower ureteric strictures: Does timing of repair influence the outcome?
George P Abraham, Krishanu Das, Krishnamohan Ramaswami, Datson P George, Jisha J Abraham, Thomas Thachil
October-December 2011, 27(4):465-469
DOI:10.4103/0970-1591.91433  PMID:22279310
Context: Influence of timing of repair on outcome following laparoscopic reconstruction of lower ureteric strictures Aims: To assess the influence of timing of repair on outcome following laparoscopic reconstruction of lower ureteric strictures in our adult patient population. Settings and Design: Single surgeon operative experience in two institutes. Retrospective analysis. Materials and Methods: All patients were worked up in detail. All patients underwent cystoscopy and retrograde pyelography prior to laparoscopic approach. Patients were categorised into two groups: early repair (within seven days of inciting event) and delayed repair (after two weeks). Operative parameters and postoperative events were recorded. Postprocedure all patients were evaluated three monthly. Follow-up imaging was ordered at six months postoperatively. Improvement in renal function, resolution of hydronephrosis and unhindered drainage of contrast through the reconstructed unit on follow-up imaging was interpreted as a satisfactory outcome. Statistical Analysis Used: Mean, standard deviation, equal variance t test, Mann Whitney Z test, Aspin-Welch unequal variance t test. Results: Thirty-six patients (37 units, 36 unilateral and 1 simultaneous bilateral) underwent laparoscopic ureteral reconstruction of lower ureteric stricture following iatrogenic injury - 21 early repair (Group I) and 15 delayed repair (Group II). All patients were hemodynamically stable at presentation. Early repair was more technically demanding with increased operation duration. There was no difference in blood loss, operative complications, postoperative parameters, or longterm outcome. Conclusions: In hemodynamically stable patients, laparoscopic repair of iatrogenically induced lower ureteric strictures can be conveniently undertaken without undue delay from the inciting event. Compared to delayed repairs, the procedure is technically more demanding but morbidity incurred and outcome is at par.
  3 3,266 74
Comparative performance of high-fidelity training models for flexible ureteroscopy: Are all models effective?
Shashikant Mishra, Rajan Sharma, Akhilesh Kumar, Pradeep Ganatra, Ravindra B Sabnis, Mahesh R Desai
October-December 2011, 27(4):451-456
DOI:10.4103/0970-1591.91431  PMID:22279308
Objective: We performed a comparative study of high-fidelity training models for flexible ureteroscopy (URS). Our objective was to determine whether high-fidelity non-virtual reality (VR) models are as effective as the VR model in teaching flexible URS skills. Materials and Methods: Twenty-one trained urologists without clinical experience of flexible URS underwent dry lab simulation practice. After a warm-up period of 2 h, tasks were performed on a high-fidelity non-VR (Uro-scopic Trainer TM ; Endo-Urologie-Modell TM ) and a high-fidelity VR model (URO Mentor TM ). The participants were divided equally into three batches with rotation on each of the three stations for 30 min. Performance of the trainees was evaluated by an expert ureteroscopist using pass rating and global rating score (GRS). The participants rated a face validity questionnaire at the end of each session. Results: The GRS improved statistically at evaluation performed after second rotation (P<0.001 for batches 1, 2 and 3). Pass ratings also improved significantly for all training models when the third and first rotations were compared (P<0.05). The batch that was trained on the VR-based model had more improvement on pass ratings on second rotation but could not achieve statistical significance. Most of the realistic domains were higher for a VR model as compared with the non-VR model, except the realism of the flexible endoscope. Conclusions: All the models used for training flexible URS were effective in increasing the GRS and pass ratings irrespective of the VR status.
  3 3,608 74
Evidence for the future - Designing a clinical trial
Sakineh Hajebrahimi, Ali Mostafaie, Homayoun Sadeghi-Bazargani
October-December 2011, 27(4):494-497
DOI:10.4103/0970-1591.91440  PMID:22279317
The quality of the evidence is a keystone in the understanding of Evidence Based Medicine. Randomized controlled trials (RCTs) rank first among the research designs providing clinical evidence. Knowing about the design of clinical trials is not only the cornerstone of clinical research, but also is a requirement for any clinician who wants to learn about new findings of clinical research in his/her field. Many clinicians have good understanding as well as some misunderstandings about the design of clinical trials. This article is going to provide some crucial comments to be considered in conducting RCTs in order to help in production of better evidence for future of urology research through RCTs
  3 2,583 103
Actinomycosis in urachal remnants: A rare cause of pseudotumor
V Chaitra, T Rajalakshmi, Suravi Mohanty, NK Lahoti, Arun George, Jyothi Idiculla
October-December 2011, 27(4):545-546
DOI:10.4103/0970-1591.91450  PMID:22279327
Actinomycosis is a chronic inflammatory condition caused by Actinomyces israeli, a gram positive anaerobic bacterium. It can have a variety of clinical manifestations and can mimic a malignancy. We present one such case of urachal actinomycosis that mimicked a tumor. A 28-year-old man presented with abdominal pain of 20 days duration. Per abdominal palpation revealed a firm mass with ill-defined borders in the suprapubic region. Computed tomography and magnetic resonance imaging scans of the pelvis showed an irregular lesion in the urinary bladder extending to the umbilicus, giving the impression of urachal remnants with inflammation. Peroperatively, an irregular, hard mass measuring 6 x 5 cm, involving the anterior and posterior bladder walls, the appendix, the terminal ileum and sigmoid colon, was seen, which was suspicious for a malignancy. Frozen sections from the mass showed extensive inflammation and a florid fibroblastic proliferation, giving the impression of an inflammatory pseudotumor. The tissue was extensively sampled for paraffin sections and only one of them revealed a colony of Gram, PAS and GMS- positive organisms, conclusive for Actinomycosis. It is important to be aware of this uncommon, yet significant, presentation of a common infectious disease in order to avoid misdiagnosis and over-treatment as a malignancy.
  2 3,078 42
Iatrogenic urethrovaginal fistula with transverse vaginal septum presenting as cyclical hematuria
Abha Singh, Manisha Kumar, Sumedha Sharma
October-December 2011, 27(4):547-549
DOI:10.4103/0970-1591.91451  PMID:22279328
We present a case of iatrogenic urethrovaginal fistula with transverse vaginal septum. The patient presented with cyclical hematuria and infertility. The vagina was blind-ending. The magnetic resonance imaging (MRI) showed normal uterus with transverse vaginal septum. The cystoscopic examination during cyclical hematuria revealed bloody efflux through a small fistula below the internal urethral sphincter. Vaginoplasty and repair of the urethrovaginal fistula was done. The vagina was reconstructed using an amniotic mould. The report emphasizes the importance of MRI and cystoscopy in diagnosing such rare and complex anomalies.
  2 5,303 43
History of evidence-based medicine
Roger L Sur, Philipp Dahm
October-December 2011, 27(4):487-489
DOI:10.4103/0970-1591.91438  PMID:22279315
This essay reviews the historical circumstances surrounding the introduction and evolution of evidence-based medicine. Criticisms of the approach are also considered. Weaknesses of existing standards of clinical practice and efforts to bring more certainty to clinical decision making were the foundation for evidence-based medicine, which integrates epidemiology and medical research. Because of its utility in designing randomized clinical trials, assessing the quality of the literature, and applying medical research at the bedside, evidence-based medicine will continue to have a strong influence on everyday clinical practice.
  2 7,950 123
How to teach evidence-based medicine to urologists
Sakineh Hajebrahimi, Ali Mostafaie
October-December 2011, 27(4):490-493
DOI:10.4103/0970-1591.91439  PMID:22279316
The goal of this article is to help develop, disseminate, and evaluate resources that can be used to practice and teach EBM for urology residents and continuing education of urologists to reduce the gap between research and clinical practice. Urology departments should build capacity for residents to shape the future of quality and safety in healthcare through translating evidence into practice. Cutting edge approaches require knowing how to teach Evidence-based urology, to make Bio-statistics easy to understanding and how to lead improvement at every level. The authors shared their experience about 'what works' in a surgical department to building an Evidence-based environment and high quality of cares.
  2 3,059 108
Primary extranodal marginal zone lymphoma - Epididymis
Shanmugasundaram Rajaian, Marie Therese Manipadam, Sheila Nair, Nitin S Kekre
October-December 2011, 27(4):553-555
DOI:10.4103/0970-1591.91453  PMID:22279330
An elderly male presented with painful swelling in the right side of scrotum. He was treated with antibiotics for epididymoorchitis without any response. Ultrasound examination revealed a hypoechoic vascular mass in the tail of the epididymis. Fine needle aspirate cytology was inconclusive. Excision of the mass was done and biopsy revealed primary extranodal marginal zone lymphoma arising from mucosa associated lymphoid tissue (MALT) of epididymis. Marginal zone lymphoma arising from the MALT of epididymis is very rare. Lymphoma should be considered as a differential diagnosis of any epididymal swelling unresponsive to conservative treatment. We report a rare case of primary extranodal marginal lymphoma of MALT arising from epididymis.
  1 2,998 49
Laparoscopic versus open nephrectomy for xanthogranulomatous pyelonephritis: An outcome analysis
Kartik J Shah, Arvind P Ganpule, Abraham Kurien, Veeramani Muthu, Ravindra B Sabnis, Mahesh R Desai
October-December 2011, 27(4):470-474
DOI:10.4103/0970-1591.91434  PMID:22279311
Context: Current literature suggests that laparoscopic nephrectomy (LN) in patients with xanthogranulomatous pyelonephritis (XGP) is associated with high conversion and complication rate. Aims: To report contemporary outcome of patients with XGP, managed with either open nephrectomy (ON) or LN. Settings and Design: In this retrospective study, medical records of 37 patients with histopathologically confirmed XGP from January 2001 to October 2009 were reviewed. Materials and Methods: The clinical presentation, preoperative course, intraoperative findings, postoperative recovery and complications in ON and LN were analyzed. Statistical Analysis: Student's t test was used to perform statistical comparison between the LN and ON groups. Values are expressed as mean ΁ standard deviation. Results: In 37 patients, 20 underwent ON and 17 underwent LN. One patient in the LN group required conversion. He had ectopic pelvic kidney, and the vascular pedicle could not be identified because of dense adhesions. There were no intraoperative complications. The mean blood loss was 257.5 ΁ 156.67 ml and 141.18 ΁ 92.26 ml in ON and LN groups, respectively. Mean hospital stay was 15.45 ΁ 7.35 days and 9.71 ΁ 4.55 days in ON and LN groups, respectively. Postoperative complications were classified according to Clavien grading for surgical complications. Grade 2 complications were seen in 40% and 29.4% of patients in ON and LN groups, respectively. One patient in LN required secondary suturing of specimen retrieval site. Conclusions: LN in patients with XGP is often challenging and requires considerable experience in laparoscopy. In properly selected patients, all benefits of minimally invasive surgery can be availed with LN.
  1 3,531 65
Sample size matters: A guide for urologists
Peter Hinh, Steven E Canfield
October-December 2011, 27(4):503-507
DOI:10.4103/0970-1591.91442  PMID:22279319
Understanding sample size calculation is vitally important for planning and conducting clinical research, and critically appraising literature. The purpose of this paper is to present basic statistical concepts and tenets of study design pertaining to calculation of requisite sample size. This paper also discusses the significance of sample size calculation in the context of ethical considerations. Scenarios applicable to urology are utilized in presenting concepts.
  1 3,159 138
Appraisal and use of a prognostic study from the urological literature
Mark Preston, Dean A Fergusson, Rodney H Breau
October-December 2011, 27(4):508-512
DOI:10.4103/0970-1591.91443  PMID:22279320
Information about prognosis can be applied to research design and is essential for patient care and counseling. Prognostic study data is only useful if it is valid, transparent, and applicable to your patient. Using a clinical scenario and a relevant study from the urological literature, we outline a method to appraise a prognostic article, understand the results, and manage patients accordingly.
  1 2,556 84
Understanding results: P-values, confidence intervals, and number need to treat
Lawrence Flechner, Timothy Y Tseng
October-December 2011, 27(4):532-535
DOI:10.4103/0970-1591.91447  PMID:22279324
Objectives: With the increasing emphasis on evidence-based medicine, the urology literature has seen a rapid growth in the number of high-quality randomized controlled trials along with increased statistical rigor in the reporting of study results. P-values, CI, and number needed to treat (NNT) are becoming increasingly common in the literature. This paper seeks to familiarize the reader with statistical measures commonly used in the evidence-based literature. Materials and Methods: The meaning and appropriate interpretation of these statistical measures is reviewed through the use of a clinical scenario. Results: The reader will be better able to understand such statistical measures and apply them to the critical appraisal of the literature. Conclusions: P-values, CI, and NNT each provide a slightly different estimate of statistical truth. Together, they provide a more complete picture of the true effect observed in a study. An understanding of these measures is essential to the critical appraisal of study results in evidence-based medicine.
  1 3,702 163
Jackstone: A rare entity of vesical calculus
Kamal Jeet Singh, Anuj Tiwari, Adarsh Goyal
October-December 2011, 27(4):543-544
DOI:10.4103/0970-1591.91449  PMID:22279326
Jackstone calculi are urinary tract stones that have a specific appearance resembling toy jacks. They are almost always composed of calcium oxalate dihydrate consist of a dense central core and radiating spicules. They are usually light brown with dark patches and are usually described to occur in the urinary bladder and rarely in the upper urinary tract. Their appearance on plain radiographs and computed tomography in human patients has been described.
  - 5,980 106
Palliation of dysphagia with radiotherapy for exophytic base tongue metastases in a case of renal cell carcinoma
Tabassum Wadasadawala, Prabhash Kumar, Jaiprakash Agarwal, Sarbani Ghosh-Laskar
October-December 2011, 27(4):550-552
DOI:10.4103/0970-1591.91452  PMID:22279329
Base tongue involvement is a rare presentation of lingual metastases from renal cell carcinoma. A 48-year-old gentleman was treated with open radical nephrectomy and adjuvant radiotherapy for Stage II Furhman grade I clear cell carcinoma of the left kidney at an outside hospital. He presented metachronously 5 years later with progressive dysphagia and change of voice. Clinicoradiological evaluation revealed a large exophytic mass in the oropharynx with epicenter in the right base of tongue. Metastatic workup revealed widespread dissemination to multiple organs and bone. In view of predominant symptom of dysphagia, base tongue metastasis was treated with protracted course of palliative radiotherapy to a dose of 50 Gy in conventional fractionation over 5 weeks. This resulted in excellent and durable response at the base tongue lesion (till the time of last follow-up). Radiation therapy is an acceptable palliative strategy for advanced lingual metastasis as it produces prompt relief of pain, bleeding, and dysphagia.
  - 3,432 29
Evidence-based urology: Overrated or need of the hour
Nitin S Kekre
October-December 2011, 27(4):435-436
DOI:10.4103/0970-1591.91428  PMID:22279305
  - 2,588 107
Laparoscopic reconstruction for dual extrinsic pathologies compressing the upper ureter: The nutcracker ureteric compression
George P Abraham, Krishanu Das, Krishnamohan Ramaswami, P Datson George, Jisha J Abraham, Thomas Thachil, Oppukeril S Thampan
October-December 2011, 27(4):558-559
DOI:10.4103/0970-1591.91455  PMID:22279332
  - 1,852 40
'Medial Pyelolymphatic Disconnection with preservation of peripheral lymphatics': A new concept in the surgical management of recurrent chyluria
Saurabh Sudhir Chipde, Anil Mandhani
October-December 2011, 27(4):559-560
DOI:10.4103/0970-1591.91456  PMID:22279333
  - 1,855 91
Laparoscopic partial nephrectomy for large renal mass: No tissue sealant, no bolster technique
George P Abraham, Krishanu Das, Krishnamohan Ramaswami, P Datson George, Jisha J Abraham, Thomas Thachil, Oppukeril S Thampan
October-December 2011, 27(4):560-561
DOI:10.4103/0970-1591.91457  PMID:22279334
  - 1,951 32
Melanoma of the female urethra
Juan A Ramos, Wilmer E Ramos, Claudia V Ramos
October-December 2011, 27(4):448-450
DOI:10.4103/0970-1591.91430  PMID:22279307
Melanoma is a malignant tumor that can affect any area of the anatomical economy. Its appearance in the female urethra is extremely rare, with approximately 121 cases in indexed literature since 1966. The subject to be described is an 86-year-old woman who seeks assessment for intermittent macroscopic hematuria with blood clots of 3 months progression. On physical examination, there are no suspicious lesions detected on the surface of the skin. On external genital examination, it is observed a friable lesion at the level of the urethral meatus, with heterogeneous digitations, dark brown to black, and irregular polycyclic borders. No inguinal adenomegalies were palpated. Cystourethroscopy and biopsy of the lesion confirm the diagnosis. Melanoma of the female urethra is an extremely infrequent pathology. Due to lack of published case reports and the absence of prospective randomized trials on treatment outcomes, treatment must be directed using the same anatomical and surgical criteria for female urethral tumors, adding also the concepts of treatment of mucosal melanoma, even though its prognosis is different from the before mentioned.
  - 3,201 87
Penile block for paediatric urological surgery: A comparative evaluation with general anaesthesia
Aparajita Panda, Sukhminder Jit Singh Bajwa, Subroto Sen, SS Parmar
October-December 2011, 27(4):457-464
DOI:10.4103/0970-1591.91432  PMID:22279309
Aim: Peri-operative pain relief in children can be provided by conventional general anaesthesia or by regional nerve blocks. The present study was carried out to evaluate and compare the effectiveness of penile block for penile surgery with the standard technique of general anaesthesia (GA) of short duration of less than two hours, and also to evaluate the postoperative pain relief obtained by penile block. Materials and Methods: The study was carried out in the department of Anaesthesiology and Intensive care of our hospital, on 60 children in the age group of 1-10 years, belonging to American Society of Anesthesiologists (ASA) grades I and II, and divided randomly into two groups: Group B and group G, comprising of 30 patients each. Group B children received a penile block whereas group G children underwent a standard general anaesthetic procedure. Baseline, intra-operative and post-operative heart rate (HR), electrocardiogram (ECG), non-invasive blood pressure (NIBP) (systolic and diastolic) and pulse oximeter oxygen saturation (SpO2 ) were recorded at regular intervals. The duration of post-operative pain relief, time to rescue analgesia and time to first feed were also evaluated and recorded. Statistical analysis was carried out using statistical package for social sciences (SPSS) 11 version for windows and employing analysis of variance (ANOVA), unpaired student t test, Chi-square test and Mann Whitney U test for various parameters. Value of P<0.05 was considered as significant and P<0.0001 as highly significant. Results: The demographic characteristics were comparable in both the groups. Heart rate, systolic blood pressure, diastolic blood pressure and pulse oximetry showed remarkable differences at various time intervals during intra-operative and post-operative period, which were statistically significant on comparison (P<0.05 and P<0.0001). Post-operative pain relief, time to first rescue analgesia and time to first feed also showed statistically significant differences. Conclusions: Penile block is very effective when used along with light sedation for distal penile surgeries of less than 2 hours duration as compared to standard GA as reflected by more stable haemodynamics in peri-operative period, excellent pain relief extending up to 6-8 hrs postoperatively and absence of any significant complications or side effects.
  - 4,398 96
Sutureless circumcision - An Indian experience
Punit Tiwari, Astha Tiwari, Suresh Kumar, Rajkumar Patil, Amit Goel, Pramod Sharma, Anup K Kundu
October-December 2011, 27(4):475-478
DOI:10.4103/0970-1591.91435  PMID:22279312
Context: Traditionally, circumcision wounds are closed by absorbable sutures. However, certain alternative methods are also being utilized to overcome the shortcomings of the conventionally used method for circumcision wound closuring. In the current study, the use of tissue glue ((iso amyl 2-cyanoacrylate) has been compared with traditional suturing for the approximation of circumcision wounds. In our study, both the methods were found to be comparable with significantly less time consumed in glue group. Aims: The purpose of the present study has been to compare directly cyanoacrylate as a better alternative to conventional suture material in terms of cosmetic result, time consumed and incidence of infection (comparative study). Materials and Methods: The results of all the patients seen in outpatient department for circumcision were included in this study. The study was conducted from Aug 2009 to May 2010. The tissue glue (iso amyl 2-cyanoacrylate) was compared to sutures as a method of wound approximation in circumcision. Results: Tissue glue group has been observed to have less wound inflammation, bleeding or hematoma rate and was cosmetically superior as compared to suture group; however, none of these findings could reach statistically significant level. The mean time taken for circumcision was 14.2 min (SD 2.42), when tissue glue was used for wound approximation. However, it was 24.4 min (SD 5.06) in case of the use of sutures. This difference was found as highly significant (P value < 0.001). However, regarding postoperative pain no significant reduction was observed when glue was used. Conclusions: This study showed that the use of tissue glue in comparison to sutures is having the following advantages:
  1. Cosmetically superior
  2. Less time consuming
All other parameters measured were nearly the same and statically insignificant.
  - 18,912 204
How to appraise a diagnostic test
Ramanitharan Manikandan, Lalgudi N Dorairajan
October-December 2011, 27(4):513-519
DOI:10.4103/0970-1591.91444  PMID:22279321
Urologists frequently encounter problems in making a clinical diagnosis whose resolution requires the use of diagnostic tests. With an ever increasing choice of investigations being available, the urologist often has to decide which diagnostic test(s) will best resolve the patient's diagnostic problem. In this article, we aim to help the urologist understand how to critically appraise studies on diagnostic tests and make a rational choice. This article presents the guiding principles in scientifically assessing studies on diagnostic tests by proposing a clinical scenario. The authors describe a standardized protocol to assess the validity of the test and its relevance to the clinical problem that can help the urologist in decision making. The three important issues to be considered when evaluating the validity of the study are to identify how the study population was chosen, how the test was performed and whether there is a comparison to the gold standard test so as to confirm or refute the diagnosis. Then, the urologist would need to know the probability of the test in providing the correct diagnosis in an individual patient in order to decide about its utility in solving the diagnostic dilemma. By performing the steps described in this article, the urologist would be able to critically appraise diagnostic studies and draw meaningful conclusions about the investigations in terms of validity, results and its applicability to the patient's problem. This would provide a scientific basis for using diagnostic tests for improving patient care.
  - 3,970 124
Role of systematic reviews and meta-analysis in evidence-based clinical practice
Erin R McNamara, Charles D Scales
October-December 2011, 27(4):520-524
DOI:10.4103/0970-1591.91445  PMID:22279322
Introduction: Systematic reviews and meta-analyses of well-designed and executed randomized controlled trials have the potential to provide the highest levels of evidence to support diagnostic and therapeutic interventions in urology. Materials and Methods: The role of systematic reviews in the urological literature is described. A three-step appraisal of the validity, magnitude and applicability of results will permit an evidence-based approach to incorporating findings of systematic reviews and meta-analyses into practice. Results: The validity of systematic reviews depends on a focused clinical question that generates specific inclusion and exclusion criteria for identifying studies through an exhaustive literature search. The primary studies must be of high methodological quality and assessments should be reproducible. Informed consumers of the urological literature should be aware of the consistency of results between trials in a review, as well as the magnitude and precision of the best estimate of the treatment effects. When making decisions about implementing the results, urologists should consider all patient-important outcomes, the overall quality of the evidence and the balance between benefits, potential harms and costs. Conclusion: This framework will lead to a more evidence-based application of systematic reviews within the urological literature. Ideally, utilization of an evidence-based approach to systematic reviews will improve the quality of urological patient care.
  - 2,883 112
How to appraise the effectiveness of treatment
Suzanne B Stewart, Phillip Dahm, Charles D Scales
October-December 2011, 27(4):525-531
DOI:10.4103/0970-1591.91446  PMID:22279323
Introduction: Advances in treatment and disease prevention occur frequently in urology. Urologists must identify a framework within which to evaluate these therapeutic innovations. Materials and Methods: The evidence-based approach to critical appraisal is described using an example from the urological literature. A three-part assessment of the trial validity, treatment effect, and applicability of results will permit the urologist to critically incorporate medical and surgical advances into practice. Results: Validity of clinical trials hinges upon balancing patient prognosis at the initiation, execution, and conclusion of the trial. Readers should be aware of not only the magnitude of the estimated treatment effect, but also its precision. Finally, urologists should consider all patient-important outcomes as well as the balance of potential benefits, harms, and costs, and patient values and preferences when making treatment decisions. Conclusion: Use of this framework for critical appraisal will lead to a more evidence-based application of new therapies for patients. Incorporation of a more evidence-based practice within urology will lead to an increase in the quality of patient care.
  - 2,857 98
How to critically appraise a clinical practice guideline
Adrian B Clubb, Philipp Dahm
October-December 2011, 27(4):498-502
DOI:10.4103/0970-1591.91441  PMID:22279318
Purpose: Clinical practice guidelines play a critical role in guiding the evidence-based clinical practice of urology. We describe a systematic approach to critical appraisal of urology guidelines. Materials and Methods: Based on a focused clinical question derived from a clinical scenario, we identified a relevant clinical practice guideline that we critically appraised using the Users' Guide to the Medical Literature framework as to whether the results are valid, what are the results, and can they be applied to the care of an individual patient. Results: A clinical practice guideline by the National Institute for Clinical Excellence on the use of sunitinib as the first line treatment for patients with metastatic renal cell carcinoma was identified. The guideline development process was found to be appropriately rigorous and included an explicit rating of the quality of evidence. The recommendations were clearly stated and appeared applicable to the specific patient in the clinical scenario. Conclusions: Clinical practice guidelines should be developed using rigorous evidence-based methodology. Urologists should have the skills and knowledge to critically appraise a guideline before applying it to the care of their patients.
  - 4,015 97
What should urologists know about evidence-based medicine?
Jan W Mazel, Rudolf W Poolman
October-December 2011, 27(4):536-542
DOI:10.4103/0970-1591.91448  PMID:22279325
Objectives: This article outlines the basic principles of evidence-based medicine (EBM) and provides urologists with some tools to further explore, understand, and work with EBM. Materials and Methods: A narrative review was conducted illustrating several aspects of EBM. Results: Based on the definition of EBM, the aspects of evidence are clarified and a systematic approach is presented for integrating the evidence with individual patient values and circumstances. Next, sources for finding the best evidence are described and misconceptions about EBM are corrected. Finally, the current state of EBM in urology is discussed. Conclusions: It is clear that EBM will have an increasing relevance for urologists. Therefore, it is essential that all urologists have an understanding of the fundamental principles of EBM.
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Another milestone toward a more evidence-based practice of urology
J Chandra Singh, Philipp Dahm
October-December 2011, 27(4):485-486
DOI:10.4103/0970-1591.91437  PMID:22279314
  - 2,353 54
Can radical orchiectomy be avoided for paratesticular adenomatoid tumor?
Apul Goel, Abhishek Jain, Deepansh Dalela
October-December 2011, 27(4):556-557
DOI:10.4103/0970-1591.91454  PMID:22279331
Paratesticular tumors are rare tumors that are difficult to diagnose preoperatively and therefore, many patients are subjected to inguinal orchiectomy. However, radical orchiectomy can be avoided as the diagnosis of paratesticular tumor can be made on the basis of clinical suspicion, findings of tumor markers and radiological tests.
  - 2,964 40
Complete foreskin removal in adult circumcision: Is it a new direction to definitive cure of premature ejaculation?
Neeraj Kumar Goyal
October-December 2011, 27(4):562-563
  - 10,816 92
Dietary counseling: An ignored aspect of urinary stone management
Neeraj Kumar Goyal
October-December 2011, 27(4):563-564
  - 1,690 99
Partial nephrectomy in chronic kidney disease: Not always a win-win situation
Bastab Ghosh
October-December 2011, 27(4):564-565
  - 1,688 45
Can serum asymmetric dimethylarginine become a marker of vasculogenic erectile dysfunction?
Rohit Kathpalia
October-December 2011, 27(4):566-567
  - 1,447 33
Phosphodiesterase-5 inhibitors: Is it the answer to all male sexual and urinary problems?
Neeraj Kumar Goyal
October-December 2011, 27(4):567-568
  - 1,826 55
How accurate is the "Guy's stone score" for predicting the stone-free rates after percutaneous nephrolithotomy?
Swarnendu Mandal
October-December 2011, 27(4):568-569
  - 3,292 267
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