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   2012| July-September  | Volume 28 | Issue 3  
    Online since October 19, 2012

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Dedicated robotics team reduces pre-surgical preparation time
Michael S Lasser, Chintan K Patel, Sammy E Elsamra, Joseph F Renzulli, George E Haleblian, Gyan Pareek
July-September 2012, 28(3):263-266
DOI:10.4103/0970-1591.102696  PMID:23204651
Context: Robot-Assisted Laparoscopic Radical Prostatectomy (RALRP) requires significant preoperative setup time for the room, staff, and surgical platform. The utilization of a dedicated robotics operating room (OR) staff may facilitate efficiency and decrease costs. Aims: We sought to determine the degree to which preoperative time decreased as experience was gained. Materials and Methods: A total of 476 patients with a mean age of 60.2 years were evaluated (11/2006 to 1/2010). Data was assimilated through an institutional review board approved blinded, prospective database. Utilizing time from patient arrival in the OR to robot docking as preoperative preparation, our experience was evaluated. Age, body mass index (BMI), and American Society of Anesthesiologists risk scores (ASA) were compared. Statistical Analysis Used: Analysis of variance; Two-sample t-test for unequal variances. Results: The first and last 100 cases were found to have similar age (P=0.27), BMI (P=0.11), and ASA (P=0.09). The average preoperative times were 66. 4 and 53.4 min, respectively (P<0.05). The second 100 patients treated were found to have a significantly shorter preoperative time when compared to the first 100 patients (P<0.05). When the first 100 cases were divided into cohorts of 10 cases the mean preoperative time for the first through fourth cohorts were 80.5, 69.3, 78.8, and 64.7 min, respectively. After treatment of our first 30 patients we found a significant drop in preoperative time. This persisted throughout the remainder of our experience. Conclusions: From the time of patient arrival a number of tasks are accomplished by the non-physician operating room staff during RALRP. The use of a consistent staff can decrease preoperative setup times and, therefore, the overall length of surgery.
  4 2,454 59
Photoselective vaporization of prostate vs. transurethral resection of prostate: A prospective, randomized study with one year follow-up
Nayan K Mohanty, Pawan Vasudeva, Anup Kumar, Sanjay Prakash, Manoj Jain, Rajender P Arora
July-September 2012, 28(3):307-312
DOI:10.4103/0970-1591.102708  PMID:23204660
Objectives: To evaluate in a prospective, randomized study, the efficacy and safety profile of photoselective vaporization of prostate (PVP) using a 80W potassium titanyl phosphate (KTP) laser when compared to standard transurethral resection of prostate (TURP) in patients with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE). Materials and Methods: Between February 2009 and August 2009, 117 patients satisfying the eligibility criteria underwent surgery [60 PVP{Group A}; 57 TURP{Group B}]. The groups were compared for functional outcome (both subjective and objective parameters), perioperative parameters and complications, with a follow up of one year. P value<0.05 was considered statistically significant. Results: The baseline characteristics of the two groups were comparable. Mean age was 66.68 years and 65.74 years, mean IPSS score was 19.98 and 20.88, mean prostate volume was 44.77 cc and 49.02 cc in Group A and B, respectively. Improvements in IPSS, QOL, prostate volume, Q max and PVRU at 12 months were similar in both groups. PVP patients had longer operating time, lesser perioperative blood loss, shorter catheterization time and a higher dysuria rate when compared to TURP patients. The overall complication rate was similar in the two groups. Conclusions: In patients with LUTS due to BPE, KTP-PVP is an equally efficacious alternative to TURP with durable results at one year follow up with additional benefits of lesser perioperative blood loss, lesser transfusion requirements and a shorter catheterization time. Long term comparative data is awaited to clearly define the role of KTP-PVP in such patients.
  3 2,782 92
Peri-operative renal protection: The strategies revisited
Sukhminder Jit Singh Bajwa, Veenita Sharma
July-September 2012, 28(3):248-255
DOI:10.4103/0970-1591.102691  PMID:23204649
Postoperative acute renal failure (ARF) is a serious complication which can result in a prolonged hospital stay and a high mortality and morbidity. Underlying renal disease, cardiac diseases, nephrotoxin exposure and renal hypoperfusion are the possible predisposing risk factors which can create a high probability for the development of ARF. The incidence of ARF is highest after major vascular, cardiac and high-risk thoraco-abdominal surgery. Among the various renal protection strategies, adequate peri-operative volume expansion and avoidance of hypovolemia is the most accepted and practiced strategy. Numerous bio-markers of renal injury are used to estimate the presence and extent of renal insult and various new are currently under trial. Traditional pharmacological interventions like dopamine, diuretics and calcium antagonists are not currently the first line of reno-protective agents. The new non-pharmacological and pharmacological methods may improve outcome in renal transplantation, contrast-induced nephropathy and in various other settings of ARF. The current review is an attempt to refresh the knowledge and put forth the various renal protection strategies during the peri-operative period.
  3 6,588 440
Genitourinary histoplasmosis in post-renal transplant patient: Diagnostic dilemma
Arun Chawla, Kiran Chawla, Joseph Thomas
July-September 2012, 28(3):359-361
DOI:10.4103/0970-1591.102730  PMID:23204674
Genitourinary histoplasmosis is very rare and to our knowledge only four cases of epididymal histoplasmosis and nine cases of prostatic histoplasmosis have been reported in literature. We hereby report a case of a middle-aged male, who presented three years after renal transplant, with complaints of fever, pain, and swelling in the scrotum. Imaging disclosed an enlarged right epididymis with prostatic and retrotrigonal abscess, suggesting tuberculosis infection. However, histopathology of the epididymal biopsy revealed histoplasmosis, and the drained pus on culture confirmed infection with Histoplasma capsulatum.
  2 3,289 70
Penile lengthening procedure with V-Y advancement flap and an interposing silicone sheath: A novel methodology
BV Srinivas, SS Vasan, Sajid Mohammed
July-September 2012, 28(3):340-342
DOI:10.4103/0970-1591.102722  PMID:23204668
Surgery to augment penile length has become increasingly common. Lack of standardization of this controversial procedure has led to a wide variety of poorly documented surgical techniques, with unconvincing results. The most commonly used technique involves release of the suspensory ligament, with an advancement of an infrapubic skin flap onto the penis via a V-Y plasty. This technique has a major drawback of the possibility of reattachment of the penis to the pubis. We describe a new technique of interposing a silicone sheath along with V-Y advancement flap that overrides this drawback and minimizes the loss of the gained length.
  1 5,319 57
Metastasis of primary testicular leiomyosarcoma to the retroperitoneal space
Mitsuru Komeya, Tamayo Sahoda, Shinpei Sugiura, Takuto Sawada, Kazuo Kitami, Youichi Iemoto
July-September 2012, 28(3):343-346
DOI:10.4103/0970-1591.102723  PMID:23204669
A 70-year-old man presented with a left scrotal swelling. A computed tomography scan showed an 8-cm left scrotal mass and no metastasis. Radical orchiectomy with high ligation of the spermatic cord was performed. The tumor was classified as a high-grade leiomyosarcoma of the left testis. An intensive follow-up including repeated computed tomography scans was performed. A computed tomography scan 34 months after the surgery showed a retroperitoneal mass in front of the left kidney. Resection of the mass was performed. Microscopically, the mass was metastatic leiomyosarcoma.Intratesticular leiomyosarcoma is rare; only 18 cases have been reported. This is the first case in which leiomyosarcoma metastasized to the retroperitoneal space postoperatively. We herein review the literature and discuss how intratesticular leiomyosarcoma metastasized to the retroperitoneal space in this patient.
  1 2,328 28
Disseminated zygomycosis with renal involvement simulating malignancy in a diabetic patient
Deepak Khandelwal, Ankur Gadodia, Rita Sood, Naval K Vikram, Prabhjot Singh, Rajeev Kumar
July-September 2012, 28(3):347-349
DOI:10.4103/0970-1591.102726  PMID:23204670
Zygomycosis or mucormycosis refers to a group of uncommon but frequently fatal mycoses caused by fungi of the class Zygomycetes. The disease is usually an opportunistic infection in patients with diabetes, immunosuppression, trauma, burn wounds and other chronic debilitating diseases. Isolated renal involvement is rare although involvement of kidneys in disseminated mucormycosis is not uncommon. Clinical awareness and thorough appropriate investigations are required for an early diagnosis and successful treatment. We herein report a case of disseminated zygomycosis presenting as renal mass with pulmonary lesions, which was initially suspected to be disseminated renal cell carcinoma before a tissue diagnosis was obtained.
  1 2,244 150
Basaloid carcinoma of the prostate: A literature review with case report
Jeffrey Tuan, Hardev Pandha, Cathy Corbishley, Vincent Khoo
July-September 2012, 28(3):322-324
DOI:10.4103/0970-1591.102714  PMID:23204663
Basal cell carcinoma of the prostate (BCP) is a neoplasm composed of prostatic basal cells. There are only a few publications outlining the diagnosis, treatment, prognosis and outcome for BCP. Traditionally surgery has been used but these tumors also respond to concomitant chemo-radiotherapy. Using a BCP case report treated with radical chemo-radiotherapy from a chemotherapy regimen used in anal cancers, we propose an alternative management to the traditional options of radical surgery and radical radiotherapy.
  1 2,480 44
Femoral blowout in a case of Carcinoma Penis
Nikhil Panse, Parag Sahasrabudhe, Bhalchandra Kashyapi
July-September 2012, 28(3):325-328
DOI:10.4103/0970-1591.102715  PMID:23204664
There is considerable literature on the potential for a femoral blowout in case of fungating inguinal lymph nodes in a case of penile carcinoma. However, reported cases of actual femoral blowout are sparse in literature. We encountered one such case of femoral blowout because of fungating inguinal lymph nodes in a case of Ca.Penis. Emergency palliative resection of the fungating nodes, ligation of the femoral vein, and emergency flap cover in the form of a perforator-based anterolateral thigh flap was performed. We believe that patients with a potential of femoral blowout should undergo resection and suitable coverage to prevent fatal hemorrhage.
  1 8,952 67
A case of penile fracture at the crura of the penis without urethral involvement: Rare entity
BV Srinivas, SS Vasan, Sajid Mohammed
July-September 2012, 28(3):335-337
DOI:10.4103/0970-1591.102718  PMID:23204666
Penile fracture is a rare injury, most commonly sustained during sexual intercourse. We report the case of a 29-year-old man who presented with bilateral rupture of the crura of the cavernosa without urethral injury. This is the first case in the literature to present with this unique finding. Urgent surgical exploration was performed and the injuries repaired primarily. At follow-up, the patient reported satisfactory erectile function. This case highlights the importance of early diagnosis with unusual presentation and early surgical repair for better outcome.
  1 21,869 66
Scientific misconduct - Why we must be careful
Nitin S Kekre
July-September 2012, 28(3):247-247
DOI:10.4103/0970-1591.102689  PMID:23204648
  1 2,629 143
Length of urethra in the Indian adult male population
Venkatesh Krishnamoorthy, Praveen B Joshi
July-September 2012, 28(3):297-299
DOI:10.4103/0970-1591.102706  PMID:23204658
Objective: The urethral length has not been measured in the Indian population. Even the international literature in this arena is very sparse. This paper is an attempt to develop a simple anatomical database for urethral length. Materials and Methods: Between January 2010 and April 2011, the urethral lengths of 422 adult male patients who required catheterization as part of regular treatment at our hospital, were recorded after obtaining consent from the patients and from the scientific and ethics review boards of the institution. Patients with history of prostatic or urethral abnormalities were excluded. The balloon of a sterile Foley's catheter was inflated using 10 cc of saline. The length from the junction of the balloon to the 'Y' junction of the Foley was measured. The catheter was then passed into the bladder and re-inflated to same volume. The penis was gently straightened and the length of the catheter outside the penis was measured till the premarked point at the 'Y' junction. Subtracting this from the original length gave the length of the urethra. Results: The mean length of the urethra was 17.55 + 1.42 cm with a range between 14 and 22.5 cm. Conclusions: Literature in which the length of the normal adult male urethra is recorded for a significant sample size is very scarce. Our data adds to basic anatomic information of the male urethra specific to the Indian population. Statistical Methods: Descriptive statistical analysis was performed. The non-linear regression analysis was employed to find the normative values of urethral length according to age class.
  1 14,863 152
Genital reconstruction in exstrophy patients
RB Nerli, SS Shirol, Ajay Guntaka, Shivagouda Patil, Murigendra B Hiremath
July-September 2012, 28(3):280-285
DOI:10.4103/0970-1591.102701  PMID:23204655
Introduction: Surgery for bladder exstrophy has been evolving over the last four to five decades. Because survival has become almost universal, the focus has changed in the exstrophy-epispadias complex to improving quality of life. The most prevalent problem in the long-term function of exstrophy patients is the sexual activity of the adolescent and adult males. The penis in exstrophy patients appears short because of marked congenital deficiency of anterior corporal tissue. Many patients approach for genital reconstruction to improve cosmesis as well as to correct chordee. We report our series of male patients seeking genital reconstruction following exstrophy repair in the past. Materials and Methods: Fourteen adolescent/adult male patients attended urology services during the period January 2000-December 2009 seeking genital reconstruction following exstrophy repair in the past. Results: Three patients underwent epispadias repair, four patients had chordee correction with cosmetic excision of skin tags and seven patients underwent chordee correction with penile lengthening. All patients reported satisfaction in the answered questionnaire. Patients undergoing penile lengthening by partial corporal dissection achieved a mean increase in length of 1.614 ± 0.279 cm dorsally and 1.543 ± 0.230 cm ventrally. The satisfactory rate assessed by the Short Form-36 (SF-36) showed that irrespective of the different genital reconstructive procedures done, the patients were satisfied with cosmetic and functional outcome. Conclusions: Surgical procedures have transformed the management in these patients with bladder exstrophy. Bladders can be safely placed within the pelvis, with most patients achieving urinary continence and cosmetically acceptable external genitalia. Genital reconstruction in the form of correction of chordee, excision of ugly skin tags and lengthening of penis can be performed to give the patients a satisfactory cosmetic and functional system.
  1 9,175 94
An evaluation to define the role of repeat transurethral resection in a treatment algorithm for non-muscle-invasive bladder cancer
Atsushi Fujikawa, Yasushi Yumura, Masahiro Yao, Futoshi Tsuchiya, Akira Iwasaki, Masatoshi Moriyama
July-September 2012, 28(3):267-270
DOI:10.4103/0970-1591.102697  PMID:23204652
Objective: Repeat transurethral resection (ReTUR) is an effective treatment for non-muscle-invasive bladder cancer (NMIBC) to prevent disease recurrence or progression. It also has an important role in stratifying patients according to histopathological results. Therefore, the end point of ReTUR should be considered in a treatment algorithm. We evaluated positive ReTUR to define its role in a treatment algorithm for NMIBC. Materials and Methods: A second TUR was performed in 111 patients between July 2006 and February 2010. A third TUR was performed in 31 patients with T1/a/is tumors at the second TUR. The incidence of residual disease was calculated according to the NMIBC risk levels proposed by the International Bladder Cancer Group. We used ReTUR as a general term to indicate second and third TURs. Results: Residual disease at the second TUR was detected in 51% of the patients; it was observed in 17%, 45%, and 65% patients in the low-, intermediate-, and high-risk disease groups, respectively (P = 0.01). Residual disease at the third TUR was detected in 48% patients; it was observed in 18% and 65% patients in the intermediate- and high-risk disease groups, respectively (P = 0.06). Conclusion: The incidence of residual disease correlated with the risk levels for NMIBC. In the intermediate-risk disease group, nearly complete resection was accomplished after the third TUR. However, in the high-risk disease group, a high incidence of residual disease was identified even after the third TUR. Our results provide important data that may be useful in establishing an end point in a treatment algorithm for NMIBC.
  1 2,268 109
Laparoscopic en bloc kidney transplantation
Pranjal Modi, Krishnaprasad Thyagaraj, Syed Jamal Rizvi, Jigish Vyas, Sukant Padhi, Kamlesh Shah, Ram Patel
July-September 2012, 28(3):362-365
DOI:10.4103/0970-1591.102731  PMID:23204675
Laparoscopic donor nephrectomy is well establish procedure and having advantages over open donor nephrectomy in terms of having less pain, early ambulation and rapid post operative recovery. To extend the advantages of laparoscopic surgery to the recipient, recently we have performed laparoscopic kidney transplantations when kidney was procured from deceased donors. As a further extension of the procedure, here we present a case of laparoscopic en bloc kidney transplantation in obese diabetic recipient who received kidneys from 70 year old non-heart beating donor.
  1 3,286 100
Equivocal pelvi-ureteric junction obstruction manifesting in a renal transplant recipient
Vivek Venkatramani, Rajiv P Mukha, Nitin S Kekre
July-September 2012, 28(3):350-352
DOI:10.4103/0970-1591.102727  PMID:23204671
Partial and intermittent pelvi-ureteric junction obstruction (PUJO) can potentially confound the diagnosis of upper tract obstruction. We report the case of a gentleman who received a renal graft from his sister. The donor kidney had a box-shaped extra-renal pelvis, which showed unobstructed drainage on the diuretic renogram. However, it manifested in the recipient as PUJO, and he needed pyelo-native ureterostomy for deteriorating graft function. The purpose of this report is to highlight a seemingly innocuous entity in the donor that may manifest in the recipient with significant consequences on graft function. It also discusses the appropriate timing of intervention in these cases.
  - 3,313 61
Incidental metastatic endocrine tumor diagnosed at laparoscopic radical prostatectomy and bilateral lymph node dissection
Alistair George Rogers, Antony Darné, Naeem A Soomro
July-September 2012, 28(3):353-356
DOI:10.4103/0970-1591.102728  PMID:23204672
The introduction and expansion of laparoscopic and robotic radical retropubic prostatectomy (LRRP and RRRP) for organ-confined prostate cancer have led to an increase in pelvic lymphadenectomy specimens. Extended lymph node dissection (eLND) involves removing nodes over the obturator fossa, external ileac vessels as well as the internal iliac and increases the number of nodes examined. This has the potential to increase incidental nonprostatic nodal pathology identified in prostatectomy specimens. For the first time in the current literature we report the incidental diagnosis of a metastatic small bowel endocrine tumor in a 69-year-old gentleman, made at the time of LRRP and bilateral lymph node dissection. This report suggests that the benefit of an extended lymph node dissection is not only to prostate cancer control and staging, but also to the possibility of diagnosing potentially treatable incidental disease. It is a possibility that both pathologists and urologists alike should be aware of.
  - 2,517 27
Complete urethrovesical disruption following obstructed labor
S Arora, P Goel, V Bhalla, N Aggarwal
July-September 2012, 28(3):338-339
DOI:10.4103/0970-1591.102719  PMID:23204667
A 22-years-old lady presented with obstructed labor with a probable preoperative diagnosis of bladder/urethral injury. When a laparotomy was performed there was a complete urethral disruption at the vesicourethral junction with a big anterior forniceal tear in the vagina with intact uterus and cervix. The fetus had pushed itself through the upper vagina and bladder neck into the extraperitoneal space leading to complete urethrovesical disruption as a result of prolonged pressure on the vesicourethral junction against pubic symphysis for which an end to end anastomosis was performed. Although trauma has been mentioned as a cause of such urethral disruption in the literature, no such case has been reported so far following obstructed labor. A brief discussion of various surgical options for such cases is discussed.
  - 1,995 36
Arteriovenous malformation of the scrotum: Is preoperative angioembolization a necessity?
Jewel R Zachariah, Ashish K Gupta, Shashank Lamba
July-September 2012, 28(3):329-334
DOI:10.4103/0970-1591.102716  PMID:23204665
Arteriovenous malformations (AVMs) of the scrotum are uncommon lesions, usually picked up incidentally during the evaluation of scrotal masses or infertility. They have also been reported to present with acute bleeding. We present a case who presented with acute pain following an abandoned surgical attempt at excision, elsewhere. Diagnosis was confirmed by duplex ultrasound and magnetic resonance imaging. Angioembolization was deferred quoting concerns with radiation exposure. The patient underwent a near total excision of the scrotal mass. This is the first reported case, in the English literature, of a surgical resection of a scrotal AVM without a preceding angioembolization. Patients should be counselled about radiation exposure risks before angioembolization, and allowed to make an informed decision.
  - 3,562 44
Dosimetric comparison of standard three-dimensional conformal radiotherapy followed by intensity-modulated radiotherapy boost schedule (sequential IMRT plan) with simultaneous integrated boost-IMRT (SIB IMRT) treatment plan in patients with localized carcinoma prostate
A Bansal, R Kapoor, SK Singh, N Kumar, AS Oinam, SC Sharma
July-September 2012, 28(3):300-306
DOI:10.4103/0970-1591.102707  PMID:23204659
Aims: Dosimeteric and radiobiological comparison of two radiation schedules in localized carcinoma prostate: Standard Three-Dimensional Conformal Radiotherapy (3DCRT) followed by Intensity Modulated Radiotherapy (IMRT) boost (sequential-IMRT) with Simultaneous Integrated Boost IMRT (SIB-IMRT). Material and Methods: Thirty patients were enrolled. In all, the target consisted of PTV P + SV (Prostate and seminal vesicles) and PTV LN (lymph nodes) where PTV refers to planning target volume and the critical structures included: bladder, rectum and small bowel. All patients were treated with sequential-IMRT plan, but for dosimetric comparison, SIB-IMRT plan was also created. The prescription dose to PTV P + SV was 74 Gy in both strategies but with different dose per fraction, however, the dose to PTV LN was 50 Gy delivered in 25 fractions over 5 weeks for sequential-IMRT and 54 Gy delivered in 27 fractions over 5.5 weeks for SIB-IMRT. The treatment plans were compared in terms of dose-volume histograms. Also, Tumor Control Probability (TCP) and Normal Tissue Complication Probability (NTCP) obtained with the two plans were compared. Results: The volume of rectum receiving 70 Gy or more (V > 70 Gy) was reduced to 18.23% with SIB-IMRT from 22.81% with sequential-IMRT. SIB-IMRT reduced the mean doses to both bladder and rectum by 13% and 17%, respectively, as compared to sequential-IMRT. NTCP of 0.86 ± 0.75% and 0.01 ± 0.02% for the bladder, 5.87 ± 2.58% and 4.31 ± 2.61% for the rectum and 8.83 ± 7.08% and 8.25 ± 7.98% for the bowel was seen with sequential-IMRT and SIB-IMRT plans respectively. Conclusions: For equal PTV coverage, SIB-IMRT markedly reduced doses to critical structures, therefore should be considered as the strategy for dose escalation. SIB-IMRT achieves lesser NTCP than sequential-IMRT.
  - 4,159 84
Correlation between voiding dysfunction symptoms and uroflowmetry in women suffering from stress urinary incontinence
Katelyne Hubeaux, Xavier Deffieux, Marylène Jousse, Gérard Amarenco
July-September 2012, 28(3):313-317
DOI:10.4103/0970-1591.102710  PMID:23204661
Objectives: To determine whether the completion of a voiding dysfunction (VD) questionnaire could have a good predictive value for uroflowmetry findings, in a population of stress urinary incontinence (SUI) women. Materials and Methods: From a urodynamic database of 415 SUI women, 93 with isolated SUI who underwent urodynamic investigations were eligible for this study. Patients with obvious etiologies of obstruction were excluded. VD symptoms were analyzed using the Bristol Female Lower Urinary Tract Symptoms Questionnaire. Bladder outlet obstruction (BOO) was defined as a maximal flow rate under 15 ml/s for a urine volume > 200 ml, or a post-void residual volume greater than 50 ml, or an abnormal pattern of the flow curve. The sensitivity, specificity, positive and negative predictive value of questioning VD were calculated. Statistical analysis was done using a Wilcoxon test for continuous data and Fisher exact test for categorical data, and multivariate analysis. Results: Reported VD had a poor specificity (41%) and positive predictive value (32%) of BOO on uroflowmetry. No statistical correlation was found between VD symptoms and BOO defined on uroflowmetry (P=0.64) in this specific SUI population showing no obvious etiologies of obstruction. Conclusions: No correlation was found between obstructive symptoms and BOO as defined on uroflowmetry, in a specific population of SUI women. Our results suggest that uroflowmetry may be necessary rather than multichannel urodynamics.
  - 3,371 81
Gerota's fascia over a pelvic ectopic kidney: Myth or reality?
Apul Goel
July-September 2012, 28(3):318-321
DOI:10.4103/0970-1591.102712  PMID:23204662
Objective: To prospectively evaluate for the presence or absence of Gerota's fascia in a pelvic ectopic kidney, as this is not well documented. Materials and Methods: Between January 2007 and July 2011, all patients with normal renal functions presenting to the Urology Clinic with pelvic ectopic kidney were evaluated for the presence of fascia similar to Gerota's fascia. Specific evaluation included a contrast-enhanced computed tomography (CT) scan and open surgery where indicated. A literature search using PubMed was also done for the period between 1990 and May 2011 using the terms 'Gerota's fascia', 'perirenal fascia,' and 'pelvic kidney'. Results: Eleven patients were evaluated. The mean age was 28.6 years (range 7 to 50). The presentation included stone disease in six, pelvi-ureteric obstruction in three, and as part of the evaluation for other causes of lower abdominal pain, it was found in two. A CT scan performed on eight patients did not show any evidence of fascia, while surgical exploration done on seven showed a well-defined fascial layer, at least on the ventral aspect of the kidney. A literature search also did not show any information about Gerota's fascia in the pelvic kidney. Conclusion: Further anatomical / radiological studies are needed to definitively document the presence of Gerota's fascia around a pelvic kidney. Our data is more in favor of the presence of such a perirenal fascia similar to Gerota's fascia.
  - 3,226 65
Nephrectomy and upper pole heminephrectomy for poorly functioning kidney: Is total ureterectomy necessary?
Eiji Hisamatsu, Shizuko Takagi, Yoshikiyo Nakagawa, Yoshifumi Sugita
July-September 2012, 28(3):271-274
DOI:10.4103/0970-1591.102699  PMID:23204653
Objective: We analyzed our experience with nephrectomy and upper pole heminephrectomy combined with subtotal ureterectomy to determine the incidence of the problems associated with the distal ureteral stump. Materials and Methods: The records of 48 children who underwent nephrectomy or upper pole heminephrectomy with subtotal ureterectomy for a poorly functioning kidney were reviewed. Results: No patient who underwent nephrectomy for a poorly functioning single-system kidney required secondary surgery. No secondary surgery was required in any patient who underwent upper pole heminephrectomy for ectopic ureter, while secondary surgery was required in five of 17 patients (29%) who underwent upper pole heminephrectomy for ectopic ureterocele. All five patients presented with recurrent febrile urinary tract infection after upper pole heminephrectomy. They also had reflux into the ipsilateral lower moiety, contralateral kidney, or distal ureteral stump. Our results and data from other reports suggest that recurrent urinary tract infections after upper pole heminephrectomy were treatment outcomes based on the initial surgical approach to ectopic ureterocele rather than isolated problems associated with the distal ureteral stump. Conclusion: We consider that total ureterectomy is unnecessary at the time of nephrectomy or heminephrectomy for a poorly functioning kidney because the distal ureteral stump rarely causes a problem.
  - 2,810 74
Does En-bloc transurethral resection of bladder tumor give a better yield in terms of presence of detrusor muscle in the biopsy specimen?
Rohit Upadhyay, Rakesh Kapoor, Amish Srivastava, Narendra Krishnani, Anil Mandhani
July-September 2012, 28(3):275-279
DOI:10.4103/0970-1591.102700  PMID:23204654
Aims: Detrusor muscle in initial transurethral resection of the bladder tumor (TURBT) may not be found in up to 50% of the cases. This study was done to assess the safety, feasibility and yield of detrusor muscle on en- bloc TURBT using a conventional electrocautery loop. Materials and Methods: Patients with bladder tumor of size 2-4 cm, from September 2007 to August 2010, who had en-bloc TURBT, were compared with patients who had conventional resection for the presence of detrusor muscle in the biopsy specimen on an initial resection. Tumor size was calculated on ultrasonography or contrast enhanced computerized tomography scan. Tumor with pedunculated base, more than 4 cm in size and tumor with hydroureteronephrosis were excluded. Conventional electrocautery loop was bent to 45° and periphery of the tumor was marked first and then the whole tumor was resected en bloc. The free-lying tumor was then cut into two or three pieces in the bladder for retrieval. Statistical analysis was done using SPSS software Version 13. Statistical Analysis Used: Statistical analysis was done using Pearson chi square test and P value of <.05 was considered significant. Results: A total of 25 patients in the control arm (with conventional TURBT) were compared with 21 patients who had en-bloc TURBT. En-bloc TURBT did not result in bladder perforation as vision was clear due to better hemostasis. Twenty of 21 (94.4%) patients had detrusor muscle but only 15 of 25 (60%) patients in the control arm had detrusor muscle on histopathological examination (P.001) Conclusions: En-bloc TURBT is safe and gives well-controlled resection of the whole tumor due to better visualization. Yield of detrusor muscle present in the specimen is significantly better with en-bloc TURBT.
  - 3,180 110
Managing disorder of sexual development surgically: A single center experience
Jatinder Kumar, Vikas Kumar, Vijaylakshmi Bhatia, Preeti Dabadghao, Samit Chaturvedi, Rakesh Kapoor, MS Ansari
July-September 2012, 28(3):286-291
DOI:10.4103/0970-1591.102703  PMID:23204656
Introduction: Ambiguous genitalia are a major cause of parental anxiety and create psychological and social problems to patient, if not managed properly. Here we present our experience in managing patients with ambiguous genitalia. Material and Methods: We retrospectively reviewed clinical records of all patients with ambiguous genitalia managed surgically at out institute between December 1989 and January 2011. Relevant history, clinical examination , investigations and surgical procedures performed were analyzed and results were evaluated in terms of anatomical, functional and psychosexual outcomes. Results: Female pseudohermaphroditism was the most common cause of genital ambiguity in our patients. Male and female genitoplasty was done according to gender of rearing, genital anatomy and parental choice. Twenty six patients (86.6%) reported satisfactory cosmetic outcome and 22 (73.3%) satisfactory functional outcome on long term follow-up. Among the 24 patients diagnosed as male pseudohermaphroditism 14 (82.3%) patient have reported satisfactory cosmetic outcome and 13 (76.4%) have reported satisfactory functional outcome. In patients with mixed gonadal dysgenesis and true hermaphroditism satisfactory cosmetic and functional outcome was seen in 70% patient. Conclusion: Managing patients of genital ambiguity according to gender of rearing, genital anatomy and parental choice carries good prognosis in terms of anatomical, functional and psychosexual outcome.
  - 8,551 124
Predictors of no-scalpel vasectomy acceptance in Karimnagar district, Andhra Pradesh
Sameer Valsangkar, Surendranath K Sai, Samir D Bele, Trupti N Bodhare
July-September 2012, 28(3):292-296
DOI:10.4103/0970-1591.102704  PMID:23204657
Introduction: Karimnagar District has consistently achieved highest rates of no-scalpel vasectomy (NSV) in the past decade when compared to state and national rates. This study was conducted to elucidate the underlying causes for higher acceptance of NSV in the district. Materials and Methods: A community-based, case control study was conducted. Sampling techniques used were purposive and simple random sampling. A semi-structured questionnaire was used to evaluate the socio-demographic, family characteristics, contraceptive history and predictors of contraceptive choice in 116 NSV acceptors and 120 other contraceptive users (OCUs). Postoperative complications and experiences were ascertained in NSV acceptors. Results: Age (χ2 =11.79, P value = 0.008), literacy (χ2 =17.95, P value = 0.03), duration of marriage (χ2 =14.23, P value = 0.008) and number of children (χ2 =10.45, P value = 0.01) were significant for acceptance of NSV. Among the predictors, method suggested by peer/ health worker (OR = 1.5, P value = 0.01), method does not require regular intervention (OR = 1.3, P value = 0.004) and permanence of the method (OR = 1.2, P value = 0.031) were significant. Acceptors were most satisfied with the shorter duration required to return to work and the most common complication was persistent postoperative pain among 12 (10.34%) of the acceptors. Conclusion: Advocating and implementing family planning is of high significance in view of the population growth in India and drawing from the demographic profile, predictors, pool of trainers and experiences in Karimnagar District, a similar achievement of higher rates of this simple procedure with few complications can be replicated.
  - 2,656 72
Functional evaluation before stone surgery: Is it mandatory?
Rishi Nayyar, Nikhil Khattar, Rajeev Sood
July-September 2012, 28(3):256-262
DOI:10.4103/0970-1591.102693  PMID:23204650
Functional evaluation of the renal unit has often been quoted as a standard practice for management of stone disease of the upper urinary tract. However, there is very little available evidence from the existing literature to directly support or refute this practice. Here we try to critically review the existing literature on related questions, put into perspective its clinical utility and attempt to rationalize the concept of functional evaluation in patients of renal stone disease in the contemporary era of minimally invasive surgery.
  - 4,036 365
A rare case of adult diphallus with anorectal malformation
Shailesh C Sahay, PN Dogra, Pramod K Rai
July-September 2012, 28(3):357-358
DOI:10.4103/0970-1591.102729  PMID:23204673
We present the case of a 24 year old man who presented with acute urinary retention and found to have diphallus with vertical duplication of penis. Superior phallus was well developed without any urethral meatus whereas inferior phallus was rudimentary but with patent urethra. History of erection was present in superior phallus only whereas patient was voiding urine from inferior phallus. It was associated with anorectal malformation and bilateral pelvic ectopic kidneys. Patient was managed by suprapubic catheter placement and planned for penile and urethral reconstructive surgery. Diphallus very rarely present in adulthood and vertical duplication is very unusual.
  - 8,046 51
Cystic change in clear cell renal carcinoma: Does the proportion affect the prognosis?
Rohit Kathpalia
July-September 2012, 28(3):366-367
  - 1,647 39
Virtual access in percutaneous nephrolithotomy - The "all-seeing needle"
Dheeraj Kumar Gupta
July-September 2012, 28(3):367-368
  - 1,332 97
Can urethral ultrasonography replace retrograde urethrogram to detect failure after buccal mucosal graft urethroplasty?
Swarnendu Mandal
July-September 2012, 28(3):368-369
  - 3,068 68
Is fluorescence in situ hybridization useful for prediction of residual tumor after transurethral resection of bladder tumor?
Swarnendu Mandal
July-September 2012, 28(3):370-371
  - 1,027 44
Can detection of circulating tumor cells in metastatic and clinically localized urothelial carcinoma determine prognosis?
Swarnendu Mandal
July-September 2012, 28(3):371-372
  - 1,186 56
Effect of variation in the anatomy of the pelvi-calyceal system on the success of percutaneous nephrolithotomy-A step ahead
Swarnendu Mandal
July-September 2012, 28(3):372-373
  - 1,612 121
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