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   2016| July-September  | Volume 32 | Issue 3  
    Online since July 1, 2016

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Follow-up imaging after pediatric pyeloplasty
Manoj Kumar, Sanjeet Kumar Singh, Sohrab Arora, Varun Mittal, Nitesh Patidar, Sanjoy Kumar Sureka, MS Ansari
July-September 2016, 32(3):221-226
DOI:10.4103/0970-1591.185090  PMID:27555681
Introduction: The duration, methods and frequency of radiographic follow-up after pediatric pyeloplasty is not well-defined. We prospectively evaluated a cohort of children undergoing pyeloplasty to determine the method for follow-up. Methods: Between 2000 and 2008, children undergoing pyeloplasty for unilateral ureteropelvic junction obstruction were evaluated for this study. All patients were evaluated preoperatively with protocol ultrasound (USG) and diuretic renal scan (RS). On the basis of preoperative split renal function (SRF), these patients were divided into four groups - Group I: SRF > 40%, Group II: SRF 30–39%, Group III: SRF 20–29%, and Group IV: SRF 10–19%. In follow-up, USG and RS were done at 3 months and repeated at 6 months, 1 year, and then yearly after surgery for a minimum period of 5 years. Improvement, stability, or worsening of hydronephrosis was based on the changes in anteroposterior (AP) diameter of pelvis and caliectasis on USG. Absolute increase in split renal function (SRF) >5% was considered significant. Failure was defined as increase in AP diameter of pelvis and decrease in cortical thickness on 3 consecutive USG, t½ >20 min with obstructive drainage on RS and/or symptomatic patient. Results: 145 children were included in the study. Their mean age was 3.26 years and mean follow-up was 7.5 years. Pre- and post-operative SRF remain unchanged within 5% range in 35 of 41 patients (85%) in Group I. While 9 of 20 patients (45%) in Group II, 23 of 50 patients (46%) in Group III, and 14 of 34 patients (41%) in Group IV exhibited changes >5% after surgery. 5 patients failed, 2 in Group III, and 3 in Group IV. None of the patients deteriorated in Group I and II. Conclusion: After pyeloplasty in children with a baseline split GFR >30%, if a diuretic renogram and USG performed 3 months postoperatively shows nonobstructive drainage with t½ <20 min and decreased hydronephrosis, no further follow-up is required.
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Current trends in kidney transplantation in India
Sunil Shroff
July-September 2016, 32(3):173-174
DOI:10.4103/0970-1591.185092  PMID:27555672
  4,686 234 -
The development and current status of Intensive Care Unit management of prospective organ donors
Margaret Kathleen Menzel Ellis, Mitchell Brett Sally, Darren Malinoski
July-September 2016, 32(3):178-185
DOI:10.4103/0970-1591.185103  PMID:27555674
Introduction: Despite continuous advances in transplant medicine, there is a persistent worldwide shortage of organs available for donation. There is a growing body of research that supports that optimal management of deceased organ donors in Intensive Care Unit can substantially increase the availability of organs for transplant and improve outcomes in transplant recipients. Methods: A systematic literature review was performed, comprising a comprehensive search of the PubMed database for relevant terms, as well as individual assessment of references included in large original investigations, and comprehensive society guidelines. Results: In addition to overall adherence to catastrophic brain injury guidelines, optimization of physiologic state in accordance with established donor management goals (DMGs), and establishment of system-wide processes for ensuring early referral to organ procurement organizations (OPOs), several specific critical care management strategies have been associated with improved rates and outcomes of renal transplantation from deceased donors. These include vasoactive medication selection, maintenance of euvolemia, avoidance of hydroxyethyl starch, glycemic control, targeted temperature management, and blood transfusions if indicated. Conclusions: Management of deceased organ donors should focus first on maintaining adequate perfusion to all organ systems through adherence to standard critical care guidelines, early referral to OPOs, and family support. Furthermore, several specific DMGs and strategies have been recently shown to improve both the rates and outcomes of organ transplantation.
  2,609 133 -
Grading of complications of transurethral resection of bladder tumor using Clavien–Dindo classification system
Ankur Bansal, Satyanarayan Sankhwar, Apul Goel, Manoj Kumar, Bimalesh Purkait, Ruchir Aeron
July-September 2016, 32(3):232-237
DOI:10.4103/0970-1591.185104  PMID:27555684
Introduction: Clavien–Dindo classification system is used for grading complications of various oncological, renal, and endourological procedures. We applied this system for grading the severity of perioperative complications in patients undergoing transurethral resection of bladder tumor (TURBT) and identify parameters predicting these complications. Materials and Methods: Data of 984 patients who underwent TURBT from 2006 to 2014 were included in this study. All data was retrospectively collected and analyzed for complications occurring within the first postoperative month. All complications were classified according to the five grades of modified CCS (.Clavien classification system). Results: A total of 172 complications were observed in 138 patients. Majority were low grade complications (Grade 1 [77.3%] and Grade 2 [12.7%]). Higher grade complications were rare (Grade 3 [6.4%] and Grade 4 [3.0%]). There was one death (Grade 5 0.6%), with an overall mortality rate of 0.1%. The incidence of complications was significantly greater for age >60 years, baseline serum creatinine >1.4 mg/dl, size of tumor >4 cm, tumor located at dome, resection time >60 min, incomplete resection and if surgery performed by a resident urologist. Conclusions: Clavien–Dindo classification system can be easily applied to grade the complications of TURBT, and it is easily reproducible. We observed that TURBT was a safe procedure. Majority of complications were Grade 1–2 (90%) and Grade 3–5 were rare (10%). Postoperative bleeding is the most common complication. A greater rate of complications of TURBT was associated with patient age, size of tumor, location of tumor, surgeon experience, resection time, and completion of tumor resection.
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Renal transplantation in 2016
John M Barry
July-September 2016, 32(3):175-177
DOI:10.4103/0970-1591.185099  PMID:27555673
  2,226 155 -
The development and current status of minimally invasive surgery to manage urological complications after renal transplantation
Ravindra B Sabnis, Abhishek G Singh, Arvind P Ganpule, Jaspreet S Chhabra, Gopal R Tak, Jaimin H Shah
July-September 2016, 32(3):186-191
DOI:10.4103/0970-1591.185100  PMID:27555675
Introduction: In the past, urological complications after renal transplantation were associated with significant morbidity. With the development and application of endourological procedures, it is now possible to manage these cases with minimally invasive techniques. Materials and Methods: A MEDLINE search for articles published in English using key words for the management of urological complications after renal transplantation was undertaken. Forty articles were selected and reviewed. Results: The incidence of urological complications postrenal transplantation was reported to be 2–13%. Ureteric leaks occurred in up to 8.6%, and 55% were managed endourologically. The incidence of lymphocele was as high as 20%, and less that 12% of the cases required treatment. Ureteric stricture was the most common complication, and endourological management was successful in 50–70%. The occurrence of complicated vesicoureteral reflux was 4.5%, and 90% of low-grade reflux cases were successfully treated with deflux injections. Stones and obstructive voiding dysfunction occurred in about 1% of kidney transplant recipients. Conclusion: Minimally invasive techniques have a critical role in the management of urological complications after renal transplantation. Urinary leakage should be managed with complete decompression. Percutaneous drainage should be the first line of treatment for lymphocele that is symptomatic or causing ureteric obstruction. Laparoscopic lymphocele deroofing is successful in aspiration-resistant cases. Deflux is highly successful for the management of complicated low-grade kidney transplant reflux. The principles of stone management in a native solitary kidney are applied to the transplanted kidney. Early identification and treatment of bladder outlet obstruction after renal transplantation can prevent urinary leakage and obstructive uropathy.
  2,206 173 -
The role of the pharmacist in the management of kidney transplant recipients
Joshua J Wiegel, Ali J Olyaei
July-September 2016, 32(3):192-198
DOI:10.4103/0970-1591.185108  PMID:27555676
Pharmacists may play a key role on the multidisciplinary transplant team. This article describes the development and current status of pharmacists in the management of transplant recipients in the United States. Traditionally, pharmacists played an important support role in transplant medicine. This role has been expanded to include direct patient care for the avoidance, detection, and/or treatment of side effects from the polypharmacy necessary in the management of these complex patients. Pharmacists provide pre- and post-transplant education to transplant recipients to enhance adherence to complicated medical regimens and thereby reduce readmission to hospital and unscheduled, costly visits to urgent care centers and/or hospital emergency departments.
  2,142 96 -
Impact of changing trends in technique and learning curve on outcome of hypospadias repair: An experience from tertiary care center
MS Ansari, Shikhar Agarwal, Sanjoy Kumar Sureka, Anil Mandhani, Rakesh Kapoor, Aneesh Srivastava
July-September 2016, 32(3):216-220
DOI:10.4103/0970-1591.185089  PMID:27555680
Introduction: Apart from numerous clinical factors, surgical experience and technique are important determinants of hypospadias repair outcome. This study was aimed to evaluate the learning curve of hypospadias repair and the impact of changing trends in surgical techniques on the success of primary hypospadias repair. Materials and Methods: We retrospectively analyzed of data of 324 patients who underwent primary repair of hypospadias between January 1997 and December 2013 at our center. During the initial 8 years, repairs were performed by multiple 5 different urologists. From 2005 onwards, all procedures were performed by a single urologist. The study cohorts was categorized into three groups; Group I, surgeries performed between 1997–2004 by multiple surgeons, Group II, between 2005–2006 during the initial learning curve of a single surgeon, and Group III, from 2007 onwards after completion of the learning curve of the single surgeon. The groups were compared in respect to surgical techniques, overall success and complications. Results: Overall 296 patients fulfilled the inclusion criterion, 93 (31.4%), 50 (16.9%), and 153 (51.7%) in Group I, II, and III, respectively. Overall success was achieved in 60 (64.5%), 32 (64%), and 128 (83.7%) patients among the three groups respectively (P < 0.01). Nineteen (20.4%), 20 (40%), and 96 (62.7%) patients underwent tubularized incised plate repair in Group I, II, and III, with successful outcome in 12 (63.2%), 15 (75%), and 91 (94.8%) patients, respectively (P < 0.01). The most common complication among all groups was urethrocutaneous fistula, 20 (21.5%) in Group I, 11 (22%) in Group II, and 17 (11.1%) in Group III. Conclusion: There is a learning curve for attaining surgical skills in hypospadias surgery. Surgeons dedicated for this surgery provide better results. Tubularized incised plate urethroplasty appear promising in both distal and proximal type hypospadias.
  1,896 91 -
Celebrity endorsements in medicine: who should be held liable?
Rajeev Kumar
July-September 2016, 32(3):171-172
DOI:10.4103/0970-1591.185093  PMID:27555671
  1,916 61 -
Cryptorchid testis with torsion: Inguinoscrotal whirlpool sign
Venkatraman Indiran
July-September 2016, 32(3):247-248
DOI:10.4103/0970-1591.185107  PMID:27555688
Non contrast helical computed tomography (CT) study of the abdomen is frequently performed in evaluation of suspected ureteric colic. We present CT images of a young adult male patient who had torsion of an undescended, non-neoplastic testis and describe the “Inguinoscrotal whirlpool sign on CT”.
  1,913 61 -
Feasibility of robotic radical prostatectomy for medication refractory chronic prostatitis/chronic pelvic pain syndrome: Initial results
Sameer Chopra, Raj Satkunasivam, Monish Aron
July-September 2016, 32(3):238-241
DOI:10.4103/0970-1591.185105  PMID:27555685
Four patients diagnosed with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), met criteria for National Institute of Health (NIH) Category III prostatitis, failed multiple medicinal treatments and underwent robotic radical prostatectomy (RRP). Median operative time (range): 157 (127–259) min. Validated functional questionnaires responses and NIH CP symptom index (NIH-CPSI) score were collected for each patient's status at different time points pre- and post-operatively. Median decreases (range) were: International Prostate Symptom Score - 14 (1–19); Sexual Health Inventory for Men - 6 (−14–22); and NIH-CPSI total - 23.5 (13–33). Median length of follow-up (range) was 34 (24–43) months. RRP appears to be an option for carefully selected patients with medication-refractory CP/CPPS who understand that baseline sexual function may not be restored postoperatively.
  1,871 55 -
Impact of assistant surgeon on outcomes in robotic surgery
Rishi Nayyar, Siddharth Yadav, Prabhjot Singh, Prem Nath Dogra
July-September 2016, 32(3):204-209
DOI:10.4103/0970-1591.185095  PMID:27555678
Introduction: It is believed that the outcomes of robotic surgery depends not only on the experience of the console surgeon but also the patient-side assistant. However, objective data supporting it is lacking. The aim of this study was to objectively determine change in operative outcomes with increasing experience of patient-side assistant. Materials and Methods: We performed a retrospective analysis of 222 urologic robotic procedures performed by two teams of surgeon-assistant and split the data into two chronological halves according to date of surgery. We considered that the assistant was inexperienced in the 1st half and had become experienced by the 2nd half, and we compared mean operative time and blood loss between these two halves of his experience. Results: We observed that with increasing experience of the assistant, the mean operative time reduced from 138.06 to 124.32 min (P = 0.001) and mean blood loss decreased from 191.93 to 187.61 ml (P = 0.57). On subset analysis, a consistent trend of reduction in the mean operative time was noted for both the assistants separately and for all surgical procedures included in the analysis. Maximum reduction was noted for pyeloplasty which was the most commonly performed surgery. The mean blood loss had a varied relation to the experience of the assistant and did not reach statistical significance in either direction. Conclusions: With increasing experience of the patient-side surgeon, the mean operative time for all robotic procedures showed a consistent trend of reduction across all types of surgery with greater reduction for commonly performed procedures.
  1,755 65 -
Assessment of the performance of Partin's nomogram (2007) in contemporary Indian cohort
Rajiv Yadav, Sohrab Arora, Manish Sachdeva, Narmada Prasad Gupta
July-September 2016, 32(3):199-203
DOI:10.4103/0970-1591.185096  PMID:27555677
Introduction: Partin's nomogram is an important prognostic tool to predict adverse pathological features for clinically localized prostate carcinoma. This tool is widely used by both radiation and surgical oncologists for pre-intervention counseling, treatment planning, and predicting the possible need for adjuvant treatment. However, the model is derived from a Western population with typical characteristics of prostate cancer in a prostate-specific antigen (PSA) screened population. Therefore, this study was conducted to assess the performance of the Partin's nomogram as applied to an Indian cohort by assessing the discrimination and calibration properties. Methods: A retrospective review of 282 patients treated with robotic radical prostatectomy from 2010 to 2015 was conducted. Partin tables (year 2007) were used to calculate the predicted probabilities for lymph node invasion (LNI), seminal vesicle invasion (SVI), and extraprostatic extension (EPE). The discrimination properties were assessed using the receiver operating characteristic (ROC) curves. Calibration of the model was done to show the relationship between predicted and observed values. Results: The mean age of the patients was 64.3 years. Most (59.4%) were clinical T2 disease. Patients with PSA >10 ng/ml comprised 60% of the population. ECE, SVI, and LNI were present in 39.2%, 22%, and 11% of cases, respectively. ROC analysis revealed area under curve values for EPE, SVI, and LNI of 68%, 67.5%, and 71.2%, respectively. Calibration plot suggested that the Partin tables under-predicted the risk whenever the values of predicted risk were more than 26%, 3%, and 1% for EPE, SVI, and LNI, respectively, and over predicted when the risk was lower. Conclusion: Our data show that Partin's tables, despite having fair discrimination properties, do not accurately predict LNI, SVI, and ECE across the entire range of predicted values in a contemporary Indian cohort.
  1,686 98 -
Hematuria among dengue patients: A note on observation
Won Sriwijitralai, Viroj Wiwanitkit
July-September 2016, 32(3):251-251
DOI:10.4103/0970-1591.185102  PMID:27555690
  1,641 49 -
Dosimetric correlation of acute and late toxicities in high-risk prostate cancer patients treated with three-dimensional conformal radiotherapy followed by intensity modulated radiotherapy boost
Rakesh Kapoor, Anshuma Bansal, Narendra Kumar, Arun S Oinam
July-September 2016, 32(3):210-215
DOI:10.4103/0970-1591.185098  PMID:27555679
Introduction: In prostate cancer, higher radiation doses are often related to higher local control rates. However, the clinical effect of these higher doses on normal tissue toxicities is generally overlooked. We dosimetrically analyze sequential intensity modulated radiotherapy (IMRT) plans in high-risk prostate cancer patients and correlate them with acute and late normal tissue toxicities. Materials and Methods: Twenty-five high-risk prostate cancer patients were planned with three-dimensional conformal radiotherapy to a dose of 50 Gy delivered in 25 fractions in 5 weeks, followed by seven-field IMRT boost, to a dose of 24 Gy delivered in 12 fractions in 2.5 weeks, along with hormonal therapy. Acute and late toxicities were analyzed using Radiation Therapy Oncology Group toxicity criteria. Student's t-test was used for correlating doses received by normal tissues with toxicity grade. Five-year disease-free survival (DFS) and biochemical relapse-free survival (RFS) were evaluated using Kaplan–Meier analysis. Results: Median follow-up of patients was 65 months. Of 25 patients, two developed acute Grade 2 rectal toxicity. Only 1 patient developed acute Grade 2 bladder toxicity. Late Grade 2 and 3 rectal toxicity was seen in 2 and 1 patient, respectively. Late Grade 2 and 3 bladder toxicity was seen in 1 patient each. Grade 2 or more acute rectal toxicity correlated significantly with rectal volume receiving >70 Gy (P = 0.04). The 5-year DFS and biochemical RFS was 70.2% and 79.2%, respectively. One patient failed locally and seven failed at distant sites. Conclusion: Sequential IMRT with a dose of 74 Gy and maximum androgen blockade is well tolerated in high-risk patients in Indian setup with adequate control rates.
  1,639 49 -
Comment on: Kumar et al. Follow-up imaging after pediatric pyeloplasty. Indian J Urol, 2016;32:221-226
V.V.S. Chandrasekharam
July-September 2016, 32(3):227-228
DOI:10.4103/0970-1591.185094  PMID:27555682
  1,614 60 -
Rare presentation of urachal adenocarcinoma with skip metastasis to colon
Rakesh Kapoor, Niharika Darasani, Anshuma Bansal
July-September 2016, 32(3):244-246
DOI:10.4103/0970-1591.185106  PMID:27555687
Urachal carcinoma is a rare malignancy constituting <1% of bladder malignancies. The disease arises from a malignant transformation of rests of enteric epithelium in the urachus. Most common sites of metastasis are lung, liver, and bone. We report a postoperative case of urachal carcinoma presenting with distant metastasis to lung and skip lesions in colon. As both urachal and colon carcinoma share common histopathological features, most of the literature suggested using chemotherapy regimens similar to those recommended for colon malignancies. There are no randomized trials till date regarding the management of urachal adenocarcinomas except for the primary treatment being surgery.
  1,558 59 -
Concomitant repair of stress urinary incontinence with proximal urethrovaginal fistula: Our experience
Subbarao Chodisetti, Yogesh Boddepalli, Malakonda Reddy Kota
July-September 2016, 32(3):229-231
DOI:10.4103/0970-1591.185097  PMID:27555683
Introduction: Proximal urethrovaginal fistula (UVF) located close to the bladder neck may cause extensive sphincter damage and is usually associated with continuous incontinence, which may mask the associated stress urinary incontinence (SUI). Simultaneous correction of SUI avoids a second surgery for SUI, which needs dissection in ischemic fields and carries a high risk of failure. The aim of this study is to describe our technique of concomitant repair of SUI with proximal UVF and our results. Methods: Between July 2010 and August 2014, 14 patients underwent UVF repair in Jackknife position by the interposition of a Martius flap and simultaneous correction of SUI by modified McGuire pubovaginal autologous fascial sling. The procedure was carried out a minimum of 3 months of presentation and after detailed preoperative evaluation. Results: After a mean follow-up of 28 months, all 14 patients were continent. None of the patients developed recurrence of the UVF. Two patients presented with retention immediately after catheter removal and clean intermittent catheterization training was given to both of them. Two patients became pregnant during the follow-up period and were advised cesarean section near term. Conclusions: Repair of proximal UVF and correction of SUI can be performed in the same session to avoid the operation in an ischemic field.
  1,566 50 -
Primary emphysematous adrenal hydatid: Unusual site for presentation with rare pathology
Gaurav Prakash, Apul Goel, Satyanarayan Sankhwar
July-September 2016, 32(3):249-250
DOI:10.4103/0970-1591.185101  PMID:27555689
Hydatid disease of the adrenal gland is uncommon. We present images and description a case of emphysematous hydatid cyst of the adrenal gland that had an unfavourable intraoperative outcome.
  1,423 55 -
Herpes zoster reactivation after extracorporeal shock wave lithotripsy: A case report
Krishnamoorthy Hariharan, Biju S Pillai, Devesh Bansal
July-September 2016, 32(3):242-243
DOI:10.4103/0970-1591.185091  PMID:27555686
Herpes zoster is a reactivated varicella-zoster virus (VZV) infection of the sensory nerve ganglion, peripheral nerve, and its branches. Mechanical trauma to the nervous system can reactivate VZV. It is well known that extracorporeal shock wave lithotripsy (SWL) can produce mechanical damage to the tissue. We report a rare case of herpes zoster reactivation after SWL for treatment of 1.2 cm size renal stone in a 63-year-old male patient.
  1,420 44 -
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