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   Table of Contents - Current issue
April-June 2023
Volume 39 | Issue 2
Page Nos. 89-178

Online since Friday, March 31, 2023

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Journal subscriptions in the changing landscape: Are they needed? Highly accessed article p. 89
Apul Goel
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Round up Highly accessed article p. 91
Swarnendu Mandal
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What's Inside? Highly accessed article p. 94
Abhishek Singh
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Urodynamics in the evaluation of lower urinary tract symptoms in young adult men: A systematic review p. 97
Gurpremjit Singh, Ankur Mittal, Sanjay Sinha, Vikas Kumar Panwar, Ajeet Singh Bhadoria, Arup Kumar Mandal
Introduction: This review aims to systematically evaluate the available evidence on the different urodynamic diagnoses of lower urinary tract symptoms (LUTS) in young adult men aged 18–50 years and to summarize the various urodynamic parameters based on these diagnoses. Methods: This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement and the search was performed in PubMed, Embase, and Cochrane library from inception till September 2021. A total of 295 records were identified using a combination of keywords such as LUTS, urodynamics (UDS), and young males. The review was registered in PROSPERO (CRD42021214045). Results: All the ten studies, which were included in this analysis, categorised the patients into either of the four primary diagnoses after the UDS – primary bladder neck obstruction (PBNO), dysfunctional voiding, detrusor underactivity (DU), or detrusor overactivity. Five of these studies used the conventional UDS, and in the other five a video UDS was performed. The most common abnormality on the conventional UDS was DU with a pooled estimate of 0.24 (95% confidence interval [CI] - 0.104–0.463, I2-95.35, (τ2-1.07). The most common abnormality on the video UDS was PBNO with a pooled estimate of 0.49 (95% CI - 0.413–0.580, I2-66.59, 2-0.09). The point estimates of various UDS parameters were also recorded. Conclusion: A urodynamic diagnosis was possible in 79% and 98% of the young men who underwent a conventional UDS or a video UDS, respectively. However, the men subjected to the conventional UDS and the video UDS had significant differences in their primary urodynamic diagnostic label. These results will help to plan future trials for the evaluation and management of LUTS in young men.
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Pediatric robotic urologic procedures: Indications and outcomes p. 107
Sean W Hou, Monica H Xing, Mohan S Gundeti
Introduction: Robotic-assisted laparoscopic surgery (RALS) has revolutionized minimally invasive surgery in pediatric urology. The robotic platform allows surgeons to maintain the benefits of laparoscopic surgery while having enhanced three-dimensional view, dexterity, range of motion, and control of high-resolution cameras. In this review, we summarize the indications and recent outcomes for various pediatric urologic RALS procedures to illustrate the current state of robotics in pediatric urology. Methods: We systematically searched the PubMed and EMBASE databases. We extrapolated and summarized recent evidence on RALS in pediatric urology patients, with an emphasis on indications and outcomes, with regard to the following procedures and search terms: pyeloplasty, kidney stone surgery, partial nephrectomy, nephroureterectomy, ureteral reimplantation, appendico-vesicostomy, augmentation cystoplasty, bladder neck reconstruction, and Malone antegrade continence enema. Additional Medical Subject Headings terms used to augment the search included “Treatment Outcome” and “Robotic Surgical Procedures.” Results: Increasing usage of RALS has shown many benefits in perioperative and postoperative outcomes. In addition, there is growing evidence that robotic procedures in pediatric urology result in similar or better surgical outcomes when compared to the standard of care. Conclusions: RALS has shown considerable effectiveness in pediatric urologic procedures and may achieve surgical outcomes comparable to the standard approaches of open or laparoscopic surgery. However, larger case series and prospective randomized controlled trials are still necessary to validate the reported outcomes, in addition to cost analyses and studies on the surgical learning curve. We believe that the continuous evolution of robotic platforms will allow for enhanced care and quality of life for pediatric urology patients.
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Comparison Between Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio As Predictors of Mortality on Fournier's Gangrene Cases p. 121
Soetojo Wirjopranoto
Introduction: Fournier's gangrene (FG) is an infection of the subcutaneous tissue and fascia that progresses quickly and leads to necrosis. It is more prevalent in male patients and immunocompromised individuals, such as those suffering from uncontrolled diabetes. It has a high mortality rate, which makes its early identification and clinical suspicion critical. This study aimed to compare two laboratory parameters, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), and to predict the mortality of FG in a tertiary care hospital. Methods: In a retrospective study, data was retrieved from medical records for the period from January 2014 to December 2020, of patients diagnosed with FG. Recorded data that is age, sex, comorbidities, mortality, and laboratory results (PLR and NLR) were used to assess determinants of survival. Results: There were 23 (17.04%) nonsurvivors among the 135 subjects studied. The mean age was 50.9 ± 14.9 years and men were 103 (83%) patients. Among the participants, diabetes mellitus was the most frequent comorbidity at 74 (54.81%) patients. NLR ≥8 was statistically significant (P = 0.013) for identifying mortality, while PLR >140 was not. In multivariate analysis, NLR ≥8 was found to be a reliable predictor of the FG mortality rate (adjusted odds ratio 12.062, confidence interval 95% 2.115–68.778, P = 0.005). Conclusion: NLR had prognosis predictive value for FG, whereas PLR did not.
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Effect of preoperative estrogen on complications after proximal hypospadias repair: A randomized controlled trial p. 126
Akash Bihari Pati, Pritinanada Mishra, Santosh K Mahalik, Bikasha Bihary Tripathy, Manoj Kumar Mohanty
Introduction: Proximal hypospadias repair has many postoperative complications such as urethrocutaneous fistulae, wound dehiscence, and urethral stricture. The beneficial effect of estrogen to promote wound healing has been known. We designed a study to determine whether preoperative stimulation of tissue with estrogen can reduce the postoperative complications associated with wound healing in patients undergoing hypospadias repair. Methods: Patients with proximal hypospadias requiring two-stage repairs (chordee correction followed by urethral tubularization) were randomized to estrogen and control groups before the second stage of surgery. In the former, topical estrogen cream (0.5 mg of estriol) was applied to the ventral penis for a month, whereas normal saline gel was applied to the latter; the urethroplasty was carried out thereafter. Patients were followed up for complications. Results: There were 29 patients in the estrogen group and 31 in the placebo group after the exclusion criteria were met. There was no significant difference in the overall postoperative complications between the estrogen group (44.8%) and the placebo group (51.6%). The occurrence of urethrocutaneous fistula (37.9% vs. 51.6%) and dehiscence (41.4% vs. 45.2%) was not significantly different between the estrogen and placebo groups. Neourethral stricture occurred in four patients in the estrogen group, while none of the patients in the placebo group developed stricture. Conclusions: The preoperative application of topical estrogen cream to the ventral penis failed to demonstrate any significant effect on wound healing and complications.
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Peri-operative antibiotic usage during endourological surgery: A multi-institutional, national-level, cross-sectional audit of prevalent practice pattern in India p. 133
Rishi Nayyar, Shritosh Kumar, Collaborative Working Group on Use of Antibiotics in Endourology
Introduction: Antibiotic use during endourological procedures is often discordant from the reported guidelines, despite the potential risks of antibiotic resistance, adverse effects, and health-care costs. A nationwide audit was conducted, with the support of the Urological Society of India, to ascertain the current antibiotic prescription practices for the endourological procedures and the reasons associated with them. Methods: A multi-institutional, national-level, cross-sectional audit analyzing elective endourological procedures was performed. The data regarding the disease profile; risk factors for infectious complications; urine culture; pre-, per-, and post-operative antibiotic use; additional antibiotic use; and patient demographics were collected in a standardized pro forma. Reasons for prescribing antibiotics divergent from the guideline recommendations were also noted. Any infectious complication that necessitated the antibiotic use was also noted prospectively up to 1 month. All the data were entered into a single centralized and customized online portal on a real-time basis. Results: One thousand five hundred and thirty-eight cases were recruited from 20 hospitals. A single-dose prophylaxis was prescribed in only 319 (20.7%) of the cases, and the majority received a multi-day prophylaxis. A combination of two or more antibiotics was prescribed as the prophylaxis in 51% of the cases. One thousand three hundred and fifty-six (88.2%) cases were continued on a long-duration prophylaxis after the discharge, with 1191 (77.4%) receiving it for > 3 days. One thousand one hundred and sixty (75.4%) cases received a guideline-discordant prophylaxis solely on the basis of the surgeon's or institution's protocol, rather than any specific case based need. Ninety eight (6.4%) cases developed postoperative urinary tract infection. Conclusions: Multi-dose, combination and post-discharge antibiotic prophylaxis for endourological surgeries is highly prevalent in India. This audit highlights the huge potential to reduce such guideline-discordant overuse of antibiotics during the endourological procedures.
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Impact of diabetes and chronic kidney disease on active surveillance outcomes for small renal masses: A cohort study p. 142
Nicolas E Alcalá, Cameron D Futral, Caroline A Miller, Alexander L Sinks, Peter E Clark, Ornob P Roy
Introduction: The American Cancer Society estimates 79,000 individuals will be diagnosed with kidney cancer in 2022, most of which are initially found as small renal masses (SRMs). Proper management of SRM patients includes careful evaluation of risk factors such as medical comorbidities and renal function. To investigate the importance of these risk factors, we examined their effect on crossover to delayed intervention (DI) and overall survival (OS) in patients undergoing active surveillance (AS) for SRMs. Methods: This is an Institutional Review Board-approved retrospective analysis of AS patients presented at kidney tumor conferences with SRMs between 2007 and 2017. Univariable and multivariable logistic regression analyses were performed to determine how factors including estimated glomerular filtration rate (eGFR), diabetes, and chronic kidney disease are associated with DI and OS. Results: A total of 111 cases were reviewed. In general, AS patients were elderly and had significant comorbidities. On univariate analysis, intervention was more likely to occur in patients with a younger age (P = 0.01), better kidney function (P = 0.01), and higher tumor growth rates (GRs) (P = 0.02). Higher eGFR was associated with better survival (P = 0.03), while higher tumor GRs (P = 0.014), greater Charlson Comorbidity Index (P = 0.01), and larger tumors (P = 0.01) were associated with worse OS. Of the comorbidities, diabetes was found to be an independent predictor of worse OS (P = 0.01). Conclusions: Patient-level factors – such as diabetes and eGFR – are associated with the rate of DI and OS among SRM patients. Consideration of these factors may facilitate better AS protocols and improve patient outcomes for those with SRMs.
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Overall survival of prostate cancer from Sangrur and Mansa cancer registries of Punjab state, India p. 148
Atul Madhukar Budukh, Jarnail S Thakur, Tapas Kumar Dora, Prithviraj R Kadam, Sonali S Bagal, Kamalesh Kumar Patel, Alok K Goel, Sankalp M Sancheti, Ashish R Gulia, Pankaj P Chaturvedi, Rajesh P Dikshit, Rajendra A Badwe
Introduction: There is a scarcity of population-based prostate cancer survival data in India. We assessed the population-based, overall survival of patients with prostate cancer from the Sangrur and Mansa cancer registries of the Punjab state, India. Methods: In the year 2013–2016, a total of 171 prostate cancer cases were registered in these two registries. Based on these registries, survival analysis was performed using the date of diagnosis as the starting date and the last follow-up date being December 31, 2021 or the date of death. Survival was calculated using STATA software. Relative survival was calculated using the Pohar Perme method. Results: Follow up was available for all the registered cases. Of the 171 cases, 41 (24%) were alive and 130 (76.0%) were dead. Of the prescribed treatments, 106 (62.7%) cases completed the treatment and 63 (37.3%) cases did not complete the treatment. Overall, 5-year age-standardized prostate cancer relative survival was 30.3%. Patients who completed the treatment had a 7.8 times higher 5-year relative survival (45.5%) compared to those who did not (5.8%). The difference between the two groups is statistically significant (hazard ratio 0.16, 95% confidence interval [0.10–0.27]). Conclusion: To improve survival, we need to raise awareness in the community and among primary physicians so that prostate cancer cases can reach the hospital early and should be treated effectively. The cancer center should develop the systems in their hospital so that there will be no hurdles to the patients in treatment completion. We found a low overall relative survival among patients of prostate cancer in these two registries. Patients who received treatment had a significantly higher survival.
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Editorial Comment p. 155
Vivek Venkatramani
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Primary retroperitoneal fibrosis presenting as a renal mass p. 157
Nikita Shrivastava, Divya Aggarwal, Rahul Jena
A 67-year-old male was incidentally found to have a large left perinephric mass with a poorly functioning left kidney. A differential diagnosis of renal cell carcinoma, lymphoma, retroperitoneal fibrosis (RPF), and IgG4 renal disease was suggested on imaging studies and biopsy of the mass. A left radical nephrectomy was performed as malignancy could not be ruled out. The final diagnosis was RPF without periaortitis and the patient is doing well at 9 months of follow-up. RPF, although characterized as a manifestation of periaortitis and large vessel vasculitis, might also present as an isolated perinephric mass without aortic involvement. Surgical management is an alternative, especially when malignancy is suspected.
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An unusual, delayed, solitary manifestation of a penile lesion in chronic lymphocytic leukemia p. 160
Tariq Abdul Hamid, Amr Elmekresh, Fariborz Bagheri
Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in the adult western population. It is characterized by the proliferation of mature but dysfunctional lymphocytes, primarily CD5+ B cells. It primarily affects the reticuloendothelial system in the majority of the cases, but can rarely manifest as extranodal and extramedullary lesions. One of the rare presentations is genitourinary cutaneous infiltration, and only a handful of cases of secondary metastases to the genitourinary skin, have been reported in the literature. The current report describes a patient with solitary lesion of CLL in the penis, manifesting almost two decades after the complete treatment of CLL.
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Hourglass appearance in cystocele with an impacted vesical calculus p. 163
Manickam Ramalingam, Senthil Kallappan, MN Janani
A 62-year-old hypertensive female presented with a mass protruding from the vagina for the past 20 years. She complained of dysuria and urinary incontinence for the past 3 months. There was no history of surgical intervention in the past. The examination revealed a tender irreducible total uterine prolapse (procidentia) and cystocele with a decubitus ulcer. Computed tomography urogram showed a total uterine prolapse along with the prolapse of a part of urinary bladder, with a vesical calculus of size 2.8 cm × 2.7 cm in the prolapsed part of the bladder, below the level of the pubic symphysis, with minimal wall thickening. After optimization, vesical lithotripsy and bilateral ureteric stenting were performed, followed by hysterectomy after 2 days.
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A rare diagnosis of renal replacement lipomatosis p. 165
Rajnandini Dasgupta, Chandan J Das, Amit Gupta
Renal replacement lipomatosis (RRL) is a rare, benign entity characterized by marked fat proliferation within the renal sinus and perinephric space. We present images of a patient with RRL.
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Early and late complications of suprapubic cystostomy – Report of two cases p. 167
Anandan Murugesan, Devdas Madhavan
Suprapubic cystostomy (SPC), although a common procedure, may be associated with complications. We present two cases of transperitoneal tract of SPC. The early complication was ileal perforation, resulting in perforation peritonitis and late complication was incisional hernia around the SPC tract. Avoiding peritoneal violation helps in preventing such complications.
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A rare case of air cysto-uretero-pyelogram due to emphysematous cystitis p. 169
Shakti Swarup Sarangi, Deepak Prakash Bhirud, Shiv Charan Navriya, Arjun Singh Sandhu
Emphysematous infection of the urinary tract is a hazardous condition and is life-threatening if not managed quickly. We report an 82-year-old woman with uncontrolled diabetes mellitus and urethral stricture who presented with emphysematous cystitis with the gas reaching up to the pelvicalyceal system on the left side (emphysematous pyelonephritis) and appearing in X-ray as air pyelogram. The patient was managed with drainage and intravenous antibiotics and she recovered.
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Rezvilutamide for metastatic castration-sensitive prostate cancer: CHART trial p. 171
Kirti Singh
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Comparing outcomes between neoadjuvant hormonal therapy followed by prostatectomy versus upfront prostatectomy in high-risk prostate cancer: The road ahead p. 173
Priyank Bhargava
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PROMPTS Trial: Screening spinal magnetic resonance imaging in castration-resistant prostate cancer p. 175
Soumya Shivasis Pattnaik
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Re: Ramadhani MZ, Kloping YP, Rahman IA, Yogiswara N, Soebadi MA, Renaldo J. Silodosin as a medical expulsive therapy for distal ureteral stones: A systematic review and meta-analysis. Indian J Urol 2023;39:21-6 p. 177
Gopal Sharma
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