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   2020| April-June  | Volume 36 | Issue 2  
    Online since April 7, 2020

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Can new, improvised Visual Prostate Symptom Score replace the International Prostate Symptom Score? Indian perspective
KN Sanman, Ranjit Shetty, Rajeshkumar Reddy Adapala, Santosh Patil, GG Laxman Prabhu, P Venugopal
April-June 2020, 36(2):123-129
Introduction: Visual Prostate Symptom Score (VPSS) was introduced to overcome the drawbacks of the International Prostate Symptom Score (IPSS). However, this score also has potential for improvement. Materials and Methods: The primary objective of this study was to evaluate the utility of VPSS in patients with benign enlarged prostate (BEP) after uroflowmetric validation of the stream component. The secondary objective was to improve VPSS by adding a new severity grading and to assess if the "new upgraded VPSS" can replace IPSS in terms of ease of completion without assistance and the time taken. Results: Of 115 patients, 42.60% of them were of thea age group between 61– 70 years; mean ± standard deviation age was 64.75 years ± 8.042 (range 48– 90 years). Nineteen (16.52%) patients, who had education level ≥10th grade completed IPSS without assistance.. One hundred and eight (93.91%) patients completed VPSS without assistance (P = 0.000). None of those (0/6) with no formal education (but able to read and write) could complete the IPSS without assistance, whereas 66.67% completed the VPSS without assistance. Six minutes and two minutes was the average time taken to complete IPSS (4– 10 min) and VPSS (1– 3 min), respectively. Responses to different variables of VPSS were statistically significant (P < 0.001) compared to the IPSS. Correlation between the severity grading of the two scores was statistically significant (P < 0.001), with a statistically significant positive correlation between VPSS and IPSS (r = +0.582, P < 0.001). The new severity grading system developed on par with the IPSS, improvising the existing VPSS, showed statistically significant positive correlation to the IPSS (r = +0.587, P < 0.001). Conclusions : VPSS correlated well with IPSS. The "new improvised VPSS" developed by incorporating severity grading is a potential tool that can replace IPSS by overcoming its limitations.
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Buccal mucosa or penile skin for substitution urethroplasty: A systematic review and meta-analysis
Gopal Sharma, Sneha Sharma, Kalpesh Parmar
April-June 2020, 36(2):81-88
Penile skin (PSG) and the buccal mucosa (BMGs) are the most commonly used grafts for substitution urethroplasty. The aim of this study was to compare the success rates of substitution urethroplasty using either of these grafts. We systematically searched PubMed/Medline, EMBASE, Scopus and Web of science to identify studies comparing the two types of graft urethroplasties. Search strategy was based on Patient, Intervention, Control and Outcome guidelines. Studies reporting data on success of PSG versus BMG within the same manuscript were included. Standard Preferred reporting Items for Systematic reviews and Metaanalysis guidelines were followed while conducting this review and study protocol was registered with PROSPERO in priori (CRD42018114258). Sixteen studies, including 5 prospective and 11 retrospective studies, with a total of 1406 (896 BMG and 510 PSG) patients were included in the final analysis. In the overall analysis, BMG had significantly higher success rate (83.7% vs. 76.1%, P ≤ 0.0001). Duration of followup was heterogeneous across the studies, ranging from 15.9 to 201 months. Comparing the five studies where the data on duration of follow up was available, BMG showed a significantly higher success rate compared to PSG (90% vs. 80.4%; P = 0.02). In the subgroup of patients with bulbar urethral strictures, BMG urethroplasty had significantly higher success rate (87.4% vs. 78.0%; P = 0.0001). From the results of this study, buccal mucosa may appear to be a better choice, however, the data is still immature and a properly conducted randomized controlled trial with an adequate duration of followup is required.
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Randomized controlled trial to compare outcomes with and without the enhanced recovery after surgery protocol in patients undergoing radical cystectomy
Devanshu Bansal, Brusabhanu Nayak, Prabhjot Singh, Rishi Nayyar, Rashmi Ramachandran, Rajeev Kumar, Amlesh Seth
April-June 2020, 36(2):95-100
Introduction: Very few randomized controlled trials are available globally to support routine use of enhanced recovery after surgery (ERAS) protocol after radical cystectomy (RC), and none so far has been conducted in the Indian subcontinent. The aim of the present study was to evaluate hospital stay and 30-day perioperative outcomes following RC with the implementation of the ERAS protocol. Materials and Methods: Fifty-four patients undergoing open RC were randomized to ERAS versus conventional surgical care (CSC) at our center from April 2017 to May 2018. Key interventions included avoidance of mechanical bowel preparation, early nasogastric tube removal, early enteral feeding, and early obligatory ambulation. Follow-up was done till 30-day postoperatively or till discharge, whichever longer. Results: Twenty-seven patients in each group were analyzed. The demographic profile of the groups was similar. Length of stay in each group (8 days [5–57] ERAS vs. 9 days [5–31] CSC group, P = 0.390) was similar, with time to recovery of bowel function being significantly less in ERAS group (12 h [12–108] vs. 36 h [12–60] for bowel sounds [P = 0.001], 48 h [12–108] vs. 72 h [36–156] for passage of flatus [P = 0.001], and 84 h [36–180] vs. 96 [60–156] for passage of stools [P = 0.013]). Perioperative complication rate (12 patients (44.4%) vs. 14 (51.9%), P = 0.786) was similar. Conclusions: ERAS protocol leads to faster bowel recovery compared to conventional care in patients undergoing open RC but fails to demonstrate a shorter length of stay and lower complication rate.
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Safety, feasibility, and quality of holmium laser en-bloc resection of nonmuscle invasive bladder tumors – A single-center experience
Pankaj N Maheshwari, Amandeep Manjeet Arora, Mahesh S Sane, Vivek Ganesh Jadhao
April-June 2020, 36(2):106-111
Introduction: Conventional transurethral resection of bladder tumor (cTURBT), despite its piecemeal resection and associated limitations, remains the most widely practiced technique of TURBT. Resecting the tumor in a single piece would avoid most of the drawbacks of cTURBT. Our objective was to assess the feasibility, safety, and quality of Holmium (Ho) laser en-bloc resection (ERBT) for nonmuscle-invasive bladder cancer (NMIBC). Materials and Methods: We retrospectively studied 67 patients who underwent Ho laser EBRT for primary NMIBC. Data were collected regarding tumor size, number and location, intraoperative complications, and postoperative course. Patients were grouped as first 20, next 20 (21–40), and last 27 cases to assess how the quality of resection improved with increasing experience. Results: The mean tumor size was 28.7 ± 7.9 mm, with 34.3% of the patients having a tumor larger than 3 cm. While 43 patients (64.17%) had a single tumor, the rest had multiple tumors, ranging from 2 to 9 in number. The mean total duration of resection was 38.7 ± 11.6 min. No case required conversion to cTURBT. No patient experienced obturator reflex or bladder perforation. Detrusor muscle was present in 85.07% of the resections. With increasing experience, requirement for bladder irrigation and the incidence of postoperative clot evacuation decreased (P < 0.0001 and P = 0.31, respectively), and the detrusor-positive rate in the specimen increased (P = 0.24). The mean duration of catheterization was 1.76 ± 0.54 days. Conclusion: Ho laser ERBT is safe and feasible for complete resection of NMIBCs with no risk of obturator-nerve reflex and a high rate of detrusor-positive specimens.
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Let's fabricate ideas!
Anil Mandhani
April-June 2020, 36(2):75-76
  1,088 126 -
Expanded criteria donors in deceased donor kidney transplantation – An Asian perspective
Ziting Wang, Pradeep Durai, Ho Yee Tiong
April-June 2020, 36(2):89-94
There is an increasing gulf between demand and supply for kidneys in end-stage renal failure patients worldwide, especially Asia. Renal transplantation is often the treatment of choice for long-suffering patients who have to undergo dialysis on a regular basis. The utilization of expanded criteria donors (ECDs) to address the donor pool shortage has been proven to be a legitimate solution. Metzger first described the classification of standard criteria donor and ECD in 2002. Since then, the criterion has undergone various modifications, with the key aims of optimizing organ procurement rate while minimizing discard and rejection rates. We review the methods to improve selection, characterization of risks, and surgical techniques. Although the ECD kidneys have a higher risk of impaired donor and recipient outcome than the “standard criteria” transplants, it may be justified by the improved overall survival of these patients compared to those who remained on dialysis. It is, therefore, crucial that we perform meticulous selection, along with state of the art surgical techniques to maximize the use of this scarce resource. In this article, we review the pre-procurement and post-procurement processes implemented to preserve outcomes.
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Clinical spectrum, diagnosis, and sexual dysfunction after repair of fracture penis: Is no news good news?
Aditya Prakash Sharma, Tushar Aditya Narain, Sudheer Kumar Devana, Shantanu Tyagi, Kalpesh M Parmar, Girdhar Singh Bora, Ravimohan S Mavuduru, Shrawan Kumar Singh
April-June 2020, 36(2):117-122
Introduction: Penile fracture is a rare urological emergency, best managed by early surgical intervention, but the data on subsequent sexual function is sparse. This study was designed to analyze the clinical spectrum and sexual function after penile fracture repair at our tertiary care center. Materials and Methods: Ambispective observational study was undertaken from July 2002 to August 2019 which included patients admitted with a history of trauma to the penis in the erect state. The clinical presentation, etiology and the details of the surgical management were noted. Patients were contacted telephonically and were called for follow-up. They were evaluated for the presence of penile nodules or curvature, and the erectile function was objectively recorded using the Sexual Health Inventory for Men (SHIM) questionnaire and the Erection Hardness Score (EHS). Results: Median age at injury was 37 years, and injury during the sexual intercourse (33/43) was the most common etiology. Five patients presented with blood at the meatus. Ultrasound was performed in 27 patients and could detect the injury with a 55% sensitivity. All but one case were repaired through a subcoronal degloving incision. At a median follow-up of 36 months, follow-up data of 20 patients were available. Of the 20 patients, 14 were sexually active. The mean SHIM score was 21.36 ± 1.33 and the mean EHS was 3.21 ± 0.43. Four of the 20 patients developed penile nodule while 2 of them had penile curvature which was not bothersome. Conclusion: Penile fracture remains primarily a clinical diagnosis. Although prompt diagnosis and an emergent surgical exploration provides good outcomes in terms of preservation of erectile function, patients should be apprised about the problems of penile nodule and curvature.
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Round up
Santosh Kumar
April-June 2020, 36(2):77-78
  963 68 -
What is inside?
Anil Mandhani
April-June 2020, 36(2):79-80
  974 42 -
A retrospective analysis of patients undergoing postchemotherapy retroperitoneal lymph node dissection and metastasectomy in advanced nonseminomatous germ cell tumors
Kanuj Malik, Anand Raja, Venkatraman Radhakrishnan, N Kathiresan
April-June 2020, 36(2):112-116
Introduction: Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) and metastasectomy play an important role in the management of advanced-stage nonseminomatous germ cell tumors (NSGCT). We aimed to analyze preoperative parameters that could predict postoperative histology. Materials and Methods: We analyzed the data of 72 patients who underwent PC-RPLND and 14 patients who underwent metastasectomy after receiving cisplatin- or carboplatin-based chemotherapy for advanced stage NSGCT at our institute from 1994 to 2015. Clinical and pathological parameters such as the histology of orchidectomy, RPLND and metastasectomy, serum tumor markers, and the pre and post chemotherapy retroperitoneal lymph node size were recorded. Results: Seventy-two patients with a mean age of 28 years underwent PC-RPLND. Of the various variables evaluated, only percentage change in nodal size was found to be statistically significant in predicting necrosis (P = 0.004). A decrease of 75% was found to predict the necrosis with a specificity of 100%. There was 84.6% concordance between the histology of RPLND and that of metastasectomy. Conclusion: A 75% reduction in tumor size is highly predictive of absence of viable tumor or teratoma, however larger series are required to confirm these findings. RPLND histopathologies have a high concordance with metastasectomy histology and thus can be used as a guide to tailor further management.
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Utility of ultrasound elastography in postoperative follow-up of children with unilateral ureteropelvic junction obstruction
Chakradhar Reddy, Venkata Sai, Utsav Shah, Ramesh Babu
April-June 2020, 36(2):101-105
Introduction: We aimed to determine whether shear wave velocity (SWV) on ultrasound elastography is useful in follow-up of children with ureteropelvic junction obstruction (UPJO) following pyeloplasty. Methods: Consecutive children with unilateral UPJO who were co-operative for elastography (n = 31) were included. SWV of normal kidney was used as control, and it was compared with that of the affected kidney (UPJO) in the same patient. They were followed up with elastography at 3 months and elastography + renogram at 6 months postoperatively. In patients with a static renogram at 6 months, the study was repeated at 1 year. Patient outcomes were classified as improved at 6 months, static at 6 months, and worsened at 1 year based on ultrasound and renogram findings. The SWV was compared between the different outcomes. Results: Thirty-one children with a median age of 8.5 years were studied (m:f = 29:2; L:R = 22:9). The mean SWV was significantly higher (3.21 m/s) in UPJO kidney compared to the SWV (2.72 m/s) found in normal kidney (P = 0.011). The mean SWV was significantly less at 3 months (2.73 m/s) and 6 months (2.57 m/s) postoperative follow-up (P = 0.018 and P= 0.001). Among the patients who improved, the mean SWV was 2.65 m/s. This SWV was significantly raised (3.57 m/s) in patients whose condition remained static (P = 0.006) and even higher (4.36 m/s) in those who worsened (P = 0.001). Conclusions: SWV was significantly higher in UPJO compared to normal kidneys in children. It is useful in assessing postoperative resolution, and a rising velocity can be useful as an early marker of recurrence in UPJO.
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A rare case of extraperitoneal gastrointestinal stromal tumor arising from kidney
DV Singh, Vinod Kumar, Ahmed Kamaal
April-June 2020, 36(2):133-135
Mesenchymal tumors of the gastrointestinal tract which arise from the interstitial cells of Cajal and express C-Kit protein or CD117 on immunohistochemistry are known as gastrointestinal stromal tumors (GISTs). Extraperitoneal GISTs (EGISTs) are rare tumors arising from the mesentery, omentum, or retroperitoneum. We report a case of a 52-year-old male who presented with a huge abdominal lump arising from the right renal capsule that was found to be EGIST on histopathological examination and immunohistochemistry.
  687 53 -
TITAN trial; shifting focus from hormone-refractory to hormone-sensitive prostate cancer
Gautam Kumar
April-June 2020, 36(2):144-145
  600 106 -
Peristomal variceal hemorrhage at the ileal conduit site due to extrahepatic portosystemic shunt
Smitha Narayana Gowda, Prince Sethi, Uma Motapothula
April-June 2020, 36(2):130-132
Peristomal variceal bleeding is a rare but known complication with portal hypertension. In patients with recurrent peristomal hemorrhage, atypical varices should be considered, and liver cirrhosis should be excluded even with normal liver function tests. We report a case of a 76-year-old male who presented with recurrent ileal conduit site peristomal hemorrhage without known chronic liver disease. His liver function tests were normal, but computed tomography of the abdomen and pelvis showed liver nodularity and peristomal varices. He was diagnosed to have cirrhosis with portal hypertension and further tested positive for active hepatitis C infection. The patient's extrahepatic portosystemic ileal conduit site shunt was successfully treated with transjugular intrahepatic portosystemic shunt and endovascular variceal coiling. This case identifies a situation where it is imperative to identify occult liver cirrhosis with portosystemic shunt as a cause of ileal conduit site recurrent stomal bleeding.
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Renal cell carcinoma in a pancake kidney: A rare entity
Anuj Kumar Yadav, Girdhar S Bora, Ujjwal Gorsi, Ravimohan S Mavuduru
April-June 2020, 36(2):140-141
Pancake kidney is a rare form of renal fusion anomaly. Renal cell carcinoma in such an entity is even rarer and poses a challenge in management due to anomalous vessels. We describe one such patient with an emphasis on successful performance of partial nephrectomy by meticulous planning, with good oncological and functional outcomes.
  595 53 -
Newer variants of retroaortic left renal vein
Ganesh B Sonawane, Krishna H Moorthy, Biju S Pillai
April-June 2020, 36(2):142-143
The left renal vein (LRV) passing behind the abdominal aorta is termed as a retroaortic LRV (RLRV) and it is a relatively uncommon condition. Since the left kidney is preferred in the setting of live donor kidney transplantation, urologists must be familiar with the anomalies of the LRV. There are four variants of RLRV mentioned in the literature. However, we came across two newer variants of RLRV in two donors for renal transplantation. Both donors underwent successful left donor nephrectomy.
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Dengue shock syndrome after percutaneous nephrolithotomy leading to hematuria and renal failure: A rare complication
Manish Kumar, Aswathaman Karthikeyan, Vilvapathy Senguttuvan Karthikeyan
April-June 2020, 36(2):136-137
Hematuria following percutaneous nephrolithotomy (PCNL) is a dreaded complication. It necessitates blood transfusion in up to 10% of patients. It may be severe enough in <1% of patients to require angioembolization. We present a 50-year-old male who underwent PCNL for renal pelvic calculus. Since the day of the surgery, he had low-grade fever (100°F) which worsened (102°F) from the 2nd postoperative day. His preoperative urine culture was sterile. His platelet counts started dropping and NS1 antigen for dengue was positive. He also developed anemia (hemoglobin: 7g%) and platelet counts dropped to 17,000/cmm. He developed anuria on the 7th postoperative day, with serum creatinine rising to 7 mg%. He required two sessions of hemodialysis and urine output improved. There is a need for high index of suspicion for dengue, especially when fever and hematuria coexist in post PCNL patients.
  580 48 -
When it takes a pandemic to help us forget our conflicts
Gopal Badlani
April-June 2020, 36(2):148-149
  530 70 -
Supernumerary kidney forming isthmus of horseshoe kidney: A rare presentation
Anand Dilip Vakade, SR Sudin, K Sasidharan, S Jayasudha
April-June 2020, 36(2):138-139
Supernumerary kidney is one of the rarest congenital anomalies of the genito-urinary tract. Around 100 cases have been reported in the literature so far. Even rare is the fusion of a supernumerary kidney. The supernumerary kidney has its own blood supply, collecting system and a capsule. We report the case of a 33 year old male with vague pain in the pelvis who was found to have a horseshoe kidney with a fused supernumerary kidney as the isthmus.
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Simplified PADUA REnal nephrometry system: A refitted PADUA score
Gopal Sharma
April-June 2020, 36(2):146-147
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