Introduction: Sarcoidosis is a multisystem disease that commonly involves the lungs, but may also present with extrapulmonary manifestations. Genitourinary (GU) tract involvement has been traditionally thought to be rare, but that view may underestimate the true prevalence of the disease due to the often, silent presentation thereof.
Methods: The literature pertaining to sarcoidosis from the general systemic point of view, etiology and therapy and with regard to specific organs was reviewed by identifying key words in a PubMed search. That material with special relevance to the Indian experience was emphasized.
Results: There are a number of isolated case reports in the literature describing symptomatic and asymptomatic GU tract sarcoidosis. The world literature associated with the generalized syndrome was reviewed and summarized. Specific aspects of GU involvement are presented for each organ of the GU tract.
Conclusions: It is critical for the practicing clinician to have a working knowledge of the clinical manifestations of this disease as it involves the GU tract, as well as to be able to distinguish it from tuberculosis and the various malignancies that affect this organ system.
Introduction: Nanotechnology has revolutionized our approach to medical diagnostics as well as therapeutics and has spanned an entirely new branch of research. This review addresses the potential applications of Nanotechnology in Urology. This article is based on the Dr. Sitharaman Best Essay award of the Urological Society of India for 2016.
Methods: A PubMed search was performed for all relevant articles using the terms, “nanotechnology, nanoparticles, nanoshells, nanoscaffolds, and nanofibers.”
Results: The developments in diagnostics include novel techniques of imaging of genitourinary malignancies, prostate-specific antigen measurement, early detection of mutations that are diagnostic for polycystic kidney disease. The potential applications of nanotechnology are in the targeted therapy of genitourinary malignancies, erectile dysfunction, overactive bladder, bladder reconstruction, construction of artificial kidneys and biodegradable stents as well as in robotic surgery.
Conclusions: Nanotechnology is a rapidly emerging branch of research in urology with diverse and clinically significant applications in diagnostics as well as therapeutics.
Neuroendocrine tumors which have the potential to secrete catecholamines are either associated with sympathetic adrenal (pheochromocytoma) or nonadrenal (paraganglioma) tissue. Surgical removal of these tumors is always indicated to cure and prevent cardiovascular and other organ system complications associated with catecholamine excess. Some of these tumors have malignant potential as well. The diagnosis, localization and anatomical delineation of these tumors involve measurement of catecholamines and their metabolic end products in plasma and urine, 123I-metaiodobenzylguanidine scintigraphy, computed tomography, and/or magnetic resonance imaging. Before surgical removal of the tumors, the optimization of blood pressure, as well as intravascular volume, is an important measure to avoid and suppress perioperative adverse hemodynamic events. Preoperative preparation includes the use of alpha-adrenergic antagonists, beta-adrenergic antagonists with or without other antihypertensive agents, fluid therapy as well as insulin therapy for hyperglycemia if required. Due attention should be given to type and dose of alpha-receptor antagonists to be used and the duration of this therapy to achieve an optimal level of preoperative “alpha-blockade.” Despite this preoperative preparation, many patients will have hypertensive crises intraoperatively which need to be promptly and carefully managed by the anesthesia team which requires intensive and advanced monitoring techniques. The most common complication after tumor removal is hypotension which may require fluid therapy and vasopressor support for a few hours. With advancement in surgical and anesthetic techniques, the incidence of severe morbidity and mortality associated with the surgery is low in high volume centers.
Introduction: The artificial urinary sphincter (AUS) is the mainstay of surgical treatment for male stress urinary incontinence. Although urethral erosions are a known complication, their temporal distribution and optimal management have not been well characterized. We seek to evaluate the timing, etiologies, and management of urethral erosions in primary AUS implantations.
Materials and Methods: 1802 male patients underwent AUS procedure at Mayo Clinic (Rochester) from 1983 to 2011, including 1082 primary placements. Of primary placements, 63 had a urethral erosion of their device requiring explanation and were included in our analysis. All cases of urethral erosion were confirmed at the time of explantation through cystoscopy and direct visualization. At our institution, explantation is typically performed without primary urethral repair.
Results: There were 63 cases (5.8%) of urethral erosions of primary AUS devices during the study time frame. The median age at AUS implantation was 74 years (interquartile range [IQR] 68–77 years) and median time to explantation was 21 months (IQR 5–59 months). The temporal trend of AUS erosions demonstrates a peak in the 1st year, with a gradual tapering of cases thereafter, persisting beyond 10 years. Three of 36 (8.3%) patients with follow-up developed a urethral stricture. Overall, 32/63 patients (51%) underwent salvage AUS reimplantation at a median of 7.1 months (IQR 3.1–12.9 months).
Conclusions: Urethral erosions tend to occur early (within 1–2 years), with gradual tapering over time. However, continued vigilance is needed after AUS placement to decrease late erosions. These data can be used for counseling and to help guide follow-up care of patients with AUS.
Introduction: The computed tomographic angiography (CTA) renal donor protocol is an established method of preoperative renal vascular pedicle evaluation in prospective renal donors. However, CTA is associated with significant radiation exposure and intravenous contrast administration. The newer noncontrast-enhanced magnetic resonance angiography (NCE-MRA) techniques, especially arterial spin labeling (ASL) with steady-state free precession (SSFP) hold promise as an effective alternative. We prospectively compared CTA with NCE MRA for accuracy in the evaluation of renal arterial anatomy in prospective renal donors.
Methods: A total of 43 subjects underwent CTA followed by NCE MRA in a prospective comparative study. The number of renal arteries and early branching of renal arteries were noted in both kidneys in all subjects. Intermodality agreement was calculated using “K” (Kappa) statistics and 95% confidence interval for both modalities.
Results: A total of 63 single, 21 double, and 2 triple arteries were detected in 43 subjects on CTA. CTA showed an early branch in 17 kidneys. NCE MRAshowed 64 single arteries, 20 double arteries, and 2 triple arteries. A total of 14 kidneys showed an early branch. Unweighted Kappa statistic of agreement between CTA and NCE MRA for number of renal arteries and for frequency of early branching was 0.9707 and 0.8822, respectively.
Conclusions: The newer NCE MRA techniques such as ASL with SSFP among others are potential alternatives for CTA, in the evaluation of prospective renal donors.
Introduction: The knowledge of detailed calyceal anatomy is essential for performing urologic procedures such as percutaneous nephrolithotomy, percutaneous nephrostomy, flexible ureterorenoscopy, endopyelotomy, and retrograde renal surgery. This study was performed to analyze the various patterns of pelvicalyceal system in the South Indian population, and compare these with previously published studies in different populations.
Methods: The study was conducted in 100 kidney specimens. Morphologically undamaged kidneys belonging to both sexes were removed en bloc from cadavers and autopsy cases of the Departments of Anatomy and Forensic Medicine, respectively. The specimens were carefully dissected, and the percentage of various patterns was compared with previous studies.
Results: The renal pelvis was found to be intrarenal in 79% of the specimens. The most common type of anatomy was a bicalyceal system with two major calyces, one each from the upper and lower poles, with the middle zone drainage dependent on any one or both of them. An interesting and rare variation of extrarenal calyces with the absence of renal pelvis was observed in 1% of the specimens. In addition, the presence of minor calyces opening directly into the renal pelvis was seen in 8% of the specimens.
Conclusion: A biclayceal system of drainage with intrarenal pelvis is the most common calyceal pattern in the kidneys. The patterns must be borne in mind while examining a radiological report involving the kidneys.
Introduction: Traditional percutaneous nephrolithotomy (PCNL) training involved subjective award of cases to the trainee. We restructured this according to the Guy's stone score (GSS) such that each trainee stepwise completed 25 cases of each grade before progressing. This study compares the outcomes of training with traditional versus stepwise approach.
Methods: Four hundred consecutive cases equally distributed for two trainees in each group were compared in terms of complications (Clavien-Dindo), stone free rate (SFR), operative and fluoroscopy time. External comparison was also done against a benchmark surgeon. Multivariable regression model was created to compare SFR and complications while adjusting for comorbidity, Amplatz size, access tract location, number of punctures, body mass index, stone complexity, and training approach.
Results: The distribution of cases in terms of calculus complexity was similar. Overall, in comparison to traditional training, stepwise training had significantly shorter median operative time (100 vs. 120 min, P < 0.05), fluoroscopy time (136 vs. 150 min, P < 0.05) and fewer overall (29.5% vs. 43.5%, P < 0.005) as well as major complications (3% vs. 8.5%, P - 0.029), though initial SFR was higher but not statistically significant (77% vs. 71.5%). On multivariable analyses, stepwise training was independently associated with lower complications (odds ratio 0.46 [0.20–0.74], P - 0.0013) along with GSS grade, number of punctures, and Amplatz size. Stepwise training had similar fluoroscopy time, major complications and final clearance rate compared to expert surgeon.
Conclusions: PCNL has a learning curve specific for each grade of calculus complexity and stepwise training protocol improves outcomes.
Introduction: Percutaneous nephrolithotomy (PCNL) has undergone significant changes in recent years in the quest for improving efficacy and reducing morbidity. Newer minimally-invasive modalities of PCNL such as mini-PCNL, ultra-mini PCNL, and micro-PCNL have evolved with advancement in optics and technology. However, with these newer advancements, migration of small fragments produced with laser lithotripsy remains a concern, which may result in incomplete stone clearance. We describe a new technique of PCNL termed “Superperc”, that utilizes suction to remove all the fragments and maintain one-way flow.
Methods: This was a prospective observational study involving 52 consecutive patients who underwent PCNL with the Superperc technique from April 2014 to June 2015. Surgery was performed using a pediatric ureteroscope used as a nephroscope and a specially designed sheath with a suction attachment. The Superperc uses a 10/12 F tract size, specially designed Superperc sheath (Shah Sheath) with suction mechanism and a pediatric ureteroscope (4.5/6 Fr, Richard Wolf) as nephroscope.
Results: The mean age of the group was 41.8 years (range 6–84) with 33 males and 19 females. Mean stone size was 19.11 mm (range 10–37 mm) and mean operative time was 40.9 min (range 26–92 min). Twenty-seven renal units had upper calyceal puncture, whereas 12 had middle, 8 lower calyceal and 5 had two punctures. DJ stent was placed in 20 patients, whereas 32 patients were totally tubeless. Only three patients required a nephrostomy tube. The mean hemoglobin drop was 0.32 g with no blood transfusion. Postoperatively, three patients had a mild fever and one had transient hematuria. The stone clearance rate in our study was 96.15% and the mean hospital stay was 31.5 h (range 22–76 h).
Conclusion: Superperc is a new technique of minimally-invasive PCNL and can be successfully done with minimal modification in armamentarium, with the potential advantage of good stone clearance.
Introduction: Double J (DJ) stents are often removed under local anesthesia using a rigid cystoscope. Patients experience significant pain during this procedure and also continue to have discomfort during voiding for a few days. We assessed the efficacy and safety of preemptive oral diclofenac in pain relief in patients undergoing DJ stent removal (DJSR) by rigid cystoscopy compared to placebo.
Methods: Consecutive consenting male patients undergoing DJSR under local anesthesia between March 2014 and July 2015 were enrolled. Patients were randomized to receive 75 mg oral diclofenac (Group A) or placebo (Group B) 1 h before procedure by double-blind randomization. Intraurethral 2% lignocaine gel (25 ml) was used in both groups. Pain during rigid cystoscopy, pain at the first void, and at 24 h after cystoscopy was assessed using visual analog scale (VAS) (0–100). Adverse reactions to diclofenac and episodes of acute urinary retention, if any, were assessed (Trial registered at clinicaltrials.gov: NCT02598102).
Results: A total of 121 males (Group A [n = 62]; Group B [n = 59]) underwent stent removal. The median (Interquartile range) VAS during the procedure in Group A was 30 (30) and Group B was 60 (30) (P < 0.001), at first void was 30 (30) and 70 (30) (P < 0.001) and at 24 h postoperatively was 20 (20) and 40 (20) (P < 0.001). The incidence of epigastric pain, nausea, vomiting, and acute urinary retention was comparable in the two groups (P > 0.05).
Conclusions: A single oral dose of diclofenac administered 1 h before DJSR using rigid cystoscope under intraurethral lignocaine anesthesia decreases pain significantly during and up to 24 h postprocedure with minimal side effects.
Introduction: The main disadvantage of currently described techniques of spongioplasty is superimposition of 3 suture lines (neourethra, spongioplasty, and skin closure) which is likely to increase the chances of a fistula. We describe and evaluate the results of a double breasting spongioplasty in urethroplasty.
Methods: A prospective study of 60 primary hypospadias was undertaken by double breasting spongioplasty from August 2012 to March 2014. Mobilization of the urethral plate and the spongiosum is done by creating a plane just proximal to the meatus. Double breasting spongioplasty is done after tubularization of urethral plate. First layer of spongiosum is sutured toward lateral side of the neourethra covering the suture line. A second double breasting layer is sutured over the first layer with its suture line toward the opposite side covering the suture line of the first layer; thus avoiding overlapping of suture lines of all the three layers.
Results: Age of the patients varied from 10 months to 16 years with a mean and median of 3.73 and 3.50 years, respectively. Hypospadias was distal, mid, and proximal in 38, 10, and 12 cases, respectively. Chordee was noticed in 35 cases and torque in 28 cases. Overall complication rate was 5% and fistula rate was 1.66%.
Conclusions: Double breasting spongioplasty avoids superimposition of suture line and adds two layers of spongiosum over neourethra, thus decreases the chances of urethral fistula and gives cylindrical shape to neourethra.
Introduction: We aimed to determine whether the number and type of risk factors are associated with biochemical recurrence-free survival after radical prostatectomy in men with D'Amico intermediate-risk prostate cancer.
Materials and Methods: Between August 1998 and May 2013, 481 Japanese patients underwent antegrade radical prostatectomy. The relationships between the rate of PSA failure after radical prostatectomy and the number and type of risk factors were examined in the intermediate-risk group.
Results: According to the D'Amico criteria, the low-, intermediate-, and high-risk groups comprised 107, 222, and 152 patients, respectively. The median follow-up period after surgery was 54.1 months. The 5-year PSA failure-free rates in the low-, intermediate-, and high-risk groups were 96.5%, 88.9%, and 72.6%, respectively (P < 0.001). The 5-year PSA failure-free rate in the intermediate-risk group with one, two, and three intermediate risk factors was 94.9%, 88.4%, and 49.0%, respectively (P < 0.001). The difference between the high- and intermediate-risk group with three intermediate risk factors was statistically significant based on the log-rank test (P = 0.039).
Conclusion: The number of intermediate risk factors is significantly associated with the PSA failure-free survival rate after radical prostatectomy in the intermediate-risk group. Patients classified into the intermediate-risk group based on all three intermediate risk factors are less likely to achieve a complete cure through surgery alone.
The stomach is the preferred augmentation option for a contracted bladder in a patient with renal failure. A 49-year-old female presented with right solitary functioning kidney with tuberculous lower ureteric stricture and contracted bladder. Her creatinine was 2.8 mg%. By laparoscopic approach, right gastroepiploic artery based gastric flap was isolated using staplers and used for augmentation and ureteric replacement. At 6-month follow-up, her creatinine was 1.9 mg%, and bladder capacity was 250 ml. She had mild hematuria, which settled with proton pump inhibitors. Laparoscopic gastrocystoplasty is feasible and effective augmentation option in those with renal failure, giving the benefits of minimally invasive approach.
Renal Angiomyolipoma (AML) is not commonly seen in the pediatric age group other than patients of tuberous sclerosis where in they can have renal AMLs within the first decade with bilateral in involvement. Diagnosis of renal AML can generally be made by the current radiological modalities in the appropriate clinical setting, but it can be mistaken for other tumors when it is large and has low-fat content. Herein we report a case of giant renal AML that was initially misdiagnosed as a Wilms tumor in a 12-year-old girl.
Tyrosine kinase inhibitors sunitinib and pazopanib are used as first-line agents in the treatment of metastatic renal cell carcinoma. Treatment-related toxicities have been described with both these drugs. This report describes a patient with metastatic renal carcinoma who developed trismus while being treated with these agents and is, to the best of our knowledge, the first such case to be reported.
Xanthoma cystitis of urinary bladder is a rare entity and may present as an intravesical mass. A 38-year-old female presented with abdominal pain and imaging was done which was suggestive of a malignant mass with surrounding tissue infiltration. Partial cystectomy was performed, and histological examination of the mass showed xanthomatous cystitis.
Pheochromocytoma has atypical presentation in 9%–10% of patients. Atypical presentations include myocardial infarction, renal failure, and rarely cerebrovascular events. Various etiologies for central nervous system (CNS) involvement in pheochromocytoma have been described in the literature. A rare association of CNS vasculitis-like features has been described with pheochromocytoma. We report a rare case of pheochromocytoma detected on evaluation for CNS vasculitis-like symptoms.
Transplantable organs from pediatric donors have been contributing significantly to donor pool worldwide. Pediatric donors are excellent resources that should be procured whenever available, and with the recent increase in deceased donations in India, more pediatric donors will be available for organ harvesting. We share a rare instance of multi-organ harvesting from a 16-month old brain dead donor and implanting both kidneys en-bloc in an adult male, while liver went to a 4-year old child. The report provides the surgical illustration of salient steps of transplanting both kidneys from pediatric donor into an adult, in an en-bloc manner.
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