A number of techniques have been described for managing anterior urethral strictures in men. In this review, we aimed to summarize contemporary considerations regarding the holistic management of such strictures. The efficacy of reported outcomes is compared to provide evidence-based treatment recommendations. For anterior urethral strictures, durable long-term success rates of >90% may be achieved if the procedure is performed in capable hands at a high-volume referral center, even in recurrent strictures after previous open reconstruction. A one-stage urethroplasty is preferable to avoid a protracted treatment course with multiple interventions after dilation and direct vision internal urethrotomy. Staged urethroplasties are useful in complex anterior strictures providing durable success rates. In addition, perineal urethrostomy represents a valid last resort option with sufficient objective and subjective results. A follow-up evaluation should incorporate objective assessments such as radiographic and functional diagnostics as well as subjective, validated, and disease-specific patient-reported outcome measurement tools to allow for a better comparability and to improve individual risk prediction.
Introduction: Programmed cell death-1/programmed cell death ligand-1 (PD-1/PDL-1) inhibitors are the newest class of approved drugs for advanced urothelial cancer (AdUC). This review aims to collate the evidence for their efficacy and safety in various treatment settings.
Methods: Extensive search of databases was performed (updated May 2018) and the protocol was registered on PROSPERO (CRD42017081568). The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement. STATA (v 12) and Revman 5.3.5 were used for data analysis.
Results: Ten nonrandomized, open-label clinical trials were included in this review. PD-1/PD-L1 inhibitors were used as second-line, stand-alone in eight trials and as first-line in cisplatin-ineligible in two trials. Heterogeneity was observed for study design, PDL-1 testing methods, cutoff criterias used and translational markers evaluated. The pooled objective response rate (ORR) was 18.2% (95% confidence interval [CI] 15.1–21.2, n = 1785) with PD-1/PDL-1 inhibitors in second-line settings as compared to 12.6% (95% CI 10.3–14.9, n = 736) with second-line chemotherapy and 23.7% (95% CI 19.9–27.4, n = 489) with PD-1/PDL-1 inhibitors as first-line therapy in cisplatin-ineligible patients. The median progression-free survival and overall survival was similar with PD-1/PD-L1 inhibitors in both second- and first-line treatment settings (1.5–2.9 vs. 2.0–2.7 months and 7.9–18.2 vs. 15.9 months) and second-line chemotherapy (3.3–4.0 months and 7.4–8 months). Odds of achieving ORR was 0.10 (95% CI 0.03–0.31, n = 229) in the second-line, stand-alone setting with a combined positive score (CPS) cutoff of 25% and was 0.34 (95% CI 0.19–0.62, n = 265) with a CPS cut-off of 10% in first-line setting in the cisplatin-ineligible.
Conclusions: PD-1/PDL-1 inhibitors appear to be promising in the treatment of AdUC and CPS may be a potentially reliable biomarker for predicting response but needs validation. Caution needs to be exercised until more data are available on imAEs and further studies are required to prove their worth as the standard of care.
Introduction: Evidence-based medicine requires systematic access and appraisal of contemporary research findings, followed by their application in clinical practice. It assumes an even greater significance in the current era of aggressive, industry-driven marketing.
Methods: A questionnaire was designed combining the McColl questionnaire and Barrier scale with relevant modifications and was administered to the urology trainees attending a continuing urological education program. Statistical analysis was performed using SPSS version 25.
Results: The meeting was attended by 110 urological trainees from 55 urological training centers all over India. One hundred and three of them agreed to participate in the study. About 92% of the questionnaires were fully completed. Less than half of the participants (47%) had access to reliable urological literature at work. Only 11% of the respondents claimed to have been formally trained in evidence-based urology (EBU). The inability to understand statistical analysis was the most common (67.4%) perceived barrier to EBU.
Conclusion: The urological trainees in India are positively inclined towards EBU. The lack of formal training in appraising the available literature and lack of protected time, and portals to access the literature at workplaces hinder them from improving their compliance to EBU.
Introduction: We present the short-term voiding patterns and functional and urodynamic outcomes of W-shaped ileal orthotopic neobladder (ONB) following radical cystectomy (RC).
Materials and Methods: Forty-one patients who underwent RC and W-shaped ONB creation between July 2015 and January 2018 were enrolled. Data were analyzed in terms of voiding patterns, urodynamic findings, and functional outcomes at 6 months after surgery. Pouch-related quality of life (QoL) was assessed using European Organization for Research and Treatment of Cancer (EORTC) Generic (QLQ C30), Bladder Cancer-Specific Instruments (QLQ BM30), and IONB–Patient-Reported Outcome (IONB-PRO).
Results: The mean length of follow-up was 19.4 months. At first follow-up, three patients had developed acidosis and rising serum creatinine, and one of them required temporary hemodialysis. One patient developed urethral-pouch anastomotic stricture, which required bladder neck incision. Balloon dilatation was performed for ureteroileal anastomotic stricture and mesh repair for incisional hernia was required in one patient each. Upper tract changes were observed in two patients. During the first and second follow-up, maximum flow rate, voided volume, and postvoid residual urine were 12 ± 4.7 mL/s, 212 ± 120 mL, and 72 + 81 mL and 14.7 ± 5.3 mL/s, 254 ± 168 mL, and 123.7 ± 42.5 mL, respectively. The mean pouch capacity and compliance were 436 ± 103.5 mL and 50.6 ± 17.8 mL/cm H2O. No patient required clean intermittent catheterization for bladder emptying. In EORTC QLQ-C30 questionnaire, the “Cognitive” domain had the highest and “global QoL” domain had the lowest level of functional scores. “Nausea and vomiting and abdominal bloating and flatulence” domain had the lowest level and “financial difficulties and urinary symptoms” had the highest level of symptomatology in EORTC QLQ questionnaire. The IONB-PRO questionnaire showed the highest level of functioning in “relation life” and the lowest level in “emotional life” domain.
Conclusion: The Ghoneim pouch has a low complication rate with near-normal voiding patterns with an acceptable QoL impairment.
Introduction: In the year 2003, Joshi et al. developed a validated outcome assessment tool to measure the ureteral stent-related symptoms. The original English language Ureteral Stent Symptom Questionnaire (USSQ) has been validated in various languages worldwide. Our objective was to develop the USSQ in Hindi, a commonlyused language in India, by validating it in patients undergoing ureteroscopic lithotripsy.
Materials and Methods: A final Hindi version of the USSQ was derived from the original English version to apply to the study population by translation, back translation, and face-to-face interviews. The Hindi and English versions were completed by 70 patients undergoing ureteroscopic lithotripsy with stent in situ, on postoperative days 7 and 8, and 4 weeks after stent removal. Similarly, discriminant validity was checked among 50 healthy individuals. A detailed statistical analysis was used to correlate results (Cronbach's α coefficient, Spearman's correlation, and Mann–Whitney U-test).
Results: A total of 70 patients were enrolled in the study and 61 completed the final assessment. The median age was 35 years (range: 18–60 years). The USSQ domain scores with the stent in situ were higher than poststent status. The test–retest reliability checked by Cronbach's α coefficient (>0.44) and Spearman's correlation coefficient (>0.44) were acceptable to good. We found high discriminant validity of the questionnaire between patients with stent and the healthy controls (P < 0.05).
Conclusion: Our results demonstrate satisfactory validity for the Hindi version of the USSQ for the assessment of quality of life in patients with stent. This is ready for application in the clinical studies and the future stent-related research in Hindi language.
Introduction: Oral mucosal graft (OMG) is the gold standard for urethral substitution but has poor results in long anterior urethral strictures and chronic tobacco-exposed oral mucosa. Saphenous vein has been recently described for long-segment anterior urethral stricture with successful initial results. Our objective was to compare the early outcomes of everted saphenous vein graft (eSVG) substitution urethroplasty in patients with tobacco-exposed oral mucosa and OMG urethroplasty in patients with nontobacco-exposed oral mucosa for long anterior urethral strictures.
Materials and Methods: 30 patients with long anterior urethral strictures underwent substitution urethroplasty using Dorsolateral onlay approach. Fifteen patients with healthy oral mucosa underwent OMG urethroplasty (Group 1) and 15 patients who had unhealthy oral mucosa due to chronic tobacco exposure underwent eSVG urethroplasty (Group 2). Outcomes were assessed with the International Prostate Symptom Score (IPSS); uroflowmetry; donor and recipient site complications at 1, 3, and 6 months; and symptomatic assessment thereafter. Retrograde urethrogram was done at 3 months in both the groups. Successful urethroplasty was defined as satisfactory voiding (Qmax>15 ml/s) and no need for endoscopic dilatation/direct vision internal urethrotomy in follow-up.
Results: Mean stricture and harvested graft length were 10.8 cm and 12.33 cm in Group 1, while in Group 2 were 13.6 cm and 15.73 cm, respectively. Nine of 13 patients in Group 1 (69.2%) and 11 of 14 in Group 2 (78.5%) with a minimum follow-up till 18 months had successful outcome at an average follow-up of 23.13 months. Donor and recipient site complications were comparable in both the groups. At 18 months, mean IPSS and Qmax in successful patients were 7.9 and 25.6 ml/s in Group 1, while in Group 2 were 8.0 and 22.6 ml/s.
Conclusions: Outcomes of great saphenous vein graft urethroplasty are comparable to OMG, and it is an acceptable option in long-segment anterior urethral stricture patients with chronic tobacco-exposed oral mucosa.
Introduction: Rational use of antibiotics and strict adherence to practice guidelines is essential to prevent antibiotic resistance. The best surgical prophylaxis protocol requires tailoring of the available guidelines in accordance to the local bacterial flora. We designed a protocol for surgical prophylaxis to check the rampant abuse of antibiotics in the department of urology and evaluated its feasibility.
Materials and Methods: Patients admitted for elective major surgeries under a single unit of our department over a period of 5 months were included in the study. A protocol for antibiotic prophylaxis was designed based on the European Association of Urology guidelines and the local hospital antibiogram. Single-dose intravenous cefuroxime was administered to the patients undergoing clean and clean-contaminated surgeries. Extended protocols were formulated for contaminated surgeries. Postoperative course and complications were recorded. Effectiveness was defined as adherence to the protocol (without an addition or a change in antibiotic regimen) along with an uneventful postoperative course. Prospectively maintained data were analyzed using descriptive statistics.
Results: Data of 277 patients were analyzed. The mean age was 48.37 ± 17.39 years and 27.1% had comorbidities. Majority of the surgeries were clean contaminated (81%), and 60.3% of the total were endoscopic. The protocol was effective in 89.5% of the patients (248/277). The failure rate was higher for the contaminated procedures (41.7%) (odds ratio – 6.43; confidence interval = 1.51–27.2, P < 0.001). Post-operative sepsis with or without shock was the commonest cause (16/29, 55.2%) of protocol failure. Fourteen out of the 16 patients who developed sepsis had undergone endourological surgeries.
Conclusions: Protocol-based perioperative antibiotic prophylaxis in urological surgeries is feasible. Similar protocols should be developed and validated at other major centers to limit the unnecessary use of antibiotics and prevent the emergence of antibiotic resistance.
Introduction: The aim of this systematic review is to compare chemotherapeutic agents commonly used in treating recurrent urinary infection in nonpregnant women by their efficacy, tolerability, adverse effects, and cost employing network meta-analysis.
Materials and Methods: We used three online databases, i.e., PubMed, ScienceDirect, and Cochrane Central Registry of Clinical Trials. Randomized controlled trials (RCTs) on the use of prophylactic chemotherapeutic agents used in treating nonpregnant women with recurrent urinary tract infections (RUTIs) published between 2002 and 2016 were selected. Only published papers in English were assessed for study quality, and meta-analyses were performed using fixed-effects model with NetMetaXL.
Results: Six RCTs fulfilled the criteria. When all three variables, i.e., efficacy, adverse effects and cost were considered, nitrofurantoin 50 mg once daily for 6 months appears to rank high for prophylaxis against RUTI. When efficacy was the only factor, fosfomycin had the highest superiority compared to D-mannose, nitrofurantoin, estriol, trimethoprim–sulfamethoxazole, and cranberry juice, respectively. However, fosfomycin was also ranked highest by adverse events. When cost alone is considered, nitrofurantoin appeared the most cost-effective agent while placed third for efficacy alone.
Conclusion: Selecting appropriate chemotherapeutic agents for RUTI will need to factor in effectiveness, adverse effects, and cost. While it is difficult to select an ideal drug, evaluation using network analysis may guide choice of medication for best practice.
Vascular complications are the most feared complication of percutaneous renal procedures. Hematuria and perirenal hematomas, if they occur, usually arise from injury to renal arteries or its branches. Lumbar artery injury after percutaneous renal procedures is a rare occurrence. We report two cases of lumbar artery injury: one after antegrade ureteric stenting and the other after percutaneous renal biopsy. Both were successfully treated by transcatheter embolization.
Stomal stenosis post perineal urethrostomy (PU) is a common problem. Management options for patients with PU stomal stenosis include dilatation, buccal mucosal augmentation of stoma, PU revision, and continent catheterizable stoma. In the present case, Turner-Warwick scrotal drop back procedure was performed as revision PU.
Duplication of ureter is an uncommon anomaly with a reported incidence of 0.6%–1%. It can be either complete or a partial duplication. We present a case of live-related renal transplant in which complete duplication of ureter was found as a surprise during bench preparation of the donor kidney, which was reported as partial duplication on the pre-operative multidetector computed tomography. A common ostium was made from the two ureters and was anastomosed to the bladder. At 2-months follow–up, the patient has good graft function and no evidence of ureteric complications. Since double ureter does not seem to increase urological complications, such donors should not be rejected.
Urethral strictures may present due to many causes. Obstructive urinary symptoms secondary to urethral malignancy is a rare presentation. Moreover, primary giant-cell tumor (GCT) arising in the urethra is an extremely unusual entity, which, to the best of our knowledge, has not been described till date; therefore, the clinical behavior is uncertain. We report a clinically unsuspected case of GCT of the urethra, who presented with urethral stricture.
A 65-year-old male patient, a known case of carcinoma bladder, underwent radical cystectomy with ileal neobladder in 2016. Eleven lymph nodes were identified in the specimen. Histopathology revealed reactive lymphadenitis with sinus histiocytosis. The patient presented with a swelling in the right thigh, associated with dull pain, about 6 months after the procedure. Ultrasound of the right thigh and computed tomography of the region showed an isolated, large, loculated, cystic collection measuring 15 cm × 6 cm with internal septation in the pectineus and adductor longus muscles. Complete aspiration of fluid from the right thigh was done with ultrasound guidance and sent for analysis. The fluid appeared to be lymph, and the lesion turned out to be a lymphocele. There was no recurrence or infection following the aspiration till last follow-up visit. We report this rare lymphocele presentation (in the thigh without any extension from pelvis or groin) after 6 months, following radical cystectomy with neobladder, which was treated by one-time aspiration.
Massive bilateral renomegaly with maintained renal morphology in infants is a rare entity. We present the images of a A 9-month-old female child who presented with massive bilateral renomegaly with maintained renal morphology due to acute lymphoblastic leukemia.
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