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   Table of Contents - Current issue
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October-December 2021
Volume 13 | Issue 4
Page Nos. 329-445

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ORIGINAL ARTICLES  

Post-transurethral resection of prostate urethral strictures: Are they often underreported? A single-center retrospective observational cohort study p. 329
Hariharasudhan Sekar, Velmurugan Palaniyandi, Sriram Krishnamoorthy, Natarajan Kumaresan
DOI:10.4103/UA.UA_165_19  
Objectives: Post-transurethral resection of prostate urethral stricture (PTS) is a well-documented delayed complication following transurethral resection of the prostate (TURP). The aim is to analyze various risk factors of PTS and see if the overall incidence is underreported. Materials and Methods: A retrospective study was conducted in our institution between January 2017 and December 2018 in men who underwent TURP. Data obtained from the medical records department were analyzed. Statistical analysis was done using Fisher's exact test. A two-tailed P < 0.05 is considered statistically significant. Results: Of the 447 men who underwent TURP, 57 developed PTS. Fifteen of 334 patients who underwent calibration before the procedure developed stricture compared to 42 of 137 without calibration (P < 0.01). There was a significantly lesser incidence of stricture with 24 Fr resectoscope compared with 26 Fr sheath (P < 0.04). Two patients with 24 Fr Foley and 30 of 35 (86%) patients with 22 Fr Foley catheter developed stricture of urethra. Distal bulbar urethra was the most common site of narrowing following TURP. Eighteen patients had Salvaris swab placed for traction and 12 patients required full-thigh traction, of which majority developed meatal stenosis. Conclusions: TURP is one of the common surgical procedures performed by urologists. Meatitis and meatal stenosis, if included as complications of TURP, would increase the overall incidence of PTS. Factors such as the size of resectoscope sheath used, size of catheter inserted, placement of Salvaris swab traction, and preoperative calibration of urethra have a significant impact on the ultimate outcome.
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Bilateral same session renal stone surgery tolerance and complications p. 336
Abdulmalik Addar, Ahmed Aljuhayman, Yahya Ghazwani, Abdullah Al Khayal, Ahmed Alasker, Esteban Emiliani, Saeed Bin Hamri
DOI:10.4103/UA.UA_128_20  
Introduction: The prevalence rate of upper urinary tract calculi in Saudi Arabia is one of the highest globally. Bilateral renal stone management is an option but is still controversial. Methodology: The study was a retrospective study, including 31 patients with bilateral renal or ureteric stones who underwent bilateral same-session ureterorenoscopy (BSS-URS). The data collected included age, gender, body mass index (BMI), stone burden bilaterally, operative time bilaterally, hospital stay, stone location, type of anesthesia, stone history, renal anomaly as well as pre- and postoperative JJ stenting. In addition, data related to complications (ureteric injury, renal failure, urinary tract infection, pain requiring an emergency department visit within 1 week of the procedure), the stone-free rate (defined as £ 3 mm asymptomatic stone fragment identified with computed tomography Kidney, Ureter and Bladder 3 months after surgery was also collected. The data were collected from the electronic patient record system, entered in an Excel spreadsheet, and descriptive analysis was done. Results: In total, 31 patients were included, with the majority (80.6%, n = 25) male. The mean age was 41.6 years, the mean BMI 28.7 ± 5.59, the mean operative time for each renal unit 46.53 ± 25.69 min, and the mean hospital stay 17.87 ± 8.43 h. The majority (96.7%, n = 30) received general anesthesia. Less than half (40.3%, n = 25) of the renal units had stones in multiple calyces and the majority (90.3%, n = 56) of the renal units were stone free at the 3-month follow-up. A small proportion (3.2%, n = 2) of the renal units were polycystic. Prestenting was documented in 40.3% (n = 25) of the renal units and the majority (95.2%, n = 59) were stented postoperatively. Conclusion: BSS-URS is a safe and a highly effective management option for bilateral renal stones.
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Postoperative infective complications following percutaneous nephrolithotomy p. 340
G Manoj Kumar, KP Nirmal, G Sathish Kumar
DOI:10.4103/UA.UA_153_20  
Introduction: Percutaneous nephrolithotomy (PCNL) is recommended as the first choice of therapeutic strategy for patients with renal stones larger than 2 cm. It is reported that up to one-third of patients might have some perioperative complications, especially fever and urinary tract infections, which constitutes about 21%–39.8% of all the complications. Primary and Secondary: The primary aim of the study was to study about the proportion of patients getting post-operative infective complications following PCNL. The secondary aim was to study the patient, stone and procedure related risk factors associated with the infective complications. Settings and Design: This is an institution-based observational study. Materials and Methods: All patients who underwent PCNL in the Department of Urology, Medical College, Thiruvananthapuram, during 3 years from September 2016– to August 2019, were included in the study. In this study, the demographic factors and factors related to the patient, stone, and the procedure were collected and analyzed. Statistical Analysis Used: Data analysis was performed using SPSS version 22.0. Results: During the 3-year period, a total of 201 patients with renal stones were treated with PCNL in our hospital. Of this 190 cases were taken for analysis. The mean age of patients was 47.7 years, 148 (77.9%) were male, 42 (22.1%) were female, The final outcomes evaluated were episodes of fever, documented urinary tract infection (UTI), pyelonephritis, and sepsis. Thirty-six (18.9%) patients had fever, of which 21 (11.1%) had UTI, 6 (3.1%) had pyelonephritis and 5 (2.6%) developed sepsis. Conclusions: Post-PCNL complications are more commonly found in patients with history of preoperative UTI, previous history of renal surgeries, large stone burden, operative procedure more than 90 min, and presence of residual calculi.
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Empirical therapy for male factor infertility: Survey of the current practice p. 346
Abdullah M Al Khayal, Faisal K Balaraj, Turki A Alferayan, Mutaz A Al Sait, Saad M Abumelha, Khalid A Alrabeeah
DOI:10.4103/UA.UA_22_20  
Background: Empirical therapy is sometimes used by urologists who desire to improve the outcomes for infertility patients. However, the literature on empirical therapies is scarce. Therefore, we aimed to assess the clinical practice of urologists regarding the use of empirical therapy in the treatment of infertility patients. Methodology: An online survey using Google Forms was used to collect data during the Saudi Urological Association Annual Meeting, February 2019. Additional data were gathered electronically in March and April 2019 and sent to respondents. The study was closed in May 2019. No incentives were provided to the respondents. Results: A total of 96 (80%) urologists participated in the survey, of whom 69.8% were consultants, and 20.8% were andrology-trained urologists. Empirical therapy was used by 86.5% of urologists for patients with idiopathic oligoasthenoteratozoospermia. The most commonly used empirical therapies were zinc, L-canitine, clomiphene citrate, and L-arginine. The main factors that influenced the selection of empirical therapy were follicle-stimulating hormone, total testosterone, and luteinizing hormone levels. Conclusion: Empirical therapy was used by more than three-quarters of the participants for idiopathic male infertility. There were no clear guidelines for the ideal therapy to be considered for individual patients while treating empirically. Our concern is that urologists use a wide variety of medications without significant data to support these medications.
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Penile fracture: Institutional experience of 14 cases p. 351
Rajendra K Shimpi, Pranay J Patel, Suraj T Bhondave
DOI:10.4103/UA.UA_27_20  
Background: Penile fracture due to various causes is urological emergency condition, which can be diagnosed on history and clinical examination of the patient. Appropriate management in each case prevents patients from future physical and psychological consequences. Materials and Methods: Fourteen patients were included in the study. The study was carried out at Ruby Hall Clinic, Pune, India, between January 1, 2016, and December 31, 2019. All patients were evaluated by history and clinical examination and radiographic investigation in suspected urethral injury. Results: Fourteen patients with penile fracture, between 20 and 50 years, were in the study. The most common mechanism of injury was abnormal positional coital activity. About 85.71% of patients were diagnosed with a history and clinical examination. Ninety-three percent of patients were treated surgically and had a successful outcome. One patient had associated urethral injury. All patients had good sexual function posttreatment except one who later recovered well on medical management. Conclusion: Early diagnosis and treatment of patients with penile fracture depend on the history and clinical examination with less role of radiological investigations. The appropriate treatment gives a good outcome.
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The accuracy of computed tomography in the diagnosis of upper urinary tract urothelial carcinoma in correlation with the final histopathology: A retrospective study in 275 patients at a Tertiary Urology Institute p. 356
Rasha T Abouelkheir, Mohamed Mohamed Elawdy, Diaa Eldin Taha, Mohamed Abd El-Hamid, Yasser Osman, Tarek El-Diasty
DOI:10.4103/UA.UA_32_20  
Introduction: Because the reports in the literature of radiologic investigations for upper tract urothelial cancer (UTUC) are limited by the number of patients, and included patients with different pathologies, we aimed to study the overall accuracy of computed tomography (CT) in the diagnosis of UTUC and their accuracy on predicting tumor location. Methods: A retrospective review from 1990 to 2017 included patients who were treated for UTUC. Unenhanced CT scan was obtained first using Multi-Detector Computed Tomography (MDCT, Philips Medical Systems), then nonionic contrast medium, containing 350 mg iodine /ml was injected at 4 mL/s. Analysis was performed using SPSS®. Results: Of 275 patients, complete data on CT was available on 270 (98%) patients. CT reported only two false positive and six false negative results and the overall accuracy was 96-97%. In comparison to the final pathological reports, CT /CTU detected 85% of the tumor location of in the renal pelvic and 50% of the calyceal tumors. In ureteric tumors, they detected distal (66/71= 93%) more than proximal ureteric tumors (60%). Conclusion: In our cohort, CT/ CTU has a high overall accuracy (97%) in diagnosing UTUC, capability to well visualize tumors of distal ureter and renal pelvis, but could miss calyceal tumors. The matter to rely only on CT without ureteroscopic biopsy in the diagnosis of UTUC especially if radical surgery is planned needs further prospective studies.
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Use of conventional DJ stent and single loop stent with string after ureterorenoscopic lithotripsy: Can we use? Can it be effective? p. 362
Sonu Sharma, Vilas Sabale, Abhirudra Mulay, Sunil Mhaske, Vikram Satav, Surya Nihar
DOI:10.4103/UA.UA_113_20  
Context: Use of conventional double j stent with string and single loop stent with string after ureterorenoscopy. Aim: The aim of this study was to compare the use of both types of stents using the Ureteral Symptom Score Questionnaire (USSQ) and assess proximal migration. Settings and Design: This was a single institute study. Subjects and Methods: A total of 96 female patients with unilateral ureteric stones were enrolled. Patients underwent ureterorenoscopic lithotripsy, conventional double J (DJ) stent with string and single loop stent with string was placed. Before stent removal at 7–10 days, they were evaluated with X-ray kidney ureter bladder for proximal migration and USSQ for stent-related complaints. Statistical Analysis Used: Data were analyzed using Chi-square and Student's t-test. Results: In our study, Group A (DJ loop with string) had 51 patients and Group B (single J loop with string) had 47 patients. The mean stone size in group A was 10.06 mm and Group B was 9.7 mm. Both groups had one case each of early stent expulsion and none had proximal migration of the stent. Group A had two cases of urinary tract infection and Group B had one case which resolved on antibiotics. Evaluating the USSQ questionnaire in both groups, urinary symptoms such as urgency (P = 0.03), dysuria (P = 0.02), interference with life (P = 0.01), and quality impact overall (P = 0.016) were statistically significant. Evaluating pain, sleep disturbance (P = 0.04), pain at voiding (P = 0.03), and flank pain during voiding (P = 0.018) was statistically significant. In general health, difficulty with heavyweight physical activity (P = 0.02), feeling calm (P = 0.16), social life enjoyment (P = 0.26), and need for extra help (P = 0.008) was significant. In sexual matters, 13 (28%) patients in Group B had no active sex (conscious) and 6 (12%) patients had stopped intercourse due to stent-related symptoms, whereas in Group A, it was 10 (20%) and 2 (4%) patients, respectively. Conclusions: The use of a single J stent with string is an effective method, has lesser complication, and is easier to remove.
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Evaluation of the urology residency training program in Saudi Arabia: A cross-sectional study p. 367
Mohammad Abdulkareem Alkhamees, Sulaiman A Almutairi, Ahmed M Aljuhayman, Hammam Alkanhal, Saad H Alenezi, Mana Almuhaideb, Sultan S Alkhateeb
DOI:10.4103/UA.UA_117_20  
Purpose: This study evaluates the satisfaction of urology residents with the Saudi Board of Urology (SBU) Training Program and identifies areas of weakness and strength to improve the educational environment, surgical competency, and overall satisfaction of urology residents with the program. Methods: We administered an electronic self-made questionnaire that included two sections. One comprised demographic data (age, gender, weight, height, marital status, level of training, city of training, and center of training), while the other concerned SBU evaluation (satisfaction with different aspects of training, such as ways of assessment, mentors' feedback, surgical competency, research, and strengths and weaknesses of SBU). Results: The overall satisfaction of urology residency program was 28.8% while 44.2% of residents had a neutral response. The highest level of satisfaction with clinical and surgical practice was among graduates (56.9%) and Riyadh residents (45.1%). Furthermore, good work/life balance received the lowest level of satisfaction (5.2%) among senior residents, while good clinical experience received the highest level (62.7%) among the graduates. Residents reported a high exposure in endourology and pediatric urology, while transplant, reconstructive, and neurourology had the lowest exposure. Forty-two percent of respondents undertook research during their residency training, but most respondents (54%) did not publish any research papers during their training. Sixty-two percent of graduates felt that their training program did not prepare them adequately to perform well on the board examinations. Conclusion: Our results confirmed that satisfaction of residents with the urology program process is variable according to the city of training. Having high satisfaction level in some cities reflects the improvement of urology training program after restructuring. We identified new areas in need of improvement, namely lack of mentorship, clear and formal assessment process, and variation of training process between central and peripheral programs.
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Comparison of single-step renal dilatation and serial renal dilatation in percutaneous nephrolithotomy: A retrospective case–control study p. 374
Amit Sharma, Sandesh Parab, Gaurav Goyal, Ajit Patel, Mukund Andankar, Hemant Pathak
DOI:10.4103/UA.UA_118_20  
Background: Access to the pelvi-calyceal system and subsequent dilatation of the tract are among the initial important steps in percutaneous nephrolithotomy (PCNL). In this study, we share our experience with single-step renal dilatation when compared to multiple serial renal dilatation in PCNL. Materials and Methods: This is a retrospective study wherein 35 patients who underwent PCNL by single-step renal dilatation by appropriate size Amplatz Dilator were compared with 35 patients who underwent multi-step serial renal dilatation using serial metallic Alken dilators. These patients were analyzed on the basis of demographic profile, total intra-operative time, fluoroscopic time, intra-operative and postoperative complications, stone clearance, requirement of blood transfusion, duration of hospital stay, and follow-up. Results: There were no significant differences in the demographic profile among the patients in these two groups. The mean total operative duration and fluoroscopic duration were less in single step renal dilatation group, and these have been found to be statistically significant (P < 0.05). There were no statistically significant differences in the rates of other complications – incomplete stone clearance, bleeding and hematoma formation, requirement of blood transfusion, duration of hospital stay, and follow-up. Conclusion: Operative duration and rate of radiation exposure are significantly less in PCNL by single-step renal dilatation; however, there is no statistically significant difference in the rates of other complications.
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The creation of unilateral intermittent and unintermittent renal ischemia-reperfusion models in rats p. 378
Mustafa Soytas, Duygu Gursoy, Mustafa Yucel Boz, Cagri Cakici, Ilknur Keskin, Turkan Yigitbasi, Selcuk Guven, Rahim Horuz, Selami Albayrak
DOI:10.4103/UA.UA_79_20  
Background and Aim: This study aims to establish unilateral intermittent and unintermittent partial nephrectomy-like renal ischemia-reperfusion (I-R) model in rats and to compare the results with biochemical findings. Material and Methods: The study was conducted on 24 adult 8-week-old male Wistar-Albino rats, each weighing s200–250 g. The rats were divided into three groups. In the Sham group (n = 8), the kidney was surgically exposed and closed. We designed experimental I-R models in the second group (n = 8, a total of 30-min ischemia model in the manner of 3 intermittent sets 8 minutes clamping and 2 min unclamping) and in the third group (n = 8, one session of 30-min unintermittent ischemia). In postoperative day 1, the rats were sacrificed, and the effects of I-R models on the renal tissue were comparatively assessed by evaluating serum Neutrophil Gelatinase-Associated Lipocalin (NGAL), serum kidney injury molecule-1 (KIM-1), urinary NGAL, urinary KIM-1, and serum creatinine levels. Results: Urinary NGAL and KIM-1 levels were significantly higher in the continuous ischemia group when compared to those in the sham and intermittent ischemia groups (P < 0.05). In the intermittent ischemia group, urinary NGAL and urinary KIM-1 levels were significantly higher than those in the sham group (P < 0.05). Although the results of serum NGAL, serum KIM-1, and serum creatinine levels seemed to be in parallel to the results of urinary markers, no statistically significant difference was found. Conclusion: Renal injury was significantly less in the intermittent I-R model when compared to that in the unintermittent I-R model in our experimental rat study.
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Safe transition from open to pure laparoscopic donor nephrectomy: Approach and results p. 384
Yusuf Saifee, CS Chamania, Sushil Bhatia, Pradeep Salgia, Jai Kriplani, Achal Sepaha
DOI:10.4103/UA.UA_56_20  
Introduction: Laparoscopic living donor nephrectomy (LLDN) offers many advantages compared to open living donor nephrectomy. However, the perceived difficulty in learning LLDN has slowed its wider implementation. Herein, we describe the evolution of LLDN at a single center, emphasizing the approach and technical modifications and its impact on outcome. Methods: The series included a 2&#s189;-year period and three different surgeons. We started with two-stage plan for establishing LLDN at the institute (introduction and consolidation). Data of laparoscopic donor nephrectomy performed at the institution were prospectively evaluated regarding donor and recipient outcome. Results: From December 2016 to April 2019, 221 donors underwent LLDN. Three donors required conversion to open surgery. The mean operation time was 96.4 (62–158) min and the mean warm ischemia time was 186 (149–423) s. The complications were observed in 11.6% of donors from LLDN group and all complications were Class I and Class II only (Clavien–Dindo classification). No Class III and Class IV complications occurred. In the present study, there was some learning curve effect observed only in operative time (OT) with longer OT in initial cases. However, the overall operative complications were minimal, showing that this learning curve had no deleterious effects on donor safety. Conclusion: The present study demonstrates that with proper planning, team approach, and a few technical modifications, the transition from open to LLDN could be safe and effective.
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The use of preoperative neutrophil–lymphocyte ratio and lymphocyte–monocyte ratio in predicting survival and groin node involvement of patients with squamous cell carcinoma of penis p. 391
Tarun Jindal, Pravin Pawar, Sanjit Agarwal, Prateek Jain, Monika Meena, Ankush Sarwal, M Dhanalakshmi
DOI:10.4103/UA.UA_112_20  
Introduction: The association between inflammation and malignancies is being recognized. In this study, we assessed the use of preoperative neutrophil–lymphocyte ratio (NLR) and lymphocyte–monocyte ratio (LMR) in predicting cancer-specific survival (CSS) and inguinal node involvement in patients with carcinoma penis. Methods: Sixty-nine patients operated for squamous cell carcinoma penis with inguinal node dissection between 2012 and 2020 were identified. We recorded the type of surgery (partial/total penectomy), T stage, grade, lymphovascular invasion (LVI), perineural invasion (PNI), pathological status of inguinal nodes and nodal stage (pN1–3), extranodal extension (ENE), and CSS. The hemogram performed within 2 weeks of surgery was used for calculating NLR and LMR. Results: Partial penectomy was the most common surgery (65.22%) and pT2 was the most common stage (53.62%). Grade 2 was seen in 66.67%, LVI in 34.78%, PNI in 37.68%, 52.17% had inguinal node involvement with pN3 being the most common (36.23%), and 36.23% had ENE. Kaplan–Meier analysis revealed that NLR of >3 and the LMR ≤3 indicated an inferior CSS (P = 0.05 and 0.04, respectively). T stage, inguinal node involvement, LVI, pN stage, and ENE were also associated with inferior CSS (P < 0.05). On multivariate analysis, T stage was significantly associated with CSS (P = 0.02). The NLR >3 and LMR ≤3 were also significantly associated with the presence of pathological inguinal node involvement (P = 0.001 and 0.026). Conclusion: NLR and LMR may help in predicting CSS and inguinal node involvement in patients of carcinoma penis.
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Pediatric urology surgical practice in the time of COVID-19: Results from tertiary Saudi Arabia hospitals p. 397
Ali Abdel Raheem, Omaya Banihani, Abdelazim Abasher, Abdulhakim Alotay, Fahad A Alyami, Tamer A Alsaad, Naif Alqarni, Ossamah Alsowayan, Yasser A Jamalalali, Mohammad Alhuwaiti, Maha Al-Madi, Subbhy Abo Rubeea, Hossam Aljallad, Ahmed Elhelaly, Abdullah Alroumaih, Faisal Almutairi, Abdulwahab E Alhams, Abdullrhman Alayad, Ahmad Alshammari
DOI:10.4103/UA.UA_130_20  
Purpose: Our study aimed to evaluate the effect of COVID-19 on pediatric urology practice in the Kingdom of Saudi Arabia (KSA). Methods: Data of 10 tertiary hospitals in KSA were retrospectively analyzed. Data of outpatient department (OPD) visits and pediatric urology surgical procedures from January 1, 2019, to April 30, 2019, and from January 1, 2020, to April 30, 2020, were extracted. The primary outcome was to compare OPD visits and pediatric urology workload in the first third of 2020 versus 2019, where there was no curfew. The secondary outcome was to compare the same variables during the full curfew time, i.e., April 2020 versus April 2019. Results: The number of OPD visits was lower in the first third of 2020 (7390 vs. 10,379 in 2019 P < 0.001). OPD visits in April 2020 were 78.6% lower than in April 2019, and teleclinics represented 850 (94.3%). Elective procedures in the first third of 2020 were 688, with a reduction rate of 34.3% compared to the same period of 2019 (P < 0.001). In April 2020, there were 18 elective surgeries, with a 91.4% decrease than in April 2019. Ureteric reimplantation, hypospadias, cryptorchidism, and circumcision stopped, while pyeloplasty (n = 14) and urolithiasis (n = 4) procedures had declined by 50% and 76.5%, respectively. Most of the procedures (71.8%) were day surgery. Emergency procedures were similar in the first third of 2020 (65 vs. 64 in 2019, P = 0.994) and declined in April 2020 by 6.7% versus April 2019. During the full curfew, the most common emergency intervention were cases with obstructive uropathy (42.8%), followed by torsion testis (28.6%), posterior urethral valve (14.3%), and urological trauma (14.3%). Conclusions: In KSA, the number of elective pediatric surgical procedures were reduced by >90%, while the number of emergency pediatric surgical procdures were similar during COVID-19 pandemic compared with non-COVID-19 time. Ureteric reimplantation, hypospadias repair, cryptorchidism, and circumcision procedures were postponed. Pyeloplasty and urolithiasis-related procedures were performed to prevent irreversible disease progression or organ damage. There was an increase in rate of teleclinic and day surgery to reduce the risk of COVID-19 infection.
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Robot-assisted laparoscopic repair of injuries to bladder and ureter following gynecological surgery and obstetric injury: A single-center experience p. 405
Suresh Kumar, Pranjal Modi, Amit Mishra, Dhruv Patel, Rohitas Chandora, Rishabh Handa, Rohit Chauhan
DOI:10.4103/UA.UA_69_20  
Introduction: The objective of the study is to evaluate the outcome of robot-assisted laparoscopic repair of injuries to urinary tract following gynecological surgery and obstetric injury. Methods: This retrospective analysis from prospectively collected data of repair of injuries to bladder and ureter using da Vinci Si robotic platform was carried out. Between April 2014 and May 2019, 27 patients were operated on in a single surgical unit; 25 had hysterectomy and 2 were obstetric cases. Fifteen patients underwent vesicovaginal fistula (VVF) repair, ten underwent ureteral reimplant, with concomitant psoas hitch, and two underwent Boari flap repair following gynecological surgery and obstetric injury. Results: Among 15 patients of VVF repair, 3 cases were previously attempted failed repair, 2 underwent concomitant ureteral reimplant, and 1 underwent concomitant ovarian cystectomy. The mean total operative time was 126 (75–206) min, and the mean hospital stay was 4.4 (3–6) days. Among 12 cases of ureteral injury, 5 were on the right side and 7 were on the left side; the mean total operative time was 150.16 (110–215) min, and the mean hospital stay was 4 (3–7) days. No case required conversion to open in this cohort. All cases were successfully cured without any recurrence of fistula or stricture during their mean follow-up period of 35.3 (9–66) months. Conclusions: Robot-assisted laparoscopic repair for injuries to bladder and ureter is effective and highly successful even in previously failed cases.
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Laparoscopy training status in India and a review of the current resident skill standards p. 412
T Krishna Prasad, Rajeev Sood, Aneesh Srivastava, Venkatesh Krishnamoorthy, Manu Gupta, Jamal S Rizvi, Surya Praksah Vaddi, Tarun Javali
DOI:10.4103/UA.UA_135_20  
Context: The aim was to identify the current training standard of laparoscopy skills among the urology residents. Aims: This paper presents the residents' subjective perception of their laparoscopy skills and evidence of an objective assessment of their actual skills. Settings and Design: An online survey was mailed, and completed by urology residents in training. The residents' perception of laparoscopy training received, exposure to laparoscopy procedures, and training facilities were queried. The assessment was done on the skill levels of the residents presenting at an annual training program. Subjects and Methods: 103 residents responded to the online survey and 115 residents were assessed at the training program. Statistical Analysis Used: Discrete data were compared using the t-test to test for significance of the means; P < 0.05 was considered significant. Pearson's correlation coefficient was used to obtain the relationship between variables. Results: An overwhelming 91% rated their laparoscopy skill as just “satisfactory” or worse, and 60% did not have any training facilities in their department. 66% continue to be “assistants only” in conventional laparoscopy surgeries. Assessment of basic laparoscopy skills in the dry lab revealed 92% of residents having poor laparoscopy skills; similar to the subjective opinion in the survey. Only 6% (n = 5) of the residents showed a good or better skill score in the dry lab; similar to the survey. Conclusions: Based on the survey, a large number of residents have a poor opinion of their own laparoscopy skills, and the training facilities available to them. The data objectively prove the self-assessment of the residents on their laparoscopy skill level.
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High rates of advanced prostate cancer in the Middle East: Analysis from a tertiary care center p. 418
Marilyne Daher, Talar Telvizian, Christelle Dagher, Zahi Abdul-Sater, Sarah Abdel Massih, Alissar EL Chediak, Maya Charafeddine, Mohammed Shahait, Raafat Alameddine, Sally Temraz, Fady Geara, Bassem Youssef, Albert El Hajj, Rami Nasr, Wassim Wazzan, Muhammad Bulbul, Raja Khauli, Ali Shamseddine, Deborah Mukherji
DOI:10.4103/UA.UA_47_20  
Objectives: Prostate cancer incidence is increasing in the Middle East (ME); however, the data of stage at the diagnosis and treatment outcomes are lacking. In developed countries, the incidence of de novo metastatic prostate cancer ranges between 4% and 14%. We hypothesized that the rates of presentation with advanced disease are significantly higher in the ME based on clinical observation. This study aims to examine the stage at the presentation of patients with prostate cancer at a large tertiary center in the ME. Methods: After Institutional Review Board approval, we identified the patients diagnosed with prostate adenocarcinoma and presented to a tertiary care center between January 2010 and July 2015. Clinical, demographic, and pathological characteristics were abstracted. Patients with advanced disease were stratified according to tumor volume based on definitions from practice changing clinical trials. Descriptive and Kaplan–Meier survival analysis was used. Results: A total of 559 patients were identified, with a median age at the diagnosis of 65 years and an age range of 39–94 years. Median prostate-specific antigen (PSA) at the presentation was 10 ng/ml, and almost a quarter of the men (23%) presented with metastatic disease. The most common site of metastasis was the bone (34/89, 38%). High-volume metastasis was present in 30.3%, 9%, and 5.2% of the cohort based on STAMPEDE, CHAARTED, and LATITUDE trial criteria, respectively. Conclusion: This is the first report showing the high proportion of men from ME presenting with de novo metastasis. This could be due to many factors, including the highly variable access to specialist multidisciplinary management, lack of awareness, and lack of PSA screening in the region. There is a clear need to raise the awareness about prostate cancer screening and early detection and to address the rising burden of advanced prostate cancer affecting men in the ME region.
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Comparing adverse effects, short term outcomes, and cost implications of hyperthermic intravesical chemotherapy with Mitomycin-C and intravesical bacillus Calmette–Guerin instillation (Moscow-I strain) in the management of intermediate and high-risk nonmuscle invasive bladder cancer p. 424
Yuvaraja B Thyavihally, Santosh S Waigankar, Preetham Dev, Ashish Asari, Abhinav P Pednekar, Nevitha Athikari, Abhijit Raut, Archan Khandekar, Naresh Badlani
DOI:10.4103/UA.UA_139_20  
Introduction: The recommended treatment for intermediate and high-risk nonmuscle invasive bladder cancer (NMIBC) is adjuvant intravesical bacillus Calmette–Guerin (BCG) instillation. However, up to 50% experience tumor recurrences even after adjuvant BCG, and many patients develop local or systemic adverse effects. Our study compared adverse effects, short-term recurrence rates, and cost-implications of BCG therapy to Hyperthermic Intra-VEsical Chemotherapy (HIVEC) with Mitomycin-C (MMC) in these patients. Materials and Methods: Retrospective analysis of intermediate and high-risk NMIBC patients who received either intravesical BCG or HIVEC® after transurethral resection of bladder tumor in our institute (January 2017 to March 2020) was done. Twenty-two patients who received HIVEC and 29 who received BCG were analyzed. We used SPSS Statistics v20.0 (IBM Corp., Armonk, NY, USA) software for the statistical analysis. Results: Nineteen (86.4%) patients in the HIVEC group had no adverse effects. Two (9.1%) patients had Grade I lower urinary tract symptoms (LUTS) treated symptomatically. One patient developed UTI after HIVEC, and further cycles were stopped (Grade II). BCG group had a higher rate of Grade III adverse effects in six (20.7%) patients. Median follow-up was 10.5 and 22 months. The tumor recurred in one (4.5%) and six (20.7%) patients in HIVEC and BCG groups, respectively. There was no difference in recurrence-free survival at 18 months and the cost for the HIVEC therapy was more. Conclusions: HIVEC with MMC is a reasonable adjuvant treatment option in NMIBC, which is well tolerated, albeit increased cost of the treatment. Randomized trials with more follow-up are required for further conclusion.
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CASE REPORTS Top

Traumatic testicular torsion: A call to look beyond the obvious p. 431
Friday Emeakpor Ogbetere
DOI:10.4103/UA.UA_159_20  
Blunt scrotal trauma results in different forms of injuries such as hematoma, rupture of the testis, and testicular torsion. The diagnosis of trauma-induced testicular torsion in patients with blunt scrotal trauma requires a high index of suspicion. As early diagnosis and management of traumatic testicular torsion obviate testicular losses, an urgent testicular scan is necessary in cases of suspected traumatic torsion, and if not readily available or indeterminate, scrotal exploration is promptly indicated. Reported herein is a case of traumatic testicular torsion which was managed as a straightforward blunt scrotal trauma in a private health facility. He eventually had an orchidectomy when he presented to us 4 months later on account of a marked reduction in testicular volume. This case report reiterates the need to look beyond the obvious in patients with blunt scrotal trauma and the necessity of testicular scan and scrotal exploration in testicular salvage in suspected trauma-induced testicular torsion.
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Primary clear cell adenocarcinoma of prostate: A diagnostic challenge p. 434
Che-Wei Chang, Hsin-Ling Yin, Ching-Chia Li
DOI:10.4103/UA.UA_187_20  
Clear cell adenocarcinoma (CCA) rarely occurs in men, not to mention in prostate. We reported a 44-year-old male patient who suffered from recurrent dysuria and frequency for 6 months. Transurethral resection of the prostate was performed to relieve bladder outlet obstruction. However, CCA of the prostate was confirmed through pathological examination. A thorough checkup was performed to distinguish it from metastatic clear cell carcinoma from other primary origins. Currently, no consensus for the treatment of CCA of the prostate has been reached. After discussing with the patient, he decided to receive immunotherapy with pembrolizumab. Herein, we reported this rare case of CCA in the prostate.
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Myiasis (maggots) around nephrostomy tube p. 438
Prashant Motiram Mulawkar, Sumit Gopal Agrawal, Utpala Prashant Mulawkar, Girdhar Shivnarayan Panpaliya
DOI:10.4103/UA.UA_185_20  
Myiasis is caused by the presence of dipterous larvae in humans and animals. It is usually associated with poor hygienic conditions. A urologist rarely comes across myiasis. We report a case of myiasis around a recently placed nephrostomy tube. A 55-year-old male farmer from a rural area underwent right percutaneous nephrolithotomy. The procedure was terminated because of bradycardia and arrhythmia. There were residual calculi. A nephrostomy was kept. His relook nephroscopy was planned, but he was not willing. Hence, he was discharged with an indwelling nephrostomy tube. Two weeks later, he presented with severe pain around the right nephrostomy tube with surrounding pruritus. The wound hygiene was poor. He was found to have maggots around the nephrostomy tube. These were treated by local instillation of turpentine oil and oral and topical ivermectin, followed by manual removal of the maggots.
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Linitis plastica of the rectum secondary to metastatic prostate cancer: A case report of a rare presentation and literature review p. 442
Vincent Khor, Mohd Ghani Khairul-Asri, Omar Fahmy, Suzana Ab Hamid, Christopher Kheng Siang Lee
DOI:10.4103/UA.UA_188_20  
Linitis plastica is a rare tumor with poor prognosis. It is a circumferentially infiltrating intramural tumor which can result in rigid, nondistensible thickening of the affected organ. It most commonly affects the stomach, followed by the rectum, and can be due to primary or secondary cancer. Secondary rectal linitis plastica (RLP) caused by metastatic cancers has been reported from the stomach, breast, gallbladder, urinary bladder, and very rarely, the prostate, with only <5 reported cases in the literature. We report the case of a 66-year-old man who presented with altered bowel habit and loss of weight, with elevated prostate-specific antigen of 180.6 ng/mL. Sigmoidoscopy showed thickened rectal mucosa, and biopsy was negative for malignancy. Magnetic resonance imaging showed circumferential wall thickening, “target sign” appearance suggestive of RLP, PIRADS 5 lesion with extraprostatic extension, infiltrating bilateral seminal vesicles, and right neurovascular bundle. Repeat colonoscopy was performed under anesthesia, and deeper biopsy revealed poorly differentiated metastatic prostate adenocarcinoma. This case report highlights the atypical presentation of metastatic prostate cancer secondary to RLP, the rarity of this condition, and emphasizes the importance of deeper biopsy in RLP due to disease involvement predominantly in the submucosa and muscularis propria layers.
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