Arabind Panda

Monopolar Versus Bipolar Transurethral Resection of Bladder Tumors: A Single Center, Parallel Arm, Randomized, Controlled Trial

PURPOSE We compared the safety and efficacy of bipolar transurethral resection and monopolar resection for bladder tumors. MATERIALS AND METHODS A single center, parallel arm, randomized, controlled trial was performed from May 2011 to August 2012. All patients with suspected bladder tumors were eligible for study inclusion. Those who refused consent and those undergoing routine restaging transurethral resection of bladder tumor were excluded from analysis. The primary end point was the incidence of obturator jerk. Secondary study outcomes included the decrease in hematocrit, rates of recoagulation and transfusion, bladder perforation, decrease in sodium, resection syndrome and resection time. Pathological quality was assessed by comparing deep muscle and the degree of severe cautery artifact in the 2 arms. RESULTS A total of 257 transurethral resections were performed during the study period. After exclusion 147 patients were randomized, including 75 in the monopolar arm and 72 in the bipolar arm. There were 6 and 4 protocol violations in the monopolar and bipolar arms, respectively. Intent to treat and per protocol analyses were performed. The incidence of obturator jerk was greater in the bipolar arm (60% vs 49.2%, p=0.27). There was no significant difference between secondary outcomes. The only significant difference was a significantly lower incidence of severe cautery artifact in the bipolar arm (25% vs 46.7%, p=0.0096). CONCLUSIONS Bipolar transurethral resection of bladder tumor was not superior to monopolar resection with respect to obturator jerk, bladder perforation and hemostasis. There was a significantly lower incidence of severe cautery artifact after bipolar resection.

Painful varicoceles: Role of varicocelectomy

The incidence of varicocele in the general population is up to 15%. It is estimated that the prevalence of pain with varicoceles is around 2-10%. Till the year 2000, only two studies evaluated efficacy of varicocelectomy in painful varicoceles with conflicting results. Over the past decade many other studies have addressed this issue and reported on the treatment outcome and predictors of success. We critically appraised studies published from March 2000 to May 2013 evaluating surgical management in painful varicoceles to provide an evidence based review of effectiveness of varicocelectomy in relieving pain in patients with symptomatic painful varicoceles. The association between varicoceles and pain is not clearly established. Conservative treatment is warranted as the first line of treatment in men with painful clinical varicoceles. In carefully selected men with clinically palpable varicoceles and associated characteristic chronic dull ache, dragging or throbbing pain who do not respond to conservative therapy, varicocelectomy is warranted and is associated with approximately 80% success. However, surgical success does not always translate into resolution of pain and pain might persist even when no varicoceles are detected postoperatively.

Emphysematous pyelonephritis in a renal transplant recipient – Is it possible to salvage the graft?

BACKGROUND Emphysematous pyelonephritis (EPN) is a rare but potentially devastating complication after renal transplantation. It carries the risk of graft loss and is associated with a high mortality. The majority of cases reported thus far have undergone graft nephrectomy. CASE REPORT We report the case of a live-related renal transplant recipient who presented 10 years later with fever, graft tenderness and worsening serum creatinine. Computed tomography (CT) revealed emphysematous pyelonephritis, with a large perinephric collection. The case was managed successfully by percutaneous drainage. CONCLUSIONS Percutaneous drainage is a safe and effective therapeutic modality in cases of EPN in transplant recipients, and allows salvage of the renal allograft in most cases.

Nanobacteria in the pathogenesis of urolithiasis: Myth or reality?

Stone formation in the urinary tract is a common phenomenon with associated morbidity. The exact physicochemical factors responsible for stone formation are not clearly known. Over the past decade considerable interest has been generated in defining the role of nanobacteria in urinary stone formation. A review of the available literature has been carried out to give insights into their nature and outline their role in stone formation. The two aspects of nanobacteria that need to be considered include its biological nature and the other merely as mineralo-protein complexes. Though the current literature favors the concept of mineralo-protein particles, further research is needed to clearly define their nature. Whether living or nonliving, these apatite forming nanoparticles appear to play role in kidney stone formation.

Tissue engineering and stem cell research in Urology: Is the moment yet to come?

Stem cell research is in itself not new. Embryonic stem cells from mouse models were first isolated in the early ‘80s and embryonic human stem cells in 1998.[1] An explosion of research into stem cells has occurred in the last 15 years. There was hope and optimism in the first few years of this century that stem cell research will provide a silver bullet that could transform the way we practice medicine.

Is thrombocytosis a useful prognostic marker in renal cell carcinoma? Results of a single-center retrospective analysis.

Introduction: Our aim was to determine the correlation of platelet count with stage and grade of renal cell carcinoma (RCC) and to determine whether progression of disease was more likely in those with thrombocytosis. Materials and Methods: A retrospective review of patients with RCC from January 2004 to December 2011 was undertaken. Patients with no preoperative platelet count and those with multiple tumors were excluded. Disease progression was defined as appearance of local recurrence or distant metastasis on follow-up. Thrombocytosis was defined as a platelet count of >400,000/cumm. Standard tests of significance and multivariate analysis using logistic regression were performed. Results: A total of 322 cases were identified. The median follow-up was 7 months (range, 2-84 months). The platelet count correlated significantly with higher Fuhrmann grade, as well as increasing TNM stage at diagnosis. Patients with a platelet count of >400,000/cumm (n = 35) had a significantly higher mean tumor size and worse grade at diagnosis than those with a normal platelet count (n = 287). Patients with thrombocytosis also had a significantly worse stage at presentation. Progression of disease was seen more often in patients with thrombocytosis (28.6% vs 11.9%, P = 0.07). The median time to progression was significantly faster in patients with thrombocytosis (9 vs 18 months, P = 0.018). However, on multivariate analysis TNM stage was the only significant predictor of time to progression. Conclusion: Rising platelet count correlated significantly with advancing stage and grade of disease. Patients with thrombocytosis were significantly more likely to have advanced tumors at presentation, poorer histological features, and rapid disease progression.

Spontaneous irreducible urethral prolapse in a post-menopausal woman: a rare differential diagnosis of an intralabial mass

A 58-year-old, post-menopausal woman presented with a gradually progressive mass near the urethral opening with associated pain for 6 months and two episodes of mild, gross, painless, intermittent hematuria. She had no urgency or incontinence. Examination revealed a donutshaped mass surrounding the urethra. The urethra and bladder were normal on cystoscopic examination, which was performed in view of the history of gross hematuria. Uroflowmetry showed a normal micturition pattern. A clinical diagnosis of urethral mucosal prolapse was made (Fig. 1). An attempt to reduce the mass after liberal application of lignocaine jelly was unsuccessful (Fig. 2). Conservative management with local application of estrogen cream did not result in reduction of the mass. The urethral catheter was removed after 10 days and she voided comfortably with no stress leakage. Histopathological examination revealed squamous metaplasia and chronic inflammation. Urethral prolapse is an uncommon condition that is often misdiagnosed. Up to 80% of cases occur in prepubertal girls with the rest in postmenopausal women. Proposed etiology includes estrogen deficiency leading to lax pelvic musculature and poor urethral support, in addition to the combined effect of raised intraabdominal pressure and decreased cohesion between the urethral smooth muscle layers [1, 2]. The usual presentation is a mass at the urethral meatus. Conservative management includes sitz baths with topical estrogen and antibiotic creams. Manual reduction with and

Revisiting prostate cancer: Can we separate the wheat from the chaff?

The technique of the standard transrectal ultrasound (TRUS)-guided prostate biopsy was initially demonstrated in the pre-PSA era, the late 1980s when prostate cancer was mostly a high volume, palpable disease.[2] Apart from the addition of extra cores in an extended biopsy technique, the technique remains essentially the same; systematic and nontargeted. It samples only 0.04% of an average size prostate, mainly the posterior gland. There is inadequate sampling of anterior, midline, and the apex of the prostate.[3] Transperineal biopsy is an alternative systematic technique where saturation biopsy is possible. It may require anesthesia and both these techniques can increase the detection of insignificant prostate cancer by chance. Furthermore, in TRUS biopsy, 47% of lesions >0.5 ml and 79% of lesions of 0.2–0.5 ml size can be missed.[4] *

A prospective randomised double-blind placebo-controlled trial to assess the effect of diuretics on shockwave lithotripsy of calculi

Abstract Objective: To assess the effect of diuretics with shockwave lithotripsy (SWL) on the treatment of renal and upper ureteric calculi. Patients and methods: Adult patients with a solitary non-obstructive radio-opaque renal or upper ureteric calculus with normal renal function were included. They were prospectively randomised to receive either SWL with placebo or SWL with diuretics (40 mg parenteral furosemide) in a double-blind manner with a sample size of 48 patients in each arm. The primary outcomes were the SWL success and failure rates. The secondary outcomes were the number of shocks and sessions. Results: Complete fragmentation was achieved in 89.6% of the patients in the furosemide arm as compared to 81.3% in the placebo arm. Clearance was achieved in 77.1% of the patients in the furosemide arm as compared to 70.8% in the placebo arm. The number of shocks and the number of sessions were higher in the placebo arm. These differences were not statistically significant. Conclusion: The use of diuretics along with SWL treatment of renal and upper ureteric calculi does not show a statistically significant improvement in fragmentation or clearance.

Urethral duplication with unusual cause of bladder outlet obstruction.

A 12-year-old boy presented with poor flow and recurrent urinary tract infections following hypospadias repair at the age of 3 years. The evaluation revealed urethral duplication with a hypoplastic dorsal urethra and patent ventral urethra. He also had duplication of the bladder neck, and on voiding cystourethrogram the ventral bladder neck appeared hypoplastic and compressed by the dorsal bladder neck during voiding. The possibility of functional obstruction of the ventral urethra by the occluded dorsal urethra was suspected, and he underwent a successful urethro-urethrostomy.