Arup K. Mandal

Tamsulosin Facilitates Earlier Clearance of Stone Fragments and Reduces Pain After Shockwave Lithotripsy for Renal Calculi : Results From an Open-Label Randomized Study

OBJECTIVES To evaluate the role of tamsulosin in the clearance of fragments after extracorporeal shock wave lithotripsy (ESWL) to treat renal calculi. METHODS In this open-label prospective randomized study conducted at our institute from 2006 to 2007, 139 patients with normal renal function and a single radiopaque renal calculus, 5-20 mm, undergoing ESWL were enrolled. All patients underwent ESWL every 3 weeks until success or for <or=3 months, whichever was earlier. They were randomly assigned to 2 groups with respect to whether they had received tamsulosin, 0.4 mg/d. The primary endpoint was the success rate, and the secondary endpoints were clearance time, sessions required for clearance, pain intensity, incidence of steinstrasse, and the need for auxiliary procedures. RESULTS Of the 139 patients, 51 in group 1 and 65 in group 2 completed the requisite follow-up. The demographic profile of both groups was comparable. The success rate after 1, 2, and 3 ESWL sessions was greater in group 1 than in group 2 (52.9%, 78.4%, and 94.1% vs 30.8%, 52.3%, and 75.4%; P = .016, P = .004, and P = .007, respectively). The total days required for success (35.53 +/- 19.47 vs 47.22 +/- 23.64; P = .006), total ESWL sessions required for success (1.66 vs 2.16; P = .005), and the pain experienced (visual analog scale score 28.67 +/- 20.35 vs 47.30 +/- 24.98, respectively; P = .0001) were significantly less in group 1. Two patients in group 1 and 9 in group 2 developed steinstrasse (P = .10); conservative management was successful in 1 patient in each group (P = .345). Three patients in group 1 and 10 in group 2 required auxiliary procedures (P = .14). CONCLUSIONS The results of our study have shown that tamsulosin facilitates earlier clearance of fragments after ESWL to renal calculi and helps reduce the severity of the pain. It tended to facilitate spontaneous clearance of steinstrasse; however, this requires additional evaluation.

Urodynamic Profile of Diabetic Patients With Lower Urinary Tract Symptoms: Association of Diabetic Cystopathy With Autonomic and Peripheral Neuropathy

OBJECTIVES To evaluate the association between diabetic cystopathy (DC) and neuropathy (autonomic and peripheral) in patients with diabetes mellitus (DM) presenting with lower urinary tract symptoms (LUTS). METHODS Men with DM who presented with bothersome LUTS were enrolled from January 2008 to June 2009. Their demographic and clinical profiles were noted. Multichannel urodynamic studies were performed using the Solar Silver digital urodynamic apparatus. Hand and foot sympathetic skin responses, and motor and sensory nerve-conduction velocity studies were performed using the Meditronic electromyographic/evoked potentials system. RESULTS A total of 52 men (mean age 61.3 ± 12.1 years, DM duration 11.0 ± 7.5 years) completed the study protocol. Of these 52 men, abnormal sympathetic skin responses, motor and sensory nerve-conduction velocity studies, and combined neuropathy (all 3 tests abnormal) were noted in 80.7% 57.7%, 57.7%, and 51.9%, respectively. Urodynamic studies showed impaired first sensation (>250 mL), increased capacity (>600 mL), detrusor underactivity, detrusor overactivity, high postvoid residual urine volume (more than one third of capacity), and bladder outlet obstruction (Abrams-Griffiths number >40) in 23.1%, 25.0%, 78.8%, 38.5%, 65.4%, and 28.8% of the men, respectively. Both sensory and motor DC correlated with abnormal motor and sensory nerve-conduction velocity studies (P = .015 and P = .005, respectively). Only motor DC correlated with abnormal sympathetic skin responses (P = .015). The correlations were stronger in the presence of combined neuropathy (sensory DC, P = .005; motor DC, P = .0001). CONCLUSIONS Men with DM and LUTS can present with varied urodynamic findings, apart from the classic sensory or motor cystopathy. A large proportion of these patients will have electrophysiologic evidence of neuropathy, and electrophysiologic evidence of neuropathy can moderately predict the presence of cystopathy.

Percutaneous Nephrolithotomy Among Patients with Renal Anomalies: Patient Characteristics and Outcomes; a Subgroup Analysis of the Clinical Research Office of the Endourological Society Global Percutaneous Nephrolithotomy Study

PURPOSE This study compared the characteristics and outcomes of percutaneous nephrolithotomy (PCNL) in patients with and without renal malformations using the Clinical Research Office of the Endourological Society (CROES) PCNL Global Study database. PATIENTS AND METHODS The CROES PCNL Global Study collected prospective data for consecutive patients who were treated with PCNL at centers around the world during 1 year. Patient characteristics, operative data, and outcomes of PCNL in patients with renal anomalies and those with normal kidneys were compared. RESULTS Of 5542 patients whose renal anatomy was recorded, 202 (3.6%) patients had a renal malformation. The most frequent anomalies were horseshoe kidneys (1.8%) and malrotated kidneys (1.3%). The prone position was the most frequently used position for patients with renal anomalies as was upper pole puncture. PCNL achieved stone-free rates of 76.6% in patients with anomalous kidneys and 76.2% in those with normal kidneys. The frequency of complications was similar in the two groups. Median operative time was significantly longer (87 min vs 75 min, P=0.037), and access for PCNL was unsuccessful in significantly more patients (5% vs 1.7%, P=0.001) in whom renal anomalies were present. CONCLUSION In patients undergoing PCNL, the presence of renal malformation is likely to extend operative time. Stone-free rates as well as incidence of complications after PCNL are similar irrespective of the presence of renal anomalies.

One Week of Nitrofurantoin Before Percutaneous Nephrolithotomy Significantly Reduces Upper Tract Infection and Urosepsis: A Prospective Controlled Study

OBJECTIVES To evaluate the role of nitrofurantoin (NFT) prophylaxis in a prospective randomized control study. Urosepsis is an important complication after percutaneous nephrolithotomy (PNL). Risk increases by around 4 times with larger stones and hydronephrosis (HDN). MATERIAL AND METHODS Patients with stones ≥2.5 cm and/or HDN and sterile urine undergoing PNL were randomized into 2 groups. Standard perioperative antibiotic prophylaxis was the same in both groups. One group received sustained-released NFT 100 mg b.i.d. for 7 days preoperatively, and the other did not. Preoperative urine, intraoperative renal pelvic urine, and stone cultures were obtained. Postoperative occurrence of SIRS was considered urosepsis after excluding other causes. Serum samples were collected immediately after PNL and stored at -20°C. Serum endotoxin was estimated using Limulus Amoebocyte Lysate gelation technique (Sigma Aldrich, Saint Louis, Missouri). The operating surgeons and the microbiologist were blinded to the group distribution. RESULTS Of 101 patients, 48 received nitrofurantoin prophylaxis. Both groups were comparable for age, gender, stone burden, degree of HDN, duration of operation, and intraoperative blood loss. There was significantly low positive pelvic urine culture (0% vs 9.8%, RR 4.95, P = .001), positive stone culture (8.3% vs 30.2%, RR 3.64, P = .001), endotoxemia (17.5% vs 41.9%, OR 0.22, P = .016), and systemic inflammatory response system (19% vs 49%, OR 0.31, P = .01) in patients receiving NFT prophylaxis. CONCLUSIONS Prophylaxis with NFT for a week before PNL is beneficial in the prevention of urosepsis and endotoxemia in patients with larger stones and HDN. NFT covers most of the urinary isolates and is preferred in areas of fluoroquinolone resistance.

Is There an Adjunctive Role of Tamsulosin to Extracorporeal Shockwave Lithotripsy for Upper Ureteric Stones: Results of an Open Label Randomized Nonplacebo Controlled Study

OBJECTIVES To investigate the role of tamsulosin as an adjunct to management of upper ureteric stones (UUS) with extracorporeal shock wave lithotripsy (SWL). METHODS In this prospective, randomized, open label study, patients with single UUS (for SWL) were randomly assigned into 2 groups based on whether they received 0.4 mg tamsulosin (group A and B, respectively) during treatment. Repeat SWL was performed at week 1, 3, and 5 after first session. Primary outcome variables were success rate and pain intensity. RESULTS A total of 40 patients (20 each group) completed the requisite follow-up. Success rate was higher in group A after 1 SWL-session (55% vs 25%, respectively; P = .05). There was an insignificant trend of decreased number of days (30.7 +/- 19.7 vs 39.0 +/- 19.9; P = .19), number of SWL sessions (1.6 vs 2.0; P = .10), and pain experienced (score on visual analog scale, 25.3 +/- 17.9 vs 38.3 +/- 28.0, respectively; P = .41) in group A. Three in group A and 6 in B developed steinstrasse (P = .69). Overall, 1 in group A required auxiliary procedures as compared with 3 in control group (P = .60). CONCLUSIONS Tamsulosin improves clearance rate of UUS after single SWL. However, it does not provide significant advantage in terms of decreasing pain associated with this treatment.

Acute postoperative complications of hypospadias repair

Purpose Complications in hypospadias surgery are higher than other reconstructive procedures. The incidence of complications can be reduced if proper preventive measures are taken. The review aims to highlight incidences, causes, and preventive measures of acute complications of hypospadias repair. Materials and Methods Literature reports were reviewed in Pubmed by giving the key word acute complications of hypospadias repair, wound infection, wound dehiscence, flap necrosis, edema, penile torsion, urethral fistula, bleeding and hematoma and urethral stents problems. Summaries of all articles were reviewed with full text of relevant article and results were analyzed. Results Besides mentioning the complications of hypospadias repair in individual articles on the subject, we did not come across any separate article on this subject in the published English literature. Fistula is the commonest complication followed by edema and penile torsion. Conclusions Most acute complications can be prevented with adherence to principles of plastic and microsurgery, meticulous preoperative planning, and judicious postoperative care. Deviation from these principles may lead to disaster and even failure of the repair. The aim in hypospadias surgery should be following these principles and bring down the complication rates < 5% in distal hypospadias and < 10% in proximal hypospadias.

A Comparative Randomized Prospective Study to Evaluate Efficacy and Safety of Combination of Tamsulosin and Tadalafil vs. Tamsulosin or Tadalafil Alone in Patients with Lower Urinary Tract Symptoms due to Benign Prostatic Hyperplasia

INTRODUCTION Lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) and erectile dysfunction are common disorders of advancing age. AIM To evaluate the efficacy and safety of tamsulosin and tadalafil in patients with LUTS due to BPH. METHODS In this prospective randomized study, 133 men complaining of LUTS due to BPH were included. Forty-five patients received tamsulosin 0.4 mg/day alone (Group A), 44 patients received tadalafil 10 mg/day (Group B), and combination therapy (tamsulosin and tadalafil both) was instituted in 44 patients (Group C). After a 2-week medication free run-in period, they were evaluated for International Prostatic Symptom Score (IPSS), International Index of Erectile Function score (IIEF5), quality of life (IPSS QoL), maximum urinary flow rate (Qmax), post-void residual urine (PVR) volume, and safety parameters before and at 3 months of treatment. MAIN OUTCOME MEASURES There were primary (IPSS, IPSS QoL index, Qmax, and PVR) and secondary (erectile function [EF] domain scores from IIEF5) efficacy end points. Safety assessment included laboratory tests and patients reporting of adverse event. RESULTS A significant improvement in IPSS score was observed in all the 3 groups A, B, and C (-50.90%, P < 0.05; -33.50%, P < 0.05; and -53.90%, P < 0.05, respectively). IIEF5 score increased significantly in these three groups (+39.28%, P < 0.05; +45.96%, P < 0.05; and +60.23%, P < 0.05, respectively). A significant increase in Qmax and decrease in PVR were also observed (33.99%, P < 0.05; 29.78%, P < 0.05; and 37.04%, P < 0.05) and (-60.90%, P < 0.05; -49.45%, P < 0.05; and -62.97%, P < 0.05, respectively). The QoL scores improved significantly (-73.35%, P < 0.05; -70.26%, P < 0.05; and -79.65%, P < 0.05, respectively). Side effects were dyspepsia, heartburn, headache, flushing, myalgia, and backache. Adverse effect dropout was 3.7%. No participant experienced any severe or serious adverse events. CONCLUSIONS In patients with LUTS due to BPH, tamsulosin and tadalafil alone or in combination cause a significant improvement in patients with LUTS. Their EF also improves with these medications. The improvement is better with combination therapy compared with single agent alone.

Factors affecting bone mineral density in patients with prostate carcinoma before and after orchidectomy

Orchidectomy is an accepted form of androgen‐deprivation therapy (ADT) for prostate carcinoma. Osteoporosis is common in elderly individuals and is accelerated by ADT. The authors studied changes in bone mineral density (BMD) after ADT and factors that affected those changes.

Efficacy of Gabapentin for Prevention of Postoperative Catheter-related Bladder Discomfort in Patients Undergoing Transurethral Resection of Bladder Tumor

OBJECTIVE To evaluate the effect of 600 mg and 1200 mg oral gabapentin pretreatment for the prevention of postoperative catheter-related bladder discomfort (CRBD) in patients undergoing catheterization after transurethral resection of bladder tumor (TURBT). MATERIALS AND METHODS One hundred adult patients undergoing elective TURBT under spinal anesthesia were randomly allocated into 3 groups. Group I patients received placebo, group II patients received 600 mg gabapentin, and group III patients received 1200 mg gabapentin 1 hour before surgery. Lumber subarachnoid block was administered with 2.5 mL 0.5% hyperbaric bupivacaine. The patients were observed for the incidence and severity of CRBD in the postoperative period. RESULTS The incidence of CRBD was 90% in group I, 66% in group II, and 26% in group III. The incidence of bladder discomfort was significantly low in group III at all time points compared with group I and at 4, 6, 12, and 24 hours compared with group II. The severity of CRBD was also less in group II and III patients compared with group I. Fifteen patients in group I developed moderate discomfort, whereas 1 patient in group II and none in group III. None of the patient receiving gabapentin had severe discomfort. The duration and level of sensory and motor block was comparable among groups. One patient in group II and 2 patients in group III were complained of dizziness in postoperative period. CONCLUSION Gabapentin 1200 mg administered before surgery is more effective than gabapentin 600 mg in decreasing the incidence of postoperative CRBD.

Tuberculosis of the prostate and urethra: A review

Genitourinary tuberculosis contributes to 10-14% of extrapulmonary tuberculosis and is a major health problem in India. Prostate tuberculosis is uncommon and is usually found incidentally following transurethral resection. The most common mode of involvement is hematogenous, though descending infection and direct intracanalicular extension is known. Predisposing factors include prior tubercular infection, immuno-compromised status, previous BCG therapy. The presentation is diffuse caseating epitheloid cell granulomas, which can be confirmed by prostate biopsy. Urine PCR has good sensitivity (95.5%) and specificity ( 98.12%) in diagnosis. Imaging techniques like TRUS and CT/MRI also allow good visualization of the lesion and its extension. Urethral tuberculosis is very rare and is usually secondary to upper tract or genital tuberculosis. The presentation may be acute urethritis or chronic stricture or fistulae. The treatment of choice is chemotherapy with 3-4 anti tubercular drugs for initial 6-12 weeks and later 2 drugs for additional 3-6 months. Surgery is usually reserved for cases where chemotherapy fails and is done after 4-6 weeks of ATT. With a high index of suspicion it may be possible to diagnose a larger number of cases of prostatic and urethral tuberculosis especially in this country where tuberculosis is almost endemic.