Diwakar Dalela

Taurine – a possible fingerprint biomarker in non-muscle invasive bladder cancer: A pilot study by 1H NMR spectroscopy

Urinary bladder cancer is a major epidemiological problem that continues to grow each year. It opens avenues for investigative research for the identification of new disease markers and diagnostic techniques. In this pilot study, utility of non-invasive (1)H NMR spectroscopy has been evaluated for probing the metabolic perturbations occurring in non-muscle invasive urinary bladder cancer. (1)H NMR spectra of urine of bladder cancer patients and controls (healthy and urinary tract infection/bladder stone) (n = 103) were acquired at 400MHz. The non-overlapping resonances of citrate, dimethylamine, phenylalanine, taurine and hippurate were first identified and then quantitated by (1)H NMR spectra, with respect to an external reference sodium-3-trimethylsilylpropionate (TSP). The concentrations of these metabolites were then statistically analyzed. The cancer patients showed significant (p < 0.05) variations in concentration of hippurate and citrate as compared with healthy controls and benign controls. The significant elevation in concentration of taurine was observed in urine of bladder cancer patients, which was below the sensitivity limit of 400MHz in control cases. However, stages Ta, T1 and carcinoma in situ (CIS) cannot be differentiated on the basis of altered metabolite indices but their composition may reflect the biochemical alterations in metabolism of cancer cells.

Silver nitrate sclerotherapy for 'clinically significant' chyluria: a prospective evaluation of duration of therapy.

Objectives: To evaluate and compare the results of regimen A (3 instillations at 8-hourly intervals in 1 day) with the control regimen B (9 instillations at 8-hourly intervals in 3 days) of using 1% silver nitrate solution for renal pelvic instillation sclerotherapy in ‘clinically significant’ filarial chyluria. Materials and Methods: Forty-seven patients with clinically significant chyluria attending on 2 different days our urology clinic were prospectively randomized between two groups; the study group received regimen A (n = 21) while the control group received regimen B (n = 26). The variables evaluated included visualization of pyelolymphatic fistulae on retrograde pyelography, hospital stay, outcome and morbidity of the two regimens. Results: Patients in both groups were comparable for age and sex. The morbidity (fever, symptomatic UTI, hematuria) following regimen A was less than that of regimen B although not statistically significant. The average hospital stay was 3 days for regimen A and 5.5 days for regimen B (p = 0.001). The initial success rate was 80.95% in group A and 92.30% in group B (p = 0.47). The mean duration of follow-up was 15 months (range 9–18). There was no significant difference in recurrence between the two groups during follow-up (group A: 21.05% and group B: 22.72%; p = 0.98). Conclusions: Regimen A was as effective as regimen B. Regimen A had the advantages of having less morbidity and shorter duration of hospital stay. We recommend only a 3-instillation regimen in patients with clinically significant chyluria, particularly those who demonstrate pyelolymphatic fistulae on retrograde pyelography.

Prevalence and risk factors of urinary incontinence in Indian women: A hospital-based survey

Background and Objectives: Urinary incontinence is a problem that creates both physical and psychological nuisance to a woman. This problem needs to be studied in detail in Indian population because of lack of precise data. The objectives of this study were to study the prevalence and risk factors of urinary incontinence in Indian women. Materials and Methods: This hospital-based cross-sectional study conducted from August 2005 to June 2007 included women attending gynecology OPD (consulters) and hospital employees (nonconsulters). Subjects who were incontinent were asked a standard set of questions. Incontinence was classified as urge, stress, or mixed based on symptoms. A univariate followed by multivariate analysis was done to look for risk factors. Results: Of 3000 women enrolled, 21.8% (656/3000) women were incontinent. There was no significant difference in incontinence rate between consulters and nonconsulters [618/2804 (22.1%) vs. 38/196 (19.4%); P value = 0.6). Of the total women having incontinence, highest numbers were found to have stress incontinence [73.8% (484/656)] followed by mixed [16.8% (110/656)] and urge incontinence [9.5% (62/656)]. Age more than 40 years; multiparity; postmenopausal status; body mass index more than 25; history of diabetes and asthma; and habit of taking tea, tobacco, pan, and betel are risk factors found to be associated with increased prevalence of urinary incontinence in univariate analysis. On multivariate analysis, age more than 40 years, multiparity, vaginal delivery, hysterectomy, menopause, tea and tobacco intake, and asthma were found to be significantly associated with overall incontinence. Stress incontinence was separately not associated with menopause. Urge incontinence was not associated with vaginal delivery. Conclusion: Urinary incontinence is a bothersome problem for women. Simple questionnaire can help to detect this problem and diagnose associated risk factors, so that necessary steps can be taken in its prevention and treatment.

Options in the management of tuberculous ureteric stricture

Ureteric stricture is a feared manifestation of genitourinary tuberculosis (TB) with the commonest site being the lower ureter. The purpose of this review is to discuss the management options for this condition. Literature search was done using PubMed and all articles on TB and ureteric stricture were reviewed published between 1990 till September 2007. The exact site and length of stricture must be defined with radioimaging (intravenous urography, retrograde, or antegrade pyelography) and renal function be quantified. The treatment of stricture mostly requires some kind of intervention after a brief period of antituberculous medicines with or without steroids. For uncomplicated/simple strictures (short segment, passable, with renal function >25%, good bladder capacity) endourologic option should be used which usually means double-J stenting with or without balloon dilatation. For complicated/complex strictures (long segment, dense fibrosis, with renal function <20%, small bladder capacity) regular surgical options should be considered which usually means ureteroureterostomy or ureteropyelostomy for upper ureteric strictures, intubated ureterostomy, or transureteroureterostomy for midureteric strictures, psoas hitch/Boari flap for lower ureteric strictures or ileal ureter/autotransplantation for whole length/multiple strictures.

Harvesting buccal mucosa graft under local infiltration analgesia--mitigating need for general anesthesia.

For buccal mucosal graft urethroplasty, nasal or oral endotracheal intubation anesthesia is used for harvesting the graft from the oral cavity. A technique of graft harvesting under local anesthesia using 2% lidocaine solution with adrenaline (1:200,000) is described. This method requires a cooperative patient but saves the morbidity of general anesthesia.

Confirmation of the correct placement of lower end of DJ stent during open surgery: point of technique.

A simple technique to confirm the correct placement of the double J (DJ) stent at the time of antegrade insertion during open surgery is described. At the time of antegrade DJ stent placement about 30–50 ml of sterile methylene blue is instilled into the bladder. Appearance of methylene blue from the upper end and side holes of the DJ stent confirms the correct placement of the lower end of the stent.

The twin amplatz sheath method: a modified technique of percutaneous cystolithotripsy for large bladder stones in female patients.

To minimize the operative time and to avoid open cystolithotomy in women with large bladder stone (>5 cm), we present here a modification of percutaneous cystolithotomy, a well-described standard procedure for urinary bladder stones. With this technique, suprapubic percutaneous access was achieved under cystoscopic guidance. The suprapubic tract was dilated and an Amplatz sheath of 30 Fr was placed. Simultaneously, the urethra was sequentially dilated with fascial dilators and a 28 Fr Amplatz sheath was guided into the bladder and the foot end of the table lowered to 20° to facilitate high-speed outflow of irrigant and stone particles. A 26.5 Fr nephroscope was passed through the suprapubic Amplatz sheath and the stone was fragmented by intracorporeal pneumatic device keeping the stone close to the proximal end of the urethral Amplatz. These maneuvers help in washing out stone fragments periurethrally and keeping the endoscopic vision clear while breaking the stone.

Three-dimensional synchronized multidirectional renal pyelo-angiography: a new imaging concept to facilitate percutaneous nephrolithotomy in technically challenging cases.

Percutaneous nephrolithotomy (PNL) is an established procedure for managing large and complex renal calculi. Septicemia and significant hemorrhage are the major complications occurring in 4.1% and 2.7% of the patients, respectively. The reported incidence of arterial injuries is about 0.9% to 3% during PNL. Almost always, the cause of severe bleeding is injury to the segmental arteries rather than the smaller intrarenal vessels. In patients with anomalous kidneys and solitary hypertrophied kidneys, vascular anatomy may not correspond to described patterns, and in patients where multiple tracts may be needed because of the complexity of pelvicaliceal anatomy vis-a-vis stone bulk, the risk of vascular injury may be more. Therefore, to execute the procedure in a safe and effective manner in these situations, more detailed preoperative imaging is desirable. The multidetector CT urography with multiplanar reconstruction and three-dimensional (3D) reformatting has previously been used for providing essential information in choosing the optimal percutaneous access into the pelvicaliceal system (PCS). Similarly, 16-slice CT scans have been utilized to obtain 3D volume-rendered movies of the PCS and stone for planning percutaneous renal stone surgery in a horseshoe kidney.3 Both these imaging techniques are primarily based on the pyelographic phase of the study. Since segmental arterial injury is the major cause of concern during PNL, we put forth a novel concept of splitting the total dose of intravenous (IV) contrast into two (40% first and 60% later) to facilitate simultaneous viewing of the renal arterial system and the PCS, that is, 3D synchronized multidirectional renal pyeloangiography.

Effect of phallic stretch on length of bulbous urethral stricture during retrograde urethrography.

Objective: The purpose of this study was to evaluate the effect of phallic stretch on bulbous urethral stricture while performing retrograde urethrography (RUG). Methods: Between July 2009 and June 2012, 197 adult males with stricture pattern on uroflowmetry underwent RUG. Two films were taken, first without (film A) and second after stretching the penis by about 5 cm (film B). 29 cases with proximal and distal bulbous strictures were included in the present analysis. The data recorded were stricture lengths in films A and B. Results: 12 men had distal bulbous or penobulbous stricture (group 1) while 17 had stricture involving the proximal bulb (group 2). Mean stricture length in group 1 was 2.82 cm (range 1.2-4.2 cm) in film A and 4.59 cm (range 3.0-6.4 cm) in film B. In group 2 stricture length was 1.76 cm (range 1.0-2.3 cm) in film A and 1.79 cm (range 1.0-2.5 cm) in film B. The percentage change in stricture length on stretching was 38.48% (p = 0.0001) in group 1 and 1.67% (p = 0.8301) in group 2. Conclusions: The impact of phallic stretch on radiographic length during RUG was found to be significant in distal bulbous but not in proximal urethral stricture, which is important when interpreting the RUG and deciding the management of stricture.

A cross-sectional pilot study to determine the prevalence of testosterone deficiency syndrome in working population of Indian men

Aim: To determine the prevalence of testosterone deficiency syndrome (TDS) in healthy Indian men employed in a hospital aged above 40 years. Materials and Methods: A general medical health check-up camp was organized for all male employees above 40 years age working in surgical departments. After clinical history and systemic inquiry, subjects were requested to fill the St. Louis Universitys ADAM Questionnaire based on which the total and free-serum testosterone estimation was then done. Results: One hundred fifty seven healthy volunteers enrolled for the study (mean age 53.1 years; range 40–60). The androgen decline in the aging male (ADAM) Questionnaire detected 106 men (67.5%) to be symptomatic for TDS. Serum testosterone estimation in these subjects revealed 41/106 to have low free-serum testosterone levels and 32/106 to have low total-serum testosterone. In 11 and 6 cases, respectively, the serum free- and total-testosterone levels were found to be low although the subjects were asymptomatic for TDS. Conclusions: The prevalence of symptomatic biochemical hypogonadism was 26.1%. The higher prevalence of symptoms alone of TDS was unusual. It could be because of the nature of the questionnaire. Free-serum testosterone may be a better single test to diagnose symptomatic hypogonadism than total-serum testosterone.