Ganesh Gopalakrishnan

Prevalence and risk factors for female sexual dysfunction in women attending a medical clinic in south India

BACKGROUND Reports from India on the prevalence and determinants of female sexual dysfunction (FSD) are scant. AIMS To determine the prevalence and risk factors for FSD. SETTINGS AND DESIGN A cross-sectional survey in a medical outpatient clinic of a tertiary care hospital. MATERIALS AND METHODS We administered a Tamil version of the Female Sexual Function Index (FSFI) to 149 married women. We evaluated putative risk factors for FSD. We elicited participants attributions for their sexual difficulties. STATISTICAL ANALYSIS We estimated the prevalence of possible FSD and sexual difficulties from published FSFI total and domain cut-off scores. We used logistic regression to identify risk factors for possible FSD. RESULTS FSFI total scores suggested FSD in two-thirds of the 149 women (73.2%; 95% confidence intervals [CI] 65.5% to 79.6%). FSFI domain scores suggested difficulties with desire in 77.2%; arousal in 91.3%; lubrication in 96.6%; orgasm in 86.6%, satisfaction in 81.2%, and pain in 64.4%. Age above 40 years (odds ratios [OR] 11.7; 95% CI 3.4 to 40.1) and fewer years of education (OR 1.2; 95% CI 1.0 to 1.3) were identified by logistic regression as contributory. Women attributed FSD to physical illness in participant or partner, relationship problems, and cultural taboos but none had sought professional help. CONCLUSIONS Sexual problems suggestive of dysfunction, as suggested by FSFI total and domain scores, are highly prevalent in the clinic setting, particularly among women above 40 and those less educated, but confirmation using locally validated cut-off scores of the FSFI is needed.

Supracostal Approach in Percutaneous Nephrolithotomy: Experience with 102 Cases

PURPOSE To assess retrospectively the safety and efficacy of the supracostal approach in percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS Among 862 patients who underwent PCNL between April 1986 and December 1999, supracostal puncture was performed in 102. Their stones were either solitary (66.5%), multiple (15.7%), or staghorn (19.6%). Upper ureteral calculi were the commonest indication (32.4%). The interspace between the 11th and 12th ribs was used in all cases. After tract dilatation with telescopic metal dilators, pneumatic or ultrasound lithotripsy was used for fragmentation. RESULTS Complete clearance was achieved in 79.5%. Ten patients (9.8%) had pleural violation in the form of hydrothorax, pneumothorax, or hydropneumothorax. All of these patients were managed successfully by intercostal chest tube drainage. CONCLUSION Supracostal puncture in a safe and effective approach with acceptable morbidity in selected cases of staghorn, upper ureteral, and upper caliceal calculi.

Surgical Management of Rectourethral Fistula

OBJECTIVES To present our experience and outcomes with the challenging problem of rectourethral fistula (RUF) using the perineal approach. RUF is a rare occurrence. METHODS This was a retrospective study of patients treated from January 1999 to December 2006. Fifteen patients (aged 16 to 64 years, mean 38) were studied, and their outcomes were assessed after surgical repair. The etiology was iatrogenic in 7, congenital in 5, and traumatic in 3. All patients presented with the passage of urine through the rectum and underwent micturating cystourethrography with retrograde urethrography, followed by preliminary cystoscopy and examination under anesthesia. All patients were treated using the perineal approach and gracilis muscle flap interposition. Six patients had associated urethral pathologic features that were managed simultaneously with RUF repair. Preoperatively, bowel diversion was done at the time of the cystourethroscopy and examination under anesthesia, if not done earlier, and the definitive repair was deferred for at least 12 weeks after bowel diversion. RESULTS RUF closure was successful in all the patients. Postoperatively, 2 patients had minimal urinary leakage through the perineum that resolved after repeat catheterization for 8 weeks. One stricture at the anastomotic site was managed with optical internal urethrotomy. One patient had extrusion of the gracilis flap, for which the muscle was repositioned. CONCLUSIONS The results of our study have shown that RUF closure using the perineal approach with pedicled gracilis muscle interposition is associated with low morbidity and a high success rate (100%). It is the method of choice for urologists because of their familiarity with the approach and because urethral pathologic features can be corrected simultaneously. We emphasize the need for bowel diversion before attempting reconstruction.

Emphysematous Pyelonephritis: Outcome of Conservative Management

OBJECTIVES To identify the prognostic factors, assess the outcome of conservative management, and modify the existing radiologic classification of emphysematous pyelonephritis. METHODS Forty-one consecutive patients diagnosed with emphysematous pyelonephritis between January 2001 and February 2007 were studied retrospectively. On the basis of computerized tomographic scan they were grouped into four classes (1 to 4). The management was conservative with antibiotics alone or with a combination of percutaneous drainage and antibiotics. RESULTS Thirty-eight (93%) of a total of 41 patients were diabetic. Escherichia coli (in 97%) was the predominant pathogen identified in pus culture. With antibiotics alone treatment was successful in 40%, and with a combination of percutaneous drainage and antibiotics the success rate was 80%. None underwent nephrectomy as a primary procedure. The risk factors for mortality were thrombocytopenia, shock, altered sensorium, and hemodialysis. In the absence of risk factors the success rate with conservative management was 100%. The mortality rate was 27%, 75%, and 100% in the presence of one, two, and three risk factors, respectively. The mortality rate in class 1, 2, 3, and 4 was 9%, 13%, 50%, and 33% respectively. The overall success rate was 78%. CONCLUSIONS A combination of percutaneous drainage with antibiotics offers an effective therapy for emphysematous pyelonephritis.

Zinc status of patients with benign prostatic hyperplasia and prostate carcinoma.

Objectives: The exact cause of benign prostatic hyperplasia (BPH) and prostatic carcinoma is unknown. Changes in the level of the trace element zinc (Zn) are known to be associated with the functioning of different organs (breast, colon, stomach, liver, kidney, prostate, and muscle). This study is aimed at estimating and comparing the zinc levels in the prostate tissue, plasma, and urine obtained from patients diagnosed with BPH or prostatic carcinoma. Materials and Methods: The prostate tissue zinc, plasma zinc, and urine zinc/creatinine ratio in BPH, prostate cancer, and normal subjects were measured by atomic absorption spectrophotometry. Results: In prostate carcinoma, the mean tissue zinc was decreased by 83% as compared to normal tissue and in BPH, there was a 61% decrease in mean tissue zinc as compared to normal tissues. Both these values were statistically significant. The plasma zinc in prostate cancer patients showed a 27% decrease (P < 0.01) as compared to controls and 18% decrease (P < 0.01) as compared to BPH. The urine zinc/creatinine (ratio) was significantly increased to 53% in prostate cancer patients, and a 20% significant increase was observed in BPH as compared to normal subjects. Conclusions: It is evident from this study that BPH or prostate carcinoma may be associated with a reduction in the levels of tissue zinc, plasma zinc, and an increase in urine zinc/creatinine.

Stone-bearing live-donor kidneys for transplantation

To evaluate potential donor kidneys with asymptomatic calculi detected during screening, and the management of the calculus before, during and after transplantation, as with fewer live donors, marginal kidneys and donors are a significant subgroup in renal transplantation.

Vesicovaginal fistula: An update

Vesicovaginal fistula (VVF) has been a social and a surgical problem for centuries and remains a challenge to surgeons. Though advances have been made in the understanding of the etiology, diagnostic procedures and management of these fistulae, controversies still exist over the ideal approach and time to repair. This review was undertaken to look into the recent literature with regard to the timing and surgical approach to VVF repair. The literature search was done using the Medline database with keywords: vesicovaginal fistula, laparoscopy and robotic repair filtered for the last 5 years.

Changing profile of prostatic abscess

PURPOSE To compare the clinical presentation of prostatic abscess and treatment outcome in two different time frames with regards to etiologies, co-morbid factors and the impact of multidrug resistant organism. MATERIALS AND METHODS We retrospectively assessed the charts of 48 patients with the diagnosis of prostatic abscess from 1991 to 2005. The period was divided arbitrarily into two different time frames; phase I (1991-1997) and phase II (1998-2005). Factors analyzed included presenting features, predisposing factors, imaging, bacteriological and antibiotic susceptibility profile, treatment and its outcome. RESULTS The mean patient age in phase I (n = 18) and phase II (n = 30) were 59.22 +/- 11.02 yrs and 49.14 +/- 15.67 respectively (p = 0.013). Diabetes mellitus was most common predisposing factor in both phases. Eleven patients in phase II had no co-morbid factor, of which nine were in the younger age group (22 - 44 years). Of these eleven patients, five presented with pyrexia of unknown origin and had no lower urinary tract symptoms LUTS. Two patients with HIV had tuberculous prostatic abscess along with cryptococcal abscess in one in phase II. Two patients had melioidotic prostatic abscess in phase II. The organisms cultured were predominantly susceptible to first line antibiotics in phase I whereas second or third line in phase II. CONCLUSION The incidence of prostatic abscess is increasing in younger patients without co-morbid factors. The bacteriological profile remained generally unchanged, but recently multi drug resistant organisms have emerged. A worrying trend of HIV infection with tuberculous prostatic abscess and other rare organism is also emerging.

Surgical management of renal tuberculosis.

Tuberculosis (TB) is one of the major health problems that our country is facing today. Despite active interventions by our government, control of TB still remains to be achieved. The emergence and exponential growth of the human immunodeficiency virus and drug-resistant strains threaten to further complicate the TB situation in our country. Even in this era of advanced chemotherapy, many lives are lost every day in our country. Tuberculosis of the urinary tract, despite being one of the commonest forms of extra-pulmonary TB, is generally overlooked. Most patients present with vague lower urinary symptoms typical of urinary tract infection. In this article, we shall highlight the various issues related to the surgical management of renal and ureteral tuberculosis.

Management of urolithiasis with chronic renal failure.

Purpose of review Epidemiological trends of urolithiasis and the prevalence of renal failure in patients with stones have changed. This is the era of minimally invasive therapy for stone disease. We review the impact of minimally invasive therapy on the management of urolithiasis in patients with renal failure and its outcome. Recent findings The prevalence of urolithiasis has reached its peak and plateaued in Europe and North America while it is still rising in the underdeveloped countries. The prevalence of renal failure in patients with chronic renal failure has reduced by half over the last decade. Minimally invasive therapy like percutaneous nephrolithotripsy has fared better than open stone surgery in all respects. Patients with kidney stones do not have normal renal function. Recently, cystine stones, and stones in patients with renal tubular acidosis and bowel disease were shown to affect renal function significantly. Summary Management of stones in chronic renal failure is challenging. Efforts should be made to minimize renal injury. Once a ‘stone-free’ kidney is achieved, steps should be taken to conserve renal function and address the issue of recurrence.