Neeraj Kumar Goyal

XANTHOGRANULOMATOUS PYELONEPHRITIS: OUR EXPERIENCE WITH REVIEW OF PUBLISHED REPORTS

Background:  The aim of this study was to analyse the cases of xanthogranulomatous pyelonephritis with review of published reports.

Oral complications after lingual mucosal graft harvest for urethroplasty.

Background:  The aim of this study was to assess the complications at donor site after lingual mucosal graft harvesting for urethroplasty.

Our experience with genitourinary fistulae.

Introduction: Our objective was to analyze the incidence, etiopathology, diagnosis and therapeutic aspects of the genitourinary fistula in an Indian population. Methods: This is a retrospective analysis of the genitourinary fistulae repaired at the Department of Urology, Institute of Medical Sciences, Banaras Hindu University, between January 1990 and December 2006. The surgical approach varied in each patient. Interposition grafts or flaps were used as and when required. The main outcomes analyzed were the incidence, etiology, surgical approaches, accessory procedure required, need for tissue interposition, cure rate per repair and overall success rate. Results: Out of 558 cases, 403 were vesicovaginal, 84 ureterovaginal, 43 urethrovaginal and 28 vesicouterine fistulae. The most common etiology was obstructed labor (72.2%), followed by hysterectomy. The transvaginal route was preferred for repair wherever possible. The transabdominal route was adopted for the repair of supratrigonal vesicovaginal, ureterovaginal and vesicouterine fistulae and if bladder augmentation was required. Conservative management was successful in 1.9% of the vesicovaginal fistulae and in 8 cases of ureterovaginal fistula. The remaining cases were managed surgically with excellent results. Conclusion: Genitourinary fistulae are not life-threatening but are socially debilitating. Surgical repair provides the definitive cure, but expectant treatment can be tried in selective patients.

Urethral Reconstruction in Balanitis Xerotica Obliterans

Objectives: To review the results of utilizing different grafts for substitution urethroplasty for anterior urethral stricture caused by balanitis xerotica obliterans (BXO). Methods: 153 patients who underwent substitution urethroplasty for anterior urethral strictures were included in this study. The stricture length varied from 3.8 to 16.4 cm (mean 10.2 cm). In 32% of the patients (49), local genital, penile (18), perineal (16) and scrotal (15) skin grafts were used. Over the 3 years our standard treatment policy has been to utilize a free mucosal graft from a non-genital area. Buccal mucosa was the most preferred, utilized in 74 (48.3%) patients and bladder mucosa in 12 (7.8%). Recently we have used lingual mucosal grafts in 18 (11.7%) patients for substitution urethroplasty. Results: The overall success rate for non-genital mucosal graft was 92.2%. The remaining 8 patients required more than one supplementary procedure postoperatively but none required a second urethroplasty. Of 49 patients who underwent substitution urethroplasty utilizing genital skin, the success rate was only 4%. 16.3% required one and 14.3% required multiple auxiliary procedures postoperatively. 34 patients (69.4%) required subsequent urethral reconstruction. Conclusions: A free graft urethroplasty using non-genital skin is recommended for anterior urethral stricture related to BXO.

Bilateral single system ectopic ureters: case report with literature review.

Bilateral single system ureteral ectopia (BSSEU) is one of the rarest entities in urology, with less than 80 cases reported so far. Incontinence resulting from the underlying anomaly can be devastating to the child. It is generally agreed that suitable urinary continence and long dry intervals are seldom obtainable because of poorly developed trigone and bladder neck area. We herein report a case of BSSEU managed by bilateral ureteric reimplantation, achieving satisfactory continence and bladder capacity without the need for urinary diversion or bladder neck reconstruction.

Transurethral Resection of Prostate Abscess: Is It Different from Conventional Transurethral Resection for Benign Prostatic Hyperplasia?

Purpose. To present our experience of prostate abscess management by modified transurethral resection (TUR) technique. Methods. Seventeen men with prostate abscess undergoing TUR between 2003 and 2011 were retrospectively analyzed. Details of demography, surgical procedures, complications, and followup were noted. Results. With a mean age of 61.53 ± 8.58 years, all patients had multifocal abscess cavities. Initially, 6 men underwent classical TUR similar to the technique used for benign prostatic enlargement (group 1). Next, 11 men underwent modified TUR (group 2) in which bladder neck and anterior zone were not resected. The abscess cavities resolved completely, and no patient required a second intervention. One patient in group 1 and three in group 2 had postoperative fever requiring parenteral antibiotics (P = 0.916). Three patients in group 1 had transient urinary incontinence, whereas none of the patients in group 2 had this complication (P = 0.055). Four and five men in group 1 and 2 reported retrograde ejaculation, respectively (P = 0.740). Conclusion. The modified technique of prostate resection edges over conventional TURP in the form of reduced morbidity but maintains its high success rate for complete abscess drainage. It alleviates the need for secondary procedures, having an apparent advantage over limited drainage techniques. Use of this technique is emphasized in cases associated with BPH and lack of proper preoperative imaging.

Re: Matthias Oelke, François Giuliano, Vincenzo Mirone, Lei Xu, David Cox, Lars Viktrup. Monotherapy with Tadalafil or Tamsulosin Similarly Improved Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia in an International, Randomised, Parallel, Placebo-controlled Clinical Trial. Eur Urol 2012; 61:917–25.

We thank the authors for conducting this randomized, placebo-controlled trial on effects of tadalafil or tamsulosin on lower urinary tract symptoms (LUTS) of benign prostatic hyperplasia (BPH) [1]. The study highlights that monotherapy with tadalafil or tamsulosin results in similar improvement in LUTS. Tadalafil 5 mg daily was found to have an additional benefit of improved sexual function in patients having baseline erectile dysfunction (ED). As the standard dosage of tadalafil for ED is 10 mg daily and 20 mg in nonresponding cases, it is unclear how the authors explain the significant improvement of ED at a suboptimal dose. In addition, this study opens new horizons for the evaluation of lower doses (eg, 5 mg daily) of tadalafil for treatment of ED not associated with LUTS or BPH.

Incidentally detected bilaterally symmetrical seminal and vas calcification in young infertile male: a case report, literature review and algorithm for diagnosis

Bilateral seminal and vas calcification is not common, especially in young age. Association with many disease conditions has been described, with diabetes mellitus being the most common association. A 34-year-old man presented with primary infertility and right upper ureteric calculus. His evaluation revealed extensive, bilateral seminal and vas calcification with normal semen analysis and first-time detected diabetes mellitus. His female partner was evaluated and found to have bilateral fallopian tubes blockage. We reviewed the literature and present here the algorithm for diagnosis of such patients, along with details of this particular patient.

Prevention of Bone Mineral Loss by Zoledronic Acid in Men with Prostate Carcinoma Receiving Androgen Deprivation Therapy: A Prospective Randomized Trial in an Indian Population

Objective: To assess the efficacy of zoledronic acid in preventing bone mineral loss in locally advanced, non-metastatic prostate carcinoma in men receiving androgen deprivation therapy. Patients and Methods: Forty-one men with locally advanced, non-metastatic prostate carcinoma were randomly divided into 2 groups to receive zoledronic acid 4 mg intravenous infusion (n = 19) or a placebo (n = 22) every 3 months. The primary efficacy variables were measurement of bone mineral density (BMD) of the lumbar spine and urinary deoxypyridinoline at the baseline and at the end of treatment. The efficacy analysis was by mean and percent-age change of these variables from the baseline to the end of the treatment. Results: The mean BMD increased significantly to 1.18 g/cm2 from a baseline value of 1.09 g/cm2 in the zoledronic acid group. In the placebo group, the mean BMD decreased to 0.99 g/cm2 from a baseline value of 1.07 g/cm2. The percentage change of BMD of the lumbar spine from the baseline was an 8.15% increase in the zoledronic acid group and a 7.0% decrease in the placebo group. There was also a significant decrease of mean urinary deoxypyridi-noline values in the zoledronic acid group (p < 0.05) and a significant increase in the placebo group (p < 0.001). Conclusion: Long-term androgen deprivation therapy for prostate carcinoma patients leads to significant loss of bone density. Bisphosphonate treatment especially with the highly potent zoledronic acid should be considered in patients with a low BMD baseline because this drug not only prevents the decrease in BMD but also improves BMD.

Re: Staghorn morphometry: a new tool for clinical classification and prediction model for percutaneous nephrolithotomy monotherapy. (From: Mishra S, Sabnis RB, Desai M. J Endourol 2012;26:6-14).

Hats-off to the authors for describing a classification for staghorn stones using morphometry that could clinically predict tract(s) and stage(s) in percutaneous nephrolithotomy (PCNL). We have a few queries. The authors have excluded 38 patients because of renal insufficiency. In an earlier study by the same group, the authors maintain that ‘‘for those with compromised renal function, we obtain a non-contrastenhanced 3D CT (NCCT), which helps us to assess the pelvicalyceal system, as well as the stone bulk and location.’’ We also think that NCCT will give adequate information that is needed for morphometry classification. Renal impairment is common (24%; ie, 38/163 in the present study itself ) in patients with staghorn stones, and this classification can be used in them also. The authors classify type 1 staghorn with lesser than 5% unfavorable calix stone percentile volume while type 3 staghorn with greater than 10% unfavorable calix stone percentile volume and type 2 staghorn is in between types 1 and 3. At the same time, they mention that in type 2, ‘‘a smaller volume ( < 2% – type 2a) may result in single stage while larger volume ( > 2% – type 2b) may result in multiple stages.’’ These data seems ambiguous and need clarification. Also we would like to know the group to which a stone will belong if total stone volume is 20,000 mm but with less than 10% unfavorable calix stone percentile. Would it be staghorn type 2 or type 3? We also treat a large number of patients with staghorn stones. From a practical point of view, however, we think that we may not change our practice after reading this article. We will still plan treatment after seeing the intravenous urography/computed tomography scan. Such classifications have a drawback of being cumbersome and turn out to be useful in the research setting only.