Pawan Vasudeva

Intravesicle gemcitabine in management of BCG refractory superficial TCC of urinary bladder—our experience

INTRODUCTION The incidence of bladder malignancy is increasing worldwide and the projected rise is 28% by 2010 for both sexes (according to the WHO). Though intravesical adjuvant therapy with bacillus Calmette-Guérin (BCG) is superior to any other immunotherapeutic/chemotherapeutic agent in reducing tumor recurrences and disease progression, its real efficacy remains controversial as one-third of the patients will soon develop BCG failure. Hence, there is a need for an alternative intravesical agent for treatment of BCG failure. Our aim is to study the efficacy, tolerability, and safety of intravesical gemcitabine in managing BCG refractory superficial bladder malignancy. MATERIAL AND METHODS Thirty-five BCG failure patients, 26 males and 9 females between 20 and 72 years of age were instilled 2000 mg of gemcitabine in 50 ml of normal saline intravesically 2 weeks post-tumor resection, for 6 consecutive weeks. Mean follow-up for 18 months with cystoscopy was done. RESULT Twenty-one patients (60%) showed no recurrences, 11 patients (31.4%) had superficial recurrences, while 3 patients (8.75%) progressed to muscle invasiveness. Average time to first recurrence was 12 months and to disease progression was 16 months. Adverse event was low and mild. Therapy was well tolerated. CONCLUSION Gemcitabine fulfills all requirements as an alternative agent in treating BCG failure patients with low adverse events, well tolerated, and highly effective in reducing tumor recurrences.

A prospective randomized comparative study of monopolar and bipolar transurethral resection of the prostate and photoselective vaporization of the prostate in patients who present with benign prostatic obstruction: a single center experience.

PURPOSE The first prospective randomized study to compare the safety and short-term efficacy of monopolar transurethral resection of the prostate (TURP), bipolar TURP, and photoselective vaporization of the prostate (PVP) using GreenLight high-performance system 120W laser in patients who presented with benign prostatic obstruction (BPO). PATIENTS AND METHODS The 186 consecutive patients who presented with BPO and who were planned for surgery were randomized into three groups: Group A, patients who underwent monopolar TURP; group B, patients who underwent bipolar TURP; and group C, patients who underwent PVP. All three groups were subdivided into two subgroups based on prostate volume: Subgroup 1 >20 cc and <50 cc, and subgroup 2, between 50 and 80 cc. Patients preoperative, perioperative, and follow-up data were recorded and analyzed. RESULTS The baseline characteristics of the three groups and subgroups 1 and 2 were comparable. The number of patients in whom postoperative irrigation was instituted, amount of fluid used for postoperative irrigation, duration of postoperative irrigation, postoperative hemoglobin concentration, and duration of catheterization were significantly in favor of group C patients except for the mean operative time, which was significantly longer among them. All three groups demonstrated an increase in International Prostate Symptom Score, quality of life score, and maximum flow rate and decrease in prostate volume and postvoid residual urine at 12-month follow-up. The mean Intgernational Index of Erectile Function-5 score did not show improvement in any group. The need for blood transfusion and clot retention necessitating intervention were significantly lower among group C patients compared with group A, whereas these values for group B patients did not reach significant level compared with either group A or C. These complications were comparable among subgroup 1 patients, whereas subgroup 2 patients had shown results in favor of subgroup C2. CONCLUSION Monopolar TURP, bipolar TURP, and PVP are equally efficacious at 12-month follow-up. PVP has added advantages of lesser blood loss, lesser need for blood transfusion (especially for prostate volume 50-80 cc), and shorter catheterization time.

A Prospective, Randomized Comparison of Shock Wave Lithotripsy, Retrograde Intrarenal Surgery and Miniperc for Treatment of 1 to 2 cm Radiolucent Lower Calyceal Renal Calculi: A Single Center Experience

PURPOSE A prospective, randomized comparison of shock wave lithotripsy, retrograde intrarenal surgery and miniperc for the treatment of 1 to 2 cm radiolucent lower calyceal renal calculi was done to evaluate the safety and efficacy of these procedures. MATERIALS AND METHODS Patients with a single 1 to 2 cm radiolucent lower calyceal renal stone who underwent treatment between January 2012 and May 2013 were included in study. They were randomized to shock wave lithotripsy, retrograde intrarenal surgery and miniperc groups. Patient demographic profiles, success and re-treatment rates, auxiliary procedures and complications were analyzed. RESULTS A total of 45 patients were enrolled in each of the shock wave lithotripsy, retrograde intrarenal surgery and miniperc groups. Three, 2 and 4 patients, respectively, were excluded from final analysis due to a matrix stone diagnosis. Mean procedure and fluoroscopy times were significantly greater in the miniperc group than in the other groups. Hospital stay (3.1 days vs 3.1 hours and 1.3 days, p = 0.01) and the blood transfusion rate (13.3% vs 0% and 0%, p = 0.03) were significantly higher for miniperc vs shock wave lithotripsy and retrograde intrarenal surgery, respectively. The re-treatment rate (63.4% vs 2.1% and 2.2%, p <0.001) and the auxiliary procedure rate (20.2% vs 8.8% and 6.6%, p = 0.02) were significantly greater for shock wave lithotripsy than for retrograde intrarenal surgery and miniperc, respectively. The 3-month stone-free rate of shock wave lithotripsy, retrograde intrarenal surgery and miniperc was 73.8% (31 of 42 patients), 86.1% (37 of 43) and 95.1% (39 of 41), respectively (p = 0.01). CONCLUSIONS Miniperc and retrograde intrarenal surgery were more effective than shock wave lithotripsy to treat 1 to 2 cm radiolucent lower calyceal renal calculi in terms of a better stone-free rate, and lesser auxiliary and re-treatment rates. However, miniperc resulted in more complications, greater operative time and radiation exposure, and a longer hospital stay.

Photoselective vaporization of prostate vs. transurethral resection of prostate: A prospective, randomized study with one year follow-up

Objectives: To evaluate in a prospective, randomized study, the efficacy and safety profile of photoselective vaporization of prostate (PVP) using a 80W potassium titanyl phosphate (KTP) laser when compared to standard transurethral resection of prostate (TURP) in patients with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE). Materials and Methods: Between February 2009 and August 2009, 117 patients satisfying the eligibility criteria underwent surgery [60 PVP{Group A}; 57 TURP{Group B}]. The groups were compared for functional outcome (both subjective and objective parameters), perioperative parameters and complications, with a follow up of one year. P value<0.05 was considered statistically significant. Results: The baseline characteristics of the two groups were comparable. Mean age was 66.68 years and 65.74 years, mean IPSS score was 19.98 and 20.88, mean prostate volume was 44.77 cc and 49.02 cc in Group A and B, respectively. Improvements in IPSS, QOL, prostate volume, Q max and PVRU at 12 months were similar in both groups. PVP patients had longer operating time, lesser perioperative blood loss, shorter catheterization time and a higher dysuria rate when compared to TURP patients. The overall complication rate was similar in the two groups. Conclusions: In patients with LUTS due to BPE, KTP-PVP is an equally efficacious alternative to TURP with durable results at one year follow up with additional benefits of lesser perioperative blood loss, lesser transfusion requirements and a shorter catheterization time. Long term comparative data is awaited to clearly define the role of KTP-PVP in such patients.

Factors implicated in pathogenesis of urinary tract infections in neurogenic bladders: some revered, few forgotten, others ignored

To comprehensively review factors implicated in the pathogenesis of urinary tract infection in patients with neurogenic bladders, and to stimulate research, especially in the somewhat ignored and forgotten areas of this important clinical subject.

Dorsal versus ventral onlay buccal mucosal graft urethroplasty for long‐segment bulbar urethral stricture: A prospective randomized study

To compare safety and efficacy of ventral versus dorsal onlay buccal mucosal graft urethroplasty in patients with long‐segment incomplete bulbar urethral stricture.

Management of BCG non-responders with fixed dose intravesical gemcitabine in superficial transitional cell carcinoma of urinary bladder

Aims and Objectives: The incidence of bladder malignancy is increasing worldwide and the projected rise is 28% by 2010 for both sexes (WHO). Though intravesical adjuvant therapy with BCG is superior to any other immunotherapeutic/chemotherapeutic agent in reducing tumor recurrences and disease progression, its real efficacy remains controversial as one-third of the patients will soon become BCG failure. Hence there is a need for an alternative intravesical agent for treatment of BCG failure. Our aim was to study the efficacy, tolerability and safety of intravesical Gemcitabine in managing BCG-refractory superficial bladder malignancy. Materials and Methods: Thirty-five BCG failure patients, 26 males and nine females between 20-72 years of age were instilled with 2000 mg of Gemcitabine in 50 ml of normal saline intravesically two weeks post tumor resection, for six consecutive weeks. Mean follow-up was for 18 months with cystoscopies. Results: Twenty-one patients (60%) showed no recurrences, 11 patients (31.4%) had superficial recurrences while three patients (8.6%) progressed to muscle invasiveness. Average time to first recurrence was 12 months and to disease progression was 16 months. Adverse event was low and mild. Therapy was well tolerated. Conclusion: Gemcitabine fulfils all requirements as an alternative agent, in treating BCG failure patients with low adverse events, is well tolerated and highly effective in reducing tumor recurrences.

Predictive role of serum and urinary cytokines in invasion and recurrence of bladder cancer

Urothelial cancer patients are prone to recurrence, and there is no marker to predict which cases become refractory to the immunotherapy given to these patients. Tumour behaviour is decided by the dynamics between the pro- and anti-tumorigenic cytokines. In this study, 27 cytokines were estimated in serum and urine of 72 urothelial cancer patients and 42 healthy volunteer controls. Serum cytokines IL-1RA, IL-4 and RANTES were in significantly higher concentration in serum of patients compared to controls, while IL-2 was significantly less in concentration. Patients were found to have significantly high concentrations of 12 urinary cytokines (IL-2, IL-4, IL-8, IL-10, GM-CSF, IFN-γ, IP-10, MIP-1a, PDGF, MIP-1b, RANTES and VEGF) in comparison to healthy controls. Serum VEGF and urinary IL-1ra, IL-4, IL-10, GM-CSF, IP-10, MIP-1a and MIP-1b concentrations were found significantly higher in concentration in high-grade tumours compared to low-grade tumours. There was no difference in either the serum or urinary cytokines between non-invasive and muscle-invasive cases. Serum IL-1ra, IL-6, IL-10, TNF-α and VEGF and urinary IL-1ra, IL-4, IL-8, IL-10, GM-CSF, IP-10, MIP-1a, PDGF, MIP-1b and VEGF were found to be significantly higher in recurrent patients compared to non-recurrent patients. Of these, high concentrations of urinary IL-1RA, IL-4, IL-10, IP-10, PDGF and VEGF and serum IL-1ra, IL-6, IL-10, VEGF and TNF-α were associated with poor recurrence-free survival. Poor recurrence-free survival was also seen with increasing number of cytokines showing high concentrations. The study shows that the estimation of a combination of these cytokines in minimally or non-invasive samples may act as a prognostic indicator.

Egg shell in bladder: A calculus around neglected Foley balloon catheter.

Suprapubic catheterization of the bladder is used as a short- or long-term alternative to urethral catheterization. As with any indwelling urinary catheter, proper care is vitally important to minimize complications.

Immune signature of urothelial cancer associated with grade, recurrence, and invasion

BACKGROUND Urothelial carcinoma (UC) is one of most common genitourinary malignancy and the spectrum of disease ranges from in situ lesions to muscle-invasive cancers. The non-muscle-invasive lesions have tendency to recur or progress to muscle-invasive disease. The study of the immune profile may identify immune determinants associated with high-grade, recurrence, and invasion in patients with UC. METHODS Pathway-focused RT(2) profiler arrays were used to screen patients with UC for dysregulation of candidate genes of Th1-Th2-Th3 and NFκB pathways, which were then validated by real-time polymerase chain reaction on tumor samples and correlated with grade, recurrence, and invasion of tumors to identify their role in predicting behavior of the tumor. The cytokines found associated with recurrence were then validated in urine of patients with UC. RESULTS IFNγ, IL2, IL4, IL10, IL17, CCL7, CTLA4, and SPP1 of the cytokine pathway and TLR4, TLR3, RELA, NFκB1, and MYD88 of the NFκB pathway were found differentially expressed in patients with urothelial cancer by array and quantative real-time polymerase chain reaction. Among these, IL10 and SPP1 were found consistently up-regulated in high-grade, invasive, and recurrent cases and up-regulated IL10 and CTLA4 were found associated with a short recurrence-free survival time (P = 0.001 and P = 0.065). Urinary IL10 concentration was significantly higher in both patients with cancer and cystitis compared with healthy controls, but the difference in concentration between patients with cancer and cystitis patients was not statistically significant. However, urinary CTLA4 concentrations were found to be significantly higher in urothelial cancer patients compared with healthy controls and cystitis cases and found to be associated with poor recurrence-free survival. CONCLUSION The study indicates that high urinary CTLA4 concentration raises the index of suspicion of recurrence in a known case of urothelial cancer and may be used as a surveillance marker.