Raguram Ganesamoni

Efficacy of holmium laser urethrotomy in combination with intralesional triamcinolone in the treatment of anterior urethral stricture.

Purpose To evaluate the outcome of visual internal urethrotomy with a holmium:yttrium-aluminum-garnet laser along with intralesional triamcinolone injection. Materials and Methods Patients with an anterior urethral stricture less than 3 cm in length were evaluated by clinical history, physical examination, uroflowmetry, and retrograde urethrogram preoperatively. All patients were treated with holmium laser urethrotomy and intralesional triamcinolone (80 mg) injection under general or regional anesthesia. An 18 F urethral catheter was placed for 5 days. All patients were followed up for 12 months postoperatively by history, uroflowmetry, and if required, retrograde urethrogram or urethroscopy every 3 months. Results The mean age of the patients was 42.9 years (range, 14 to 70 years). The overall recurrence rate was 24%. The success rate in patients with strictures less than 1 cm in length was 95.8%, whereas that in patients with strictures of 1 to 3 cm in length was 57.7% (p=0.002). The outcome did not depend on age, duration of symptoms, etiology, or location of stricture. Conclusions Holmium laser urethrotomy with intralesional triamcinolone is a safe and effective minimally invasive therapeutic modality for urethral strictures. This procedure has an encouraging success rate, especially in those with stricture segments of less than 1 cm in length.

Status of Oxidative Stress in Patients With Renal Cell Carcinoma

PURPOSE Although oxidative stress is implicated in renal cell carcinoma pathogenesis, to our knowledge changes in oxidative stress parameters in patients who undergo surgery for renal cell carcinoma have not been studied previously. We investigated the status of oxidative stress in patients with renal cell carcinoma. MATERIALS AND METHODS Reactive oxygen species, nitric oxide and glutathione were measured in the blood of 68 patients with renal tumor and in 30 age matched normal controls. Levels were measured again 1 week, and 1 and 2 months postoperatively in patients who underwent surgery for renal cell carcinoma. Levels of superoxide dismutase, catalase and lipid peroxidation were measured in tumor tissue and in normal renal parenchyma in 51 patients with renal tumor. RESULTS Significantly increased reactive oxygen species and nitric oxide, and decreased glutathione were observed in patients with renal cell carcinoma compared to normal subjects and in patients with benign tumors. Superoxide dismutase and lipid peroxidation were increased and catalase was decreased in tumor tissue compared to normal renal tissue. Oxidative stress correlated with renal cell carcinoma grade and stage but decreased after curative resection. Patients with metastatic disease had persistently increased oxidative stress parameters. Antioxidant enzyme levels in benign tumor tissue were significantly higher than in renal cell carcinoma. CONCLUSIONS Patients with renal cell carcinoma have increased oxidative stress, which is effectively alleviated by curative resection. In patients with benign tumors antioxidant defense mechanisms maintain normal redox status.

Tranexamic Acid Reduces Blood Loss During Percutaneous Nephrolithotomy: A Prospective Randomized Controlled Study

PURPOSE Bleeding is a significant morbidity associated with percutaneous nephrolithotomy. This study was conducted to evaluate the safety and efficacy of the antifibrinolytic agent tranexamic acid in reducing blood loss in patients undergoing percutaneous nephrolithotomy. MATERIALS AND METHODS A total of 200 patients undergoing percutaneous nephrolithotomy were randomized into 2 equal groups. Patients in the tranexamic acid group received 1 gm tranexamic acid at induction followed by 3 oral doses of 500 mg during 24 hours, while those in the control group did not receive tranexamic acid. The patient demographics and clinical data of the 2 groups were compared. RESULTS Baseline patient demographics were similar in both groups. Mean hemoglobin decrease in the tranexamic acid group was significantly lower than that of the control group (1.39 vs 2.31 gm/dl, p <0.0001). Mean operative time in the tranexamic acid group was significantly lower than that in the control group (48.3 vs 70.8 minutes, p <0.0001). The stone clearance rate was similar in both groups (91% vs 82%, p = 0.06). The blood transfusion rate was lower in the tranexamic acid group (2% vs 11%, p = 0.018), as was the complication rate (33% vs 59%, p <0.0001). Two patients with a solitary functioning kidney in the tranexamic acid group required ureteral stenting to relieve anuria due to clot obstruction. CONCLUSIONS The use of tranexamic acid in percutaneous nephrolithotomy is safe, and is associated with reduced blood loss and a lower complication rate.

Randomized Controlled Trial to Compare the Safety and Efficacy of Naftopidil and Tamsulosin as Medical Expulsive Therapy in Combination With Prednisolone for Distal Ureteral Stones

Purpose To compare the safety and efficacy of naftopidil and tamsulosin with prednisolone as medical expulsive therapy for distal ureteric stones. Materials and Methods Between July 2010 and March 2012, 120 adult patients presenting with distal ureteric stones of size 5 to 10 mm were randomized equally to tamsulosin (group A), naftopidil (group B) or watchful waiting (group C). Tamsulosin or naftopidil was given for a maximum of four weeks. In addition patients in group A and B were given 5 mg prednisolone once daily (maximum one week). Stone expulsion rate, time to stone expulsion, analgesic use, number of hospital visits for pain, follow-up and endoscopic treatment and adverse effects of drugs were noted. Statistical analyses were done using chi-square test, Mann-Whitney test and analysis of variance. Results There was a statistically higher expulsion rate in groups A (70%) and B (87.5%) as compared to group C (32.5%) (p<0.001). The expulsion rates were not statistically different between groups A and B (p=0.056). The mean time to expulsion was comparable between groups A and B but longer in group C. Analgesic use was significantly lower in groups A and B. Average number of hospital visits for pain, follow-up and endoscopic treatment was similar in all groups. There was no serious adverse event. Conclusions Medical expulsive therapy for the distal ureteric stones using either naftopidil or tamsulosin in combination with prednisolone is safe and efficacious.

Prospective Randomized Controlled Trial Comparing Laser Lithotripsy with Pneumatic Lithotripsy in Miniperc for Renal Calculi

BACKGROUND AND PURPOSE The energy source used for stone fragmentation is important in miniperc. In this study, we compared the stone fragmentation characteristics and outcomes of laser lithotripsy and pneumatic lithotripsy in miniperc for renal calculi. PATIENTS AND METHODS After Institutional Review Board approval, 60 patients undergoing miniperc for renal calculi of 15 to 30 mm were equally randomized to laser and pneumatic lithotripsy groups. Miniperc was performed using 16.5F Karl Storz miniperc sheath and a 12F nephroscope. Laser lithotripsy was performed using a 550-μm laser fiber and 30 W laser with variable settings according to the need. Pneumatic lithotripsy was performed using the EMS Swiss lithoclast. Patient demographics, stone characteristics, intraoperative parameters, and postoperative outcomes were analyzed. RESULTS The baseline patient demographics and stone characteristics were similar in both groups. The total operative time (P = 0.433) and fragmentation time (P=0.101) were similar between the groups. The surgeon assessed that the Likert score (1 to 5) for fragmentation was similar in both groups (2.1 ± 0.8 vs 1.9 ± 0.9, P=0.313). Stone migration was lower with the laser (1.3 ± 0.5 vs 1.7 ± 0.8, P=0.043), and fragment removal was easier with the laser (1.1 ± 0.3 vs 1.7 ± 1.1, P=0.011). The need for fragment retrieval using a basket was significantly more in the pneumatic lithotripsy group (10% vs 37%, P=0.002). The hemoglobin drop, complication rates, auxiliary procedures, postoperative pain, and stone clearance rates were similar between the groups (P>0.2). CONCLUSION Both laser lithotripsy and pneumatic lithotripsy are equally safe and efficient stone fragmentation modalities in miniperc. Laser lithotripsy is associated with lower stone migration and easier retrieval of the smaller fragments it produces.

Role of Active Mentoring During Flexible Ureteroscopy Training

PURPOSE To evaluate the outcome of flexible ureteroscopy training with or without an active mentor. MATERIALS AND METHODS Thirty-six flexible ureteroscopy naive practicing urologists and urology residents, after an initial introductory refreshment course, underwent training under a mentor for 15 minutes each in a high-fidelity nonvirtual reality Endo-Urologie-Modell (Karl Storz). The trainees were then randomized into two equal groups for training: One under a mentor and the other without. These two groups completed the training for 2 hours. Global rating scale (GRS) for the performance of flexible ureteroscopy was measured by a blinded expert at the beginning and end of the training. A specific task completion time (TCT) was noted at the end of the training. The trainees noted their own global rating scale at the end of the training. RESULTS The GRS by the expert at the end of the training was significantly higher in the mentor group. TCT was significantly lower in the mentor group. TCT correlated well with the GRS as measured by the expert rather than the trainee. CONCLUSION Mentorship during flexible ureteroscopy training results in higher GRS and lower TCT at the end of the training. Self-assessment GRS by trainee does not correlate well with the skills acquired.

Randomized Controlled Trial to Assess the Efficacy of the Combination Therapy of Alfuzosin and Tadalafil in Patients with Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia

The purpose of our study was to evaluate the effect of alfuzosin and tadalafil as combination therapy compared with each monotherapy, in patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH).

Large pelvic masses of obscure origin: urologist's perspective.

Background: Large pelvic masses pose unique diagnostic and therapeutic challenges due to varied aetiology, paucity of characteristic imaging features, lack of therapeutic algorithms and surgical difficulties in resection inside the narrow confines of the pelvis with close proximity of vital structures. Methods: Records of 22 patients with large pelvic masses in the last six years were analysed. Their demographic and clinical features were noted, along with imaging features, preoperative biopsy, surgical procedure, intraoperative difficulties, complications, adjuvant therapy and outcome. Results: There were 14 men and 8 women with a median age of 45 years. Presenting symptoms were abdominal mass, pain, lower urinary tract symptoms, urinary retention and constipation. Imaging was mostly unable to determine the organ of origin of the tumour. Histopathology revealed pelvic fibromatosis (2), chondrosarcoma (1), liposarcoma (1), haemangioendothelioma (1), lymphangioma (2), fibroleiomyoma (1), leiomyosarcoma (3), schwannoma (4), malignant nerve sheath tumour (1), rectal gastrointestinal stromal tumour (1), retrovesical hydatid cysts (3), sacral chordoma (1) and Ewing’s sarcoma (1). In 5 patients complete excision was not possible because of extension into vital structures. Fifteen patients were alive at 1–5 years of follow-up. Conclusions: Urologists, being the ‘gatekeepers of the pelvis’, are usually involved in the management of large pelvic masses. Good outcome can be achieved with careful surgical planning.

A Randomized Controlled Trial Comparing Combined Spongiosum Block and Intraurethral Lignocaine with Intraurethral Lignocaine Alone in Optical Internal Urethrotomy for Urethral Stricture

BACKGROUND AND PURPOSE Optical internal urethrotomy is the most commonly performed procedure for the management of anterior urethral stricture. This study was performed to compare the safety and efficacy of spongiosum block along with intraurethral lignocaine with intraurethral lignocaine alone for optical internal urethrotomy. PATIENTS AND METHODS Fifty patients with anterior urethral stricture were prospectively randomized to undergo optical internal urethrotomy under spongiosum block along with intraurethral lignocaine (group 1=25 patients) and intraurethral lignocaine only (group 2=25 patients). The procedure-related pain was noted using the visual analogue scale. Postprocedure evaluation was performed by uroflowmetry and urethral calibration. Retrograde urethrography and micturating cystourethrography were performed as needed. RESULTS Optical internal urethrotomy was successfully completed in all patients. The mean visual analogue score for pain in group 1 (1.5 ± 1.4) was significantly lower than the score in group 2 (2.7 ± 1.8) (P=0.006). At 6 months follow-up, recurrent strictures developed in three patients in group 1 and five patients in group 2. CONCLUSIONS Spongiosum block with intraurethral lignocaine has a better anesthetic effect than intraurethral lignocaine alone for performing optical internal urethrotomy. Spongiosum block with intraurethral lignocaine is a viable alternative for regional and general anesthesia in the management of anterior urethral stricture with optical internal urethrotomy.

Renal Deterioration Index: Preoperative Prognostic Model for Renal Functional Outcome After Treatment of Bilateral Obstructive Urolithiasis in Patients with Chronic Kidney Disease

BACKGROUND AND PURPOSE Patients who present with varying severity of obstructive urolithiasis behave differently after the treatment. Some patients recover with improved renal function while others progress to renal failure. Our objective was to objectively quantify which patients would progress to renal failure after treatment for obstructive urolithiasis. PATIENTS AND METHODS A prospective analysis of 167 patients with renal failure from bilateral obstructive urolithiasis who were treated and subsequently followed for at least 1 year was performed. Failure was defined as glomerular filtration rate (GFR) values less than 15 mL/min at 1 year follow-up. All patients had preoperative placement of a percutaneous nephrostomy tube for at least 5 days before treatment with either ureteroscopy or percutaneous nephrolithotomy. Multiple logistic regression analysis of affecting parameters was performed. A renal deterioration index (RDI) was constructed based on scores assigned to varying severity of multivariate significant factors and the receiver operating characteristic (ROC) curve was analyzed. RESULTS There were 48(28.7%) patients who progressed to CKD stage V at 1-year follow-up. Combined cortical width (≤ 0.001), proteinuria (0.01), positive urine culture (0.004), and nadir preoperative GFR postbilateral percutaneous nephrostomy (0.016) were statistically significant factors affecting renal deterioration on multivariate analysis. RDI has a high ROC curve (AUC=0.90) for predicting renal functional outcome. Combining these parameters in a prediction table yielded a RDI score ≥ 12 being associated with high odds risk (odds ratio=11.2) of treatment failure. CONCLUSION RDI ≥ 12 is associated with renal deterioration after appropriate treatment of bilateral obstructive urolithiasis.