Rajiv Yadav

Assessment of the performance of Partin's nomogram (2007) in contemporary Indian cohort

Introduction: Partins nomogram is an important prognostic tool to predict adverse pathological features for clinically localized prostate carcinoma. This tool is widely used by both radiation and surgical oncologists for pre-intervention counseling, treatment planning, and predicting the possible need for adjuvant treatment. However, the model is derived from a Western population with typical characteristics of prostate cancer in a prostate-specific antigen (PSA) screened population. Therefore, this study was conducted to assess the performance of the Partins nomogram as applied to an Indian cohort by assessing the discrimination and calibration properties. Methods: A retrospective review of 282 patients treated with robotic radical prostatectomy from 2010 to 2015 was conducted. Partin tables (year 2007) were used to calculate the predicted probabilities for lymph node invasion (LNI), seminal vesicle invasion (SVI), and extraprostatic extension (EPE). The discrimination properties were assessed using the receiver operating characteristic (ROC) curves. Calibration of the model was done to show the relationship between predicted and observed values. Results: The mean age of the patients was 64.3 years. Most (59.4%) were clinical T2 disease. Patients with PSA >10 ng/ml comprised 60% of the population. ECE, SVI, and LNI were present in 39.2%, 22%, and 11% of cases, respectively. ROC analysis revealed area under curve values for EPE, SVI, and LNI of 68%, 67.5%, and 71.2%, respectively. Calibration plot suggested that the Partin tables under-predicted the risk whenever the values of predicted risk were more than 26%, 3%, and 1% for EPE, SVI, and LNI, respectively, and over predicted when the risk was lower. Conclusion: Our data show that Partins tables, despite having fair discrimination properties, do not accurately predict LNI, SVI, and ECE across the entire range of predicted values in a contemporary Indian cohort.

Continence outcomes following robotic radical prostatectomy: Our experience from 150 consecutive patients

Introduction: Urinary continence is an important outcome parameter after robot assisted radical prostatectomy (RARP). We evaluated the continence outcomes following RARP using a double-layered urethrovesical reconstruction. Materials and Methods: One hundred fifty consecutive patients undergoing RARP and double-layered urethrovesical reconstruction were prospectively studied for preoperative, intraoperative and post operative parameters. Key points followed during surgery were: Minimal dissection of sphincteric complex, preservation of puboprostatic ligament, selective ligation of deep venous complex and both posterior and anterior reconstruction using the Von Velthoven stitch. Intraoperative bladder fill test was done at the end of anastomosis to rule out urine leak. Check cystogram was done prior to catheter removal in the outpatient department. Patients were subsequently followed at regular intervals regarding the status of urinary continence. All patients irrespective of adjuvant therapy were included in the analysis. Results: The mean age was 64 years (standard deviation ± 6.88), and mean serum PSA was 20.2 ng/ml. The mean BMI was 25.6 (SD: ±3.84). The mean prostate weight was 44.09 gm (range 18-103 gm, SD: ±15.59). Median days to catheter removal after surgery was 7 (range 4-14 days) days. Cystographically determined urinary leaks were seen in two patients. Urine leak was managed by delaying catheter removal for 1 week. Minimum 6 month follow up was available in 126 patients. ‘No pad’ status at 1 week, 1 month, 3 months, 6 months and 1 year was 15.1%, 54.9%, 78%, 90.5% and 94.1%, respectively. Conclusion: Excellent continence outcomes are observed in patients undergoing double-layered urethrovesical reconstruction.

Multiparametric magnetic resonance imaging-transrectal ultrasound fusion prostate biopsy: A prospective, single centre study

Introduction: Transrectal rectal ultrasound (TRUS)-guided systematic biopsy is the gold standard for diagnosis of prostate cancer. However, systematic biopsy has high false-negative rate and often misses anteriorly located tumors. Magnetic resonance imaging (MRI)-TRUS fusion biopsy can potentially improve cancer detection by better visualization and targeting of cancer focus. We evaluated the role of fusion biopsy in detection of prostate cancer and the association of prostate imaging reporting and data system (PI-RADS) score for predicting cancer risk and its aggression. Methods: Ninety-six consecutive men with suspected prostate cancer underwent MRI-TRUS fusion-targeted biopsy of suspicious lesions and standard 12 core biopsy from May 2014 to July 2015 in our institution. All patients underwent 3.0 T multiparametric MRI before biopsy. mp-MRI included T2W, DWI, DCE and MRS sequences to identify lesions suspicious for prostate cancer. Suspected lesions were scored according to PI-RADS scoring system. Comparison of cancer detection between standard 12 core biopsy and MRI-TRUS fusion biopsy was done. Detection of prostate cancer was primary end point of this study. Results: Mean age was 64.4 years and median prostate-specific antigen was 8.6 ng/ml. Prostate cancer was detected in 57 patients (59.3%). Of these 57 patients, 8 patients (14%) were detected by standard 12 core biopsy only, 7 patients (12.3%) with MRI-TRUS fusion biopsy only, and 42 patients (73.7%) by both techniques. Of the 7 patients, detected with MRI-TRUS fusion biopsy alone, 6 patients (85.7%) had Gleason ≥7 disease. Prostate cancer was detected on either standard 12 core biopsy or MRI-TRUS fusion biopsy in 0%, 42.8%, 74%, and 89.3% patients of suspicious lesions of highest PI-RADS score 2, 3, 4, and 5, respectively. Conclusions: MRI-TRUS fusion prostate biopsy improves cancer detection rate when combined with standard 12 cores biopsy and detects more intermediate or high-grade prostate cancer (Gleason ≥7). With increasing PI-RADS score, there is an increase chance of detection of cancer as well as its aggressiveness.

Giant Sarcomatoid Carcinoma with Osseous Metaplasia from Urinary Bladder Diverticulum

Sarcomatoid carcinoma is an extremely rare aggressive tumor variant comprising about 0.3% of all primary tumors of the urinary bladder. We report a rare case of giant bladder sarcomatoid tumor arising from a bladder diverticulum. A 60-year-old male on evaluation for long-standing obstructive voiding symptoms with recurrent pyuria found to have renal failure and bladder mass with bilateral hydroureteronephrosis (HDUN) on ultrasound. Further radiologic evaluation revealed multiple bladder diverticulae and anteriorly displaced bladder with a large mass arising from one of the posteriorly located bladder diverticulum with extrinsic compression of both the distal ureters leading to severe bilateral HDUN. Rigid cystourethroscopy was not successful due to anteriorly displaced urethra. Tissue biopsy taken with flexible cystoscope revealed low-grade, noninvasive transitional cell carcinoma. After staging workup, bilateral percutaneous nephrostomy was performed initially for stabilization of renal function. This was followed by radical cystoprostatectomy with bilateral extended pelvic lymphadenectomy with ileal conduit diversion. Histopathology revealed high-grade muscle-invasive sarcomatoid variant of urothelial carcinoma with osseous metaplasia. It is imperative to recognize the rare variants of bladder tumors with different therapeutic and prognostic considerations and hence tailor the management of individual variant.

Atypical presentation of pheochromocytoma: Central nervous system pseudovasculitis

Pheochromocytoma has atypical presentation in 9%–10% of patients. Atypical presentations include myocardial infarction, renal failure, and rarely cerebrovascular events. Various etiologies for central nervous system (CNS) involvement in pheochromocytoma have been described in the literature. A rare association of CNS vasculitis-like features has been described with pheochromocytoma. We report a rare case of pheochromocytoma detected on evaluation for CNS vasculitis-like symptoms.

Robot Assisted Boari Flap Ureteric Reimplantation

Boari’s bladder flap reconstruction is one of the management options for lower ureteric stricture. It is the preferred treatment option in situation where the stricture segment is either proximal or is longer in length, thus precluding tension free reimplantation with direct vesico ureteric anastomosis with or without psoas hitch. Other than open surgery, Boari’s flap can also be performed by minimally invasive surgical approach with laparoscopy. Extensive suturing involved in laparoscopy, increases the operative duration and also increases the surgeon fatigue. Robot assisted approach is helpful in such cases, mainly because of the ease of the suturing and the preservation of vascularity due to minimal and delicate handling of tissues.

Selective indication for check cystogram before catheter removal following robot assisted radical prostatectomy.

Introduction: With the improvement in anastomotic technique, it is rare to find anastomotic site leak after robot-assisted radical prostatectomy (RARP). It may not always be necessary to do regular check cystogram before catheter removal. We evaluated our 230 consecutive RARP patients and their cystograms to determine the indications for selective use of cystogram before catheter removal. Materials and Methods: We reviewed our prospectively collected RARP database of 230 consecutive patients. Cystography was performed at low pressure by gravity instillation of diluted contrast through the catheter. Patients were observed under fluoroscopy in lateral oblique position for any contrast leak at the site of anastomosis. All patients were followed for a minimum of 6 months, and the longest follow-up was 5 years. Results: A total of 207 patients (90%) underwent catheter removal on postoperative day 7. Nine patients (3.9%) had extravasation on initial cystogram. Two patients with leak had a history of transurethral resection of prostate (TURP) and seven other had bladder neck reconstruction for wide bladder neck. Three patients with minimal leak did not require catheter replacement. In rest of the 6 patient with leak, continued catheter drainage was done. No significant difference in the intraoperative variables, blood loss, duration of drain, length of hospital stay, and continence outcomes was noted between the patients with leak compared to rest of the patients. None of the patient needed any procedure/intervention related to the surgery and none developed bladder neck stenosis. Conclusion: In usual circumstances, catheter removal can be done safely on a postoperative day 7 without routine cystography. Selective use of check cystogram can be done in the case where bladder neck reconstruction is performed or those had a prior TURP and a wide bladder neck.

68Gallium-DOTANOC positron emission tomography/computed tomography scintigraphy for an unusual case of malignant pheochromocytoma: Findings and review of literature

Functional imaging is an important step in the diagnostic approach of patients with pheochromocytoma (PCC). Metaiodobenzylguanidine (MIBG) scintigraphy (single-photon emission computed tomography) is currently the most widely used functional imaging modality for evaluating a case of PCC. However, it has some limitations and poor sensitivity, especially in cases of malignant PCC (MPCC). Positron emission tomography (PET) scanning with gallium-68 (68Ga)-DOTA-coupled somatostatin analogs is the newer upcoming modality with some superiority over MIBG scan. We present a case of MPCC with unusual invasion and metastasis positive on DOTANOC PET scan along with relevant review of literature.