Shalom J. Srirangam

Management of Urinary Calculi in Pregnancy : A Review

Nephrolithiasis during pregnancy can represent a clinical dilemma because of potential risks to both mother and fetus. While the incidence of symptomatic nephrolithiasis during pregnancy varies between 1 in 244 to 1 in 2000 pregnancies, the actual incidence is likely to be higher. A significant proportion of patients with asymptomatic renal calculi are detected incidentally in the nonpregnant population compared with pregnant women. Factors that contribute to the diagnostic challenges include anatomic and physiologic changes to the female urinary tract during pregnancy and the limitations on the use of ionizing radiation. The treatment of such patients requires a multidisciplinary team approach involving the urologist, obstetrician, and radiologist. The potential hazards of intervention (either surgical or medical) and anesthesia need to be considered carefully.

Management of acute urinary retention secondary to benign prostatic hyperplasia in the UK: a national survey.

To analyse current practice in the management of acute urinary retention (AUR) secondary to benign prostatic hyperplasia (BPH) in the UK, and to assess how much of this is evidence‐based.

Early and late morbidity after vasectomy: a comparison of chronic scrotal pain at 1 and 10 years

To evaluate the incidence and timing of the onset of chronic scrotal pain after vasectomy in two populations at 1 and 10 years after surgery.

Diethylstilboestrol versus Bicalutamide in Hormone Refractory Prostate Carcinoma: A Prospective Randomized Trial

Objective: To compare the efficacy of diethylstilboestrol (DES) with bicalutamide in the treatment of hormone refractory prostate cancer in relation to its effect on prostate-specific antigen (PSA) and survival. Methods: Patients on LHRH analogues for prostate carcinoma with evidence of biochemical or clinical progression were randomized into one of the treatment arms (n = 58). The first group (group A, n = 26) received 1 mg of DES with 75 mg of aspirin per day in addition to the primary hormonal treatment. The second group (group B, n = 32) received bicalutamide at a dose of 50 mg/day in addition to the primary treatment. Patients were followed up every 3 months with their PSA being checked and were also monitored for any clinical progression and adverse effects as a result of treatment. Any adverse event occurring after patients were started on treatment was attributed to the drug and patients were clinically assessed at each visit. Failure of treatment was defined as a 50% or greater increase in PSA after commencing treatment. Once randomized, all patients were followed up for survival regardless of failure of second-line hormonal manipulation. Results: The mean age of the patients was 76.7 years (60–88, SD 7.4) in group A and 76 years (67–86, SD 6.9) in group B. Twelve patients in each group had metastatic disease. The median follow-up periods for both groups were 24 months (range 6–48 in group A, range 3–54 in group B). 65% of the patients in group A (17/26) and 43.5% (14/32) in group B had a fall in their PSA levels (p = 0.08, Fisher’s exact test) with 23% (6/26) and 31% (10/32) having a >50% response respectively (p = 0.34, Fisher’s exact test). Mean PSA nadir in those who responded were 20.6 ng/ml (range 1.6–59.4) and 7.41 ng/ml (range 0.1–42.6) in groups A and B respectively. The median duration of response was 9 months (3–18 months) for group A and 12 months (3–18 months) for group B. Seven patients in group A and 6 in group B experienced adverse events. Three of the 7 in the group A experienced cardiovascular related adverse effects (1 congestive cardiac failure, 1 pulmonary embolism and 1 stroke). At the end of the study period, 14 (54%) of group A patients were alive and 12 (46%) were dead. In group B, 15 (47%) were alive, 16 (50%) were dead and 1 (3%) lost to follow-up. At the completion of the study, 3 patients in each group were still on treatment. Conclusion: Low-dose DES and 50 mg of bicalutamide per day are equally effective in hormone refractory prostate carcinoma with respect to biochemical response, although DES has more severe adverse effects. This is a small sample and larger multicentre trials are needed to give us a definite conclusion.

High-performance system GreenLight laser: indications and outcomes.

Purpose of review In this review, we present recent clinical and urodynamic data on transurethral photoselective vaporization of the prostate, and report on the recent introduction of the 120 W GreenLight laser (GLL) high-performance system. Recent findings Published studies provide substantial evidence that photoselective prostate vaporization is an efficacious treatment for lower urinary tract symptoms caused by benign prostatic hyperplasia. Recent studies confirm improved urodynamic findings following GLL treatment. Moreover, it can be used safely in high-risk patients (e.g. those on anticoagulant medication and patients with cardiopulmonary diseases), and has been proposed as an alternative to prostate enucleation for larger glands. Depending on the reimbursement system in different countries, it can be a cost-effective procedure. The introduction of the 120 W high-performance system GLL does, however, place distinct demands on training and operative schemes. Summary The clinical results of GreenLight prostate vaporization are equivalent to those following transurethral resection of the prostate, with reduced operative risks, even for the high-risk patient. These clinical benefits have been confirmed by improved urodynamic parameters. The potential advantages of the new 120 W high-performance system GLL are yet to be unequivocally proven in larger randomized trials.

Nephroptosis: seriously misunderstood?

Nephroptosis has been one of the most controversial and often debated urological diagnoses for more than a century. Anatomically, it is defined as a significant descent ( > 5 cm or two vertebral bodies on IVU) of the kidney as the patient moves from supine to erect [1]. The kidney might move into an abnormal position but is capable of moving back into a normal anatomical site, which differentiates it from an ectopic kidney, which would constantly remain in an abnormal position. The gross downward displacement of the kidney can give rise to symptoms either due to effects on the ureter or the renal hilar vessels.

Laparoscopic Nephroureterectomy: The Distal Ureteral Dilemma

Transitional cell carcinoma affecting the upper urinary tract, though uncommon, constitutes a serious urologic disease. Radical nephroureterectomy remains the treatment of choice but has undergone numerous modifications over the years. Although the standard technique has not been defined, the laparoscopic approach has gained in popularity in the last two decades. The most appropriate oncological management of the distal ureteral and bladder cuff has been a subject of much debate. The aim of the nephroureterectomy procedure is to remove the entire ipsilateral upper tract in continuity while avoiding extravesical transfer of tumor-containing urine during bladder surgery. A myriad of technical modifications have been described. In this article, we review the literature and present an overview of the options for dealing with the lower ureter during radical nephroureterectomy.

Vesicocutaneous fistula : An unusual complication of inguinoscrotal hernia

Abstract  Involvement of the urinary bladder in an inguinal hernia is common, but massive bladder hernia is rare. Most urinary bladder herniations are discovered and repaired during surgery. We report a case of large incarcerated inguino‐scrotal hernia, which was reduced only to present as a scrotal abscess and vesicocutaneous fistula; an unusual complication. The patient was managed conservatively due to underlying comorbidities.

Ureteric Obstruction Caused by Aneurysm of the Hypogastric Artery

We present the case of a 70-year-old man with haematuria who was found to have an internal iliac artery aneurysm causing ureteric obstruction. Urgent repair of the iliac artery aneurysm was performed but no urological intervention was necessary.

Penile tuberculosis after intravesical bacillus Calmette-Guérin instillation.

A 79-year-old man was investigated for haematuria and found to have carcinoma in situ of the bladder. Although hypertensive he was otherwise fit and well for his age. He had six instillations of intravesical BCG; after the last instillation he developed cold sweats and low-grade pyrexia associated with weight loss. At about the same time he also developed a rash and pain over the penis, which was initially thought to be a reaction to BCG. Clinical examination revealed a 0.5–1 cm nodule over the base of the penis. A chest X-ray was normal and urine culture failed to grow any acid-fast bacilli. As the nodule failed to subside it was biopsied by excision, which was reported as a noncaseating epithelioid granuloma (Fig. 1). After this he developed a cold abscess over his chest wall, which grew Mycobacterium bovis , and he was treated successfully with antituberculous drugs.