Urmila Dhakad

Retrograde Intrarenal Surgery vs Extracorporeal Shock Wave Lithotripsy for Intermediate Size Inferior Pole Calculi: A Prospective Assessment of Objective and Subjective Outcomes

OBJECTIVE To assess objective and subjective outcomes of retrograde intrarenal surgery (RIRS) and extracorporeal shock wave lithotripsy (SWL) for the treatment of intermediate size (1-2 cm) inferior calyceal (IC) stones in a prospective randomized fashion. METHODS Between March 2011 and January 2013, 70 symptomatic adults who had isolated IC stone between 10 and 20 mm underwent RIRS or SWL by computer-generated pseudorandom assignment (1:1). Success rate, mean procedure time, hospital stay, pain score on day 1 and 2 using visual analog scale, analgesic requirement after discharge, complications, retreatment rate, auxiliary procedure, and patient-reported outcomes (using self-made nonvalidated questionnaire) were compared. RESULTS Baseline parameters and mean stone size (SWL 16.45 ± 2.28 mm, RIRS 15.05 ± 3.56 mm; P = .0542) were comparable. Success rate was significantly higher after a single session of RIRS compared with 3 sessions of SWL (85% vs 54%; P = .008). Retreatment rate (65% vs 5.7%; P = .0001) and auxiliary procedure (45% vs 8%; P = .0009) were significantly higher in SWL. Pain score on postoperative day 1 and 2 was significantly higher in RIRS, but patients with SWL required significantly more analgesics afterward. Most of the complications were of Clavien grade I and/or II in both groups. Average time to return to normal activity and voiding symptoms were significantly higher in RIRS. Overall satisfaction score (2.17 ± 1.24 vs 2.82 ± 1.17; P = .026) was significantly higher in RIRS than SWL. CONCLUSION For the treatment of intermediate size IC calculi, RIRS is superior to SWL in terms of objective and subjective outcomes.

Sexual dysfunctions and lower urinary tract symptoms in ankylosing spondylitis.

To determine sexual dysfunctions and urinary symptoms in male ankylosing spondylitis (AS) patients and their association with various disease and patient factors.

Re: Li et al.: Percutaneous Nephrolithotomy Under Local Infiltration Anesthesia: A Single-center Experience of 2000 Chinese Cases (Urology 2013;82:1020-1025)

male infertility. Int J Androl. 2004;27:251-256. 6. Li H,WenQ, Li H, et al. Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) in Chinese patients with congenital bilateral absence of vas deferens. J Cyst Fibros. 2012;11:316-323. 7. Ni WH, Jiang L, Fei QJ, et al. The CFTR polymorphisms poly-T, TG-repeats and M470V in Chinese males with congenital bilateral absence of the vas deferens. Asian J Androl. 2012;14:687-690. 8. Petreska L, Koceva S, Plaseska D, et al. Molecular basis of cystic fibrosis in the Republic of Macedonia. Clin Genet. 1998;54: 203-209.

Response to Advantages of self-tailored mesh for vaginal prolapse

We appreciate authors successfully demonstrating the use of mesh self-tailoring in complex transvaginal pelvic organ repair and for expanding the scope of mesh in these surgeries. 1 However, certain issues related to self-tailoring of the mesh need to be highlighted. First, one should be well aware of breaching the virginity of mesh by “ex vivo prosthesis exposure” – allowing more implantation time and using non-disposable instruments, such as scissors for cutting, even in the best sanitized operating environments. This might be of particular concern in the vaginal area, which is often heavily colonized. Our personal experience (unpubl.) with self-tailored transobturator mesh (cut from a prolene mesh used for abdominal hernia repair, which is much more cost-effective than pretailored mesh) has not been pleasant because of infection and extrusion in many cases, as compared with pretailored mesh. Complexity of tailoring can be another important issue, more so in difficult situations. Thus, self-tailoring might be an option, but with precautions in mandatory situations, such as those described by the author, or where pretailored mesh are unavailable. Preferably, one should refrain from self-tailoring the mesh for regular indications, as there have also been cautionary notes for tailoring mesh in other surgical fields. 2 Developing a mechanism of obtaining a pretailored mesh suitable for the

Arthritis and adult respiratory distress syndrome: unusual presentations of typhoid fever

A middle-aged woman presented with fever of 1-month duration along with bilateral knee joint pain, swelling and difficulty in walking for 2 weeks. The patients Typhidot test was positive for IgM antibodies. Her Widal test was negative, and blood culture and synovial fluid culture were sterile. She was started on ceftriaxone, to which her fever initially responded. However, after 4 days of treatment her disease course was complicated by relapse of fever and acute respiratory distress syndrome (ARDS). This settled with respiratory support and addition of azithromycin. Following recovery from ARDS and fever, her persistent knee arthritis responded to intra-articular methyl prednisolone instillation.

Andersson lesion in ankylosing spondylitis

A middle-aged male patient developed acute back pain and a lumbar vertebral lesion following trivial physical trauma. The lesion was considered as tuberculous on vertebral x-rays and MRI. After biopsy of the lesion and spinal fixation, the patient was kept on empirical antituberculous treatment (ATT) to which he did not respond. On re-evaluation he was diagnosed to have an Andersson lesion in ankylosing spondylitis (AS). ATT was stopped and he was successfully managed by rest, steroids, methotrexate and sulfasalazine. A careful look at the patient’s plain x-ray spine and awareness about the lesion can avoid misdiagnosis of this characteristic vertebral lesion found in AS.

PD03-08 VITAMIN D, BONE TURNOVER MARKERS AND BONE MINERAL DENSITY IN RECURRENT CALCIUM STONE FORMERS

INTRODUCTION AND OBJECTIVES: The aim of this study was to examine the status and interrelationship of vitamin D, bone mineral density, bone turnover markers in recurrent calcium stone formers. METHODS: This prospective case control study was conducted between November 2015 and July 2017 at urology & rheumatology departments of a tertiary care teaching institution. A total of 99 adult subjects were recruited, including 55 patients of recurrent renal calcium calculi (Group A) and 44 healthy controls (Group B, without any history or evidence or intervention for urolithiasis). These subjects underwent metabolic evaluation including serum creatinine, calcium, phosphorous, sodium, potassium, uric acid, 25-OH-Vitamin D. Bone turnover markers studied were serum alkaline phosphatase and serum b-crosslaps levels. 24 hour urine tests included calcium, uric acid, phosphorous. Bone mineral density (BMD) was measured at multiple sites in body. Parameters between two groups were analysed and compared. The SPSS 16.0 statistics program was used for the analysis and p value 0.05 was considered statistically significant. RESULTS: Mean age and sex ratio were similar between group A and group B (Table1). Mean serum 25-OH vitamin D levels (18.20 6.13 ng/ml vs. 21.79 6.20 ng/ml, p1⁄40.042), serum alkaline phosphatase (235.15 58.22IU/L vs. 245.26 89.44 IU/L, p1⁄40.046) and BMD at left forearm (0.810 0.118 vs. 0.866 0.093, p1⁄40.030) were significantly lower whereas mean serum b-crosslaps levels (3700.86 1299. 01 pg/ml vs. 3583.53 1203.51 pg/ml, p1⁄40.039), serum calcium levels (9.62 1.04 vs. 9.43 0.63 mg/dl; p1⁄40.027) and 24 hours urine calcium (192. 95 93.87 mg vs. 122.93 72.82 mg, p1⁄40.001) were significantly higher in recurrent stone formers as compared to controls. On multivariate analysis, 24 hour urine calcium (p1⁄40.006), 24 hour urine phosphorous (p1⁄40.019), 25-OH Vitamin D (p1⁄40.029) and BMD right femur neck (p1⁄40.032) were found to be risk factors associated with recurrent calcium stone formation. CONCLUSIONS: Idiopathic recurrent calcium stone formation may results from complex interplay between low serum 25-OH vitamin D, higher normal serum calcium levels and higher urinary calcium excretion, with attendant low alkaline phosphatase and higher serum bcrosslaps levels. Source of Funding: none

Lean mass and disease activity are the best predictors of bone mineral loss in the premenopausal women with rheumatoid arthritis

Background and Objectives: Factors determining bone mineral (BM) loss in rheumatoid arthritis (RA) are not well known. This study aimed to determine the occurrence and predictors of BM loss in the young premenopausal women with RA. Methods: Ninety-six females with RA and 90 matched controls underwent clinical, biochemical, BM density (BMD), and body composition assessments. RA disease activity was assessed using disease activity score-28 (DAS-28) and hand X-ray. Results: In the young premenopausal females with RA having median symptom and treatment duration of 30 (18–60) and 4 (2–12) months, respectively, with moderate disease activity (DAS-28, 4.88 ± 1.17), occurrence of osteoporosis and osteopenia was 7.29% and 25% at spine, 6.25% and 32.29% at hip, and 17.7% and 56.25% at wrist, respectively (significantly higher than controls). RA patients had lower BMD at total femur, lumbar spine (LS), radius total, and radius ultra-distal. Total lean mass (LM) and BM content were significantly lower in RA (P = 0.022 and <0.001, respectively). In RA, BMD at majority of sites (LS, neck of femur, greater trochanter, radius total, and radius 33%) had the strongest positive correlation with LM followed by body fat percent. RA patients with most severe disease had lowest BMD at different sites and lowest LM. Stepwise linear regression revealed LM followed by DAS-28 to be best predictors of BMD. RA patients receiving glucocorticoids did not have significantly different BMDs from patients not taking glucocorticoids. Interpretation and Conclusion: BM loss is a significant problem in the young premenopausal women with recent-onset RA. LM and disease severity were the best predictors of BMD.

Performances of Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI) appear to be better than the gold standard Disease Assessment Score (DAS‐28‐CRP) to assess rheumatoid arthritis patients

To compare the performance of Disease Assessment Score of 28 joints – C‐reactive protein (DAS‐28‐CRP), Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI) composite measures to assess status of patients with rheumatoid arthritis (RA) on methotrexate, versus DAS‐28 CRP as the gold standard.

Synovial chondromatosis involving multiple joints in rheumatoid arthritis: A case report review of the literature

Dear Editor, Synovial chondromatosis is a benign disorder of the synovial lining, characterized by the presence of loose cartilaginous bodies. Ossification of these cartilaginous bodies is known as osteochondromatosis. Although often benign, malignant transformation can occur. It typically presents unilaterally in large joints. The knee is the most commonly involved joint but it can also involve the shoulder, elbow, hip, ankle and temporomandibular joints. Synovial chondromatosis in patients with rheumatoid arthritis (RA) are reported. To the best of our knowledge, multiple-joint synovial chondromatosis with RA has not been reported in the literature thus far. Here we present a 48-year-old man, a case of seropositive RA with secondary synovial chondromatosis involving multiple joints.