Vivek Venkatramani

Monopolar Versus Bipolar Transurethral Resection of Bladder Tumors: A Single Center, Parallel Arm, Randomized, Controlled Trial

PURPOSE We compared the safety and efficacy of bipolar transurethral resection and monopolar resection for bladder tumors. MATERIALS AND METHODS A single center, parallel arm, randomized, controlled trial was performed from May 2011 to August 2012. All patients with suspected bladder tumors were eligible for study inclusion. Those who refused consent and those undergoing routine restaging transurethral resection of bladder tumor were excluded from analysis. The primary end point was the incidence of obturator jerk. Secondary study outcomes included the decrease in hematocrit, rates of recoagulation and transfusion, bladder perforation, decrease in sodium, resection syndrome and resection time. Pathological quality was assessed by comparing deep muscle and the degree of severe cautery artifact in the 2 arms. RESULTS A total of 257 transurethral resections were performed during the study period. After exclusion 147 patients were randomized, including 75 in the monopolar arm and 72 in the bipolar arm. There were 6 and 4 protocol violations in the monopolar and bipolar arms, respectively. Intent to treat and per protocol analyses were performed. The incidence of obturator jerk was greater in the bipolar arm (60% vs 49.2%, p=0.27). There was no significant difference between secondary outcomes. The only significant difference was a significantly lower incidence of severe cautery artifact in the bipolar arm (25% vs 46.7%, p=0.0096). CONCLUSIONS Bipolar transurethral resection of bladder tumor was not superior to monopolar resection with respect to obturator jerk, bladder perforation and hemostasis. There was a significantly lower incidence of severe cautery artifact after bipolar resection.

Exstrophy-epispadias Complex Presenting in Adulthood: A Single-center Review of Presentation, Management, and Outcomes

OBJECTIVE To study the presentation, management, and outcome of patients with exstrophy-epispadias complex, who present in adulthood (aged >18 years). MATERIALS AND METHODS A retrospective review of the electronic medical records of patients with exstrophy-epispadias complex managed from January 2001 to December 2010 was undertaken. Patients aged >18 years at presentation, with detailed medical records were selected. They were classified into 2 groups: group A (previously untreated) and group B (residual defects or complications after childhood surgery). RESULTS Thirty-nine patients with exstrophy-epispadias complex presented to our institution over this 10-year period. Of these 26 were adults (aged >18 years; range, 18-48 years). Detailed medical records could be obtained for 21 of them and they were included. Group A consisted of 4 patients--2 male and 2 female. All underwent cystectomy; 2 had an ileal conduit and 2 had ureterosigmoidostomy (Mainz II). All had improved quality of life and a stable renal function at follow-up. Group B consisted of 17 patients. Mean number of surgeries attempted previously was 4.4 (range, 2-13). Presentation was varied but primarily involved incontinence of urine (n = 12). Four patients were lost to follow-up, 2 were managed conservatively, and 11 underwent a surgical procedure. All patients returned to normal activity with an improvement in the quality of life postoperatively. CONCLUSION Exstrophy-epispadias complex is difficult to manage in resource-poor settings associated with illiteracy and poverty. However, successful rehabilitation and an improved quality of life are possible even in cases presenting in adults.

Urovision 2020: The future of urology

Urology, as a specialty, has always been at the forefront of innovation and research. Newer technologies have been rapidly embraced and, in many cases, improved upon in order to achieve better patient outcomes. This review addresses the possible future directions that technological advances in urology may take. The role of further miniaturization of urolithiasis treatment, robotic surgery and other minimally invasive techniques is addressed. The potential for enhanced imaging and diagnostic techniques like magnetic resonance imaging and ultrasonography modifications, as well as the potential applications of nanotechnology and tissue engineering, are reviewed. This article is based on the Dr. Sitharaman Best Essay award of the Urological Society of India for 2013.

Is thrombocytosis a useful prognostic marker in renal cell carcinoma? Results of a single-center retrospective analysis.

Introduction: Our aim was to determine the correlation of platelet count with stage and grade of renal cell carcinoma (RCC) and to determine whether progression of disease was more likely in those with thrombocytosis. Materials and Methods: A retrospective review of patients with RCC from January 2004 to December 2011 was undertaken. Patients with no preoperative platelet count and those with multiple tumors were excluded. Disease progression was defined as appearance of local recurrence or distant metastasis on follow-up. Thrombocytosis was defined as a platelet count of >400,000/cumm. Standard tests of significance and multivariate analysis using logistic regression were performed. Results: A total of 322 cases were identified. The median follow-up was 7 months (range, 2-84 months). The platelet count correlated significantly with higher Fuhrmann grade, as well as increasing TNM stage at diagnosis. Patients with a platelet count of >400,000/cumm (n = 35) had a significantly higher mean tumor size and worse grade at diagnosis than those with a normal platelet count (n = 287). Patients with thrombocytosis also had a significantly worse stage at presentation. Progression of disease was seen more often in patients with thrombocytosis (28.6% vs 11.9%, P = 0.07). The median time to progression was significantly faster in patients with thrombocytosis (9 vs 18 months, P = 0.018). However, on multivariate analysis TNM stage was the only significant predictor of time to progression. Conclusion: Rising platelet count correlated significantly with advancing stage and grade of disease. Patients with thrombocytosis were significantly more likely to have advanced tumors at presentation, poorer histological features, and rapid disease progression.

Spontaneous perinephric hemorrhage (Wunderlich syndrome) secondary to polyarteritis nodosa: Computed tomography and angiographic findings

We report the case of a young man who presented with spontaneous left perinephric hematoma and per-rectal bleeding. Evaluation revealed renal and superior mesenteric arterial aneurysms secondary to polyarteritis nodosa (PAN). Computed tomography and angiographic findings are presented. The aetiology of spontaneous perinephric hemorrhage along with relevant features of PAN are discussed.

Perioperative complications and postoperative outcomes of partial nephrectomy for renal cell carcinoma: Does indication matter?

Introduction: The aim of the study was to determine whether perioperative complications and postoperative outcomes varied with the indication of partial nephrectomy (PN). Materials and Methods: We reviewed data of 184 consecutive PN for suspected renal cell carcinoma operated between January 2004 and December 2013. Complications using the Clavien-Dindo classification were compared between surgeries for absolute indications (chronic renal failure, bilateral tumors, or solitary kidney), those for relative indications (comorbid illnesses with the potential to affect renal function) and elective indications (patients without risk factors). Complex tumors were defined as size >7 cm, multiple, hilar, and endophytic tumors. Results: Patients with an absolute indication had larger tumors (P = 0.001) and tumors of a higher pathological T-stage (P = 0.03). Minor complications (Clavien 1 and 2) occurred in 25.4% patients in the elective arm versus over 40% in the other arms (P = 0.049). Major complications (Clavien 3+) were less common in the elective arm (3.2% cases vs. 12.7% in the relative arm and 13.8% in the absolute arm) with a trend to significance (P = 0.09). On multivariate analysis, absolute indication (odds ratio [OR] = 2.4, P = 0.04) and surgery for a complex renal mass (OR = 2.5 times, P = 0.03) remained significant predictors of minor complications. Major complications were more common in the relative (OR = 5.5, P = 0.057) and absolute indication arm (OR = 5.231, P = 0.051) with a trend toward significance. Conclusions: Elective indication was associated with fewer complications than PN for relative or absolute indications.

Urethral duplication with unusual cause of bladder outlet obstruction.

A 12-year-old boy presented with poor flow and recurrent urinary tract infections following hypospadias repair at the age of 3 years. The evaluation revealed urethral duplication with a hypoplastic dorsal urethra and patent ventral urethra. He also had duplication of the bladder neck, and on voiding cystourethrogram the ventral bladder neck appeared hypoplastic and compressed by the dorsal bladder neck during voiding. The possibility of functional obstruction of the ventral urethra by the occluded dorsal urethra was suspected, and he underwent a successful urethro-urethrostomy.

Bilateral ovarian metastases from ureteric urothelial cancer: Initial case report and distinguishing role of immunohistochemistry

Urothelial cancers of the upper tract are aggressive malignancies with a propensity for distant metastases. Transitional cell carcinoma can also develop de novo in the ovaries and differentiation between these lesions requires immunohistochemistry. We report a case of right lower ureteric urothelial carcinoma with metastases to both ovaries. To our knowledge, this is the first reported case of bilateral ovarian metastases from an upper tract primary, diagnosed with immunohistochemistry.

Visualization of male reproductive tract during urethrography: sequel of intense backpressure

A 36-year-old gentleman presented with right flank pain, poor flow of urine and straining to void for 1 year. He had previously undergone cystolithotomy (1995), bladder neck incision and urethral dilatation for stricture (2002), and right percutaneous nephrolithotomy (PCNL) for renal calculus (2005). Evaluation revealed a hydronephrotic non-functioning right kidney with a staghorn calculus and a small bladder calculus (Fig. 1). The nonfunction of the right kidney was attributed to the persistence of a staghorn calculus that was incompletely cleared during the first PCNL. Retrograde urethrogram (RGU) revealed a tight shortsegment stricture at the peno-scrotal junction (Fig. 2). Voiding cystourethrogram (VCUG) confirmed these findings and showed opacification of the peri-urethral glands. Further films revealed opacification of both vas deferens and seminal vesicles secondary to the intense backpressure generated proximal to the tight stricture during attempted voiding (Fig. 3). He underwent endoscopic internal urethrotomy, cystolitholapaxy and right nephrectomy. Histopathology revealed chronic pyelonephritis with focal xanthogranulomatous involvement. He voided with a good flow post-operatively. He is presently on a self-dilatation regimen with a 16 French Nelaton catheter to reduce the risk of stricture recurrence. He has been advised regarding the need for a definitive urethroplasty in case the stricture recurs. RGU and VCUG are used to delineate length and severity of urethral strictures. High-pressure voiding secondary to distal obstruction can cause reflux of urine into the reproductive tract via the ejaculatory ducts. In the presence of urinary tract infection, this reflux can lead to epididymo-orchitis, which is a known complication of urethral stricture disease.

Incidental detection of retroperitoneal lymphangioleiomyomatosis (LAM) - CT and MRI findings with relevance to the urologist.

A 48 year old lady presented with blunt abdominal trauma following a road traffic acci-dent. She had no hematuria or other injuries. Vi-tals were normal. Examination was significant for left loin tenderness. Ultrasound was suspicious for retroperitoneal fluid. Computed tomography reve-aled normal abdominal viscera but multiple diffu-se low attenuating cystic retroperitoneal masses showing peripheral enhancement (Figure-1). Lung segments showed multiple thin walled parenchy-mal cysts bilaterally (Figure-2, arrows). T2-wei-ghted MRI revealed conglomerated cystic masses in the paraaortic and parailliac regions (Figure-3, arrows) suggesting multiple lymphangiomyomas.