Computer based receptogram approach: an objective way of assessing immunohistochemistry of androgen receptor staining and its correlation with hormonal response in metastatic carcinoma of prostate

AIMS

To categorise the immunostaining heterogeneity of androgen receptors in metastatic carcinoma of the prostate using a pattern oriented approach and to correlate the results with response to hormonal treatment.

METHODS

Paraffin wax embedded tumour sections from 85 patients with metastatic carcinoma of the prostate were processed for immunocytochemistry and stained for the androgen receptor using antiandrogen receptor antibodies. A computer based image analysis system was used to analyse the pattern of nuclear immunostaining in a minimum of 500 nuclei/slide. Depending on the nuclear receptor content and concentration, receptogram patterns were established for each specimen. The receptogram pattern was correlated with clinical response to hormonal treatment.

RESULTS

Clinical response to hormonal treatment was documented using prostate specific antigen as the marker into responders (good, fair, stable) and non-responders. Forty four of 48 patients who responded to hormonal treatment had type 1 (35) or type 3 (nine) receptograms, which are characterised by a unimodal peak or multimodal peaks within a narrow concentration range. Thirteen of the 18 patients who stabilised had type 1 or type 3 receptograms. Seventeen of the 19 patients who did not respond to hormonal treatment had either type 2 or type 4 receptograms, which are characterised by skewed or bimodal androgen receptor distribution. Positive and negative predictive values of receptograms were 96.5% and 63%, respectively.

CONCLUSIONS

Image analysis of androgen receptor immunostaining with a receptogram oriented approach provides important prognostic information that can be used to predict response to hormone treatment in patients with metastatic carcinoma of the prostate.

Primary Non-Hodgkin’s Lymphoma of Urinary Bladder

Primary extranodal lymphoma of the urinary bladder is a rare disorder that is diagnosed on the basis of histopathology and immunostaining. We report a case of diffuse B cell primary lymphoma of the urinary bladder and review the literature.

Renal stone masquerading as an occult renal cell cancer (incidental RCC)

We report an unusual case of 40-year-old adult man who presented as a case of urolithiasis but was found to be harboring an incidental renal cell adenocarcinoma. He underwent an uneventful radical nephrectomy. The literature regarding incidental renal cancer and it's association with urolithiasis has been reviewed and discussed.

Skeletal muscle metastasis from transitional cell carcinoma of the urinary bladder: clinicoradiological features

AIM

To define the clinicoradiological characteristics of skeletal muscle metastasis from transitional cell carcinoma of the urinary bladder.

MATERIALS AND METHODS

A retrospective review of all patients with skeletal muscle metastasis was undertaken between January 1999 to December 2001. Patients suspected of having a metastasis on radiological examinations, and subsequently proven to have metastatic disease on histological examination were included in study. The clinical presentation and radiological features of five patients with skeletal muscle metastasis from bladder tumours were reviewed from hospital records.

RESULTS

Twenty-four patients had skeletal muscle metastasis from various primaries. Of these five patients had previous or concurrent primary tumours in the bladder. Patients were aged between 27-70 years (mean 52 years), and all had persistent, localized pain with or without accompanying swelling. The muscles involved were psoas in three patients, adductor muscles of thigh in one and rectus abdominis in one. Four patients had radical cystectomy with urinary diversion (two ileal conduit and two orthotopic sigmoid neobladder). One patient presented with bladder tumour and concomitant muscular metastasis. All patients underwent helical computed tomography (CT) before confirmation of diagnosis by fine-needle aspiration (FNA) or biopsy. The typical appearance of low-density enhancing lesions on CT was mistaken for abscess in two patients and failure to respond to conservative treatment led to suspicion of metastasis. Diagnosis was proven histologically in all patients (FNA in three and biopsy in two). All patients had palliative chemotherapy (Mitomycin, Vincristine, Adriamycin and Cyclophosphamide). Two patients had local palliative 3500 rad radiotherapy for persistent pain. Mean survival was 8 months (range 6-12 months).

CONCLUSION

Muscular metastasis from urothelial tumours typically presents with persistent localized pain with or without swelling. The characteristic low-density, ring-enhancing lesions on CT in a patient with previous or concomitant urothelial tumours should raise the suspicion of metastasis until proven otherwise. Prognosis is dismal.

Relook percutaneous nephrolithotomy: a simple technique to re-enter the pelvicalyceal system

We describe a simple technique of reentry into the pelvicalyceal system for removal of residual fragments that is simple, rapid and cheap.

Laparoscopy for the diagnosis and treatment of radiologically occult but symptomatic hypoplastic kidneys

OBJECTIVES

To evaluate the efficacy of different imaging modalities for visualization of small poorly functioning hypoplastic and dysplastic kidneys and to assess the role of laparoscopy in localization and treatment.

METHODS

Between 1998 and 2002, 10 female patients who presented with urinary incontinence, flank pain, or hypertension secondary to small, poorly functioning hypoplastic or dysplastic kidneys were treated at our institute. We reviewed the results of the imaging studies, cystoscopy, and evaluation under anesthesia for these patients. After the diagnosis, all patients were treated with laparoscopic retroperitoneal or transperitoneal nephroureterectomy or nephrectomy.

RESULTS

Intravenous urography and ultrasonography failed to visualize the affected renal units in all 10 cases. Computed tomography could locate small dysplastic renal units in only 5 patients (50%). Dimercaptosuccinic acid renal scintigraphy was diagnostic in all 10 cases (100%). Magnetic resonance urography was done in 2 cases only, and the affected renal units were identified in both. Cystoscopy and vaginoscopy were inconclusive in all but 2 cases. Laparoscopy efficiently located the offending renal units in all 10 cases. In 9 cases, the affected renal units were located in the lumbar region, and in 1 case it was situated ectopically in the pelvis. All 10 patients underwent laparoscopic retroperitoneal or transperitoneal nephroureterectomy or nephrectomy and were asymptomatic after surgery.

CONCLUSIONS

Dimercaptosuccinic acid scintigraphy is an accurate and specific imaging modality for visualization of small hypoplastic renal units that are not visualized by conventional radiologic imaging techniques. Laparoscopy can be recommended as the ideal method of management, because it provides a minimally invasive technique for detecting the kidney and simultaneously correcting the problem.

Recurrent adrenal pheochromocytoma: a case report

We report an unusual case of benign recurrent pheochromocytoma that developed at the same site 8 years following initial treatment. This tumor was managed successfully through the 11th rib bed using the transperitoneal extrapleural approach.

A comparison of lycopene and orchidectomy vs orchidectomy alone in the management of advanced prostate cancer

OBJECTIVE

To compare the efficacy of lycopene plus orchidectomy with orchidectomy alone in the management of advanced prostate cancer.

PATIENTS AND METHODS

Fifty-four patients with histologically confirmed metastatic prostatic cancer (M1b or D2) and a performance status of 0-2 (World Health Organization) were entered into the trial between March 2000 and June 2002. The trial comprised two treatment arms, i.e. patients were randomized to orchidectomy alone or orchidectomy plus lycopene (OL), each of 27 patients. Lycopene was started on the day of orchidectomy at 2 mg twice daily. Patients were evaluated clinically before and every 3 months after the intervention, with measurements of prostate-specific antigen (PSA), a bone scan and uroflowmetry, with the clinical response assessed as the change in these variables.

RESULTS

At 6 months there was a significant reduction in PSA level in both treatments, but more marked in the OL group (mean 9.1 and 26.4 ng/mL, P = 0.9). After 2 years these changes were more consistent in the OL group (mean 3.01 and 9.02 ng/mL; P < 0.001). Eleven (40%) patients in orchidectomy and 21 (78%) in the OL group had a complete PSA response (P < 0.05), with a partial response in nine (33%) and four (15%), and progression in seven (25%) and two (7%), respectively (P < 0.05). Bone scans showed that in the orchidectomy arm only four (15%) patients had a complete response, vs eight (30%) in the OL group (P < 0.02), with a partial response in 19 (70%) and 17 (63%), and progression in four (15%) and two (7%), respectively (P < 0.02). There was a significant improvement in peak flow rate in the OL group, with a mean difference of +1.17 mL/s (P < 0.04). Of the 54 patients who entered the trial, 19 (35%) died, 12 (22%) in orchidectomy and seven (13%) in OL group (P < 0.001).

CONCLUSION

Adding lycopene to orchidectomy produced a more reliable and consistent decrease in serum PSA level; it not only shrinks the primary tumour but also diminishes the secondary tumours, providing better relief from bone pain and lower urinary tract symptoms, and improving survival compared with orchidectomy alone.

Impact of socioeconomic status in etiology and management of urinary stone disease

INTRODUCTION

The diverse manifestations of urolithiasis provide a very interesting epidemiological study from the standpoints of geography, socioeconomic status, nutrition and culture. Stone disease not only affects the patient, but also the national economy, as the disease is prevalent in the productive age group. There has been a continuous search for the cost-effectiveness of different treatment modalities not only to treat the patient but also to prevent its recurrence.

MATERIALS AND METHODS

The various socioeconomic and dietary factors playing roles in the etiology of urinary calculi in the stone-prevalent areas of the world were analyzed. The impact of urinary tract stone disease on the socioeconomic infrastructure of the patient and national economy was studied. A cost-effectiveness analysis vis-à-vis the safety and efficacy of various treatment modalities in both developed and developing countries was done.

RESULTS

The standard of living and level of nutrition have directly influenced the process of urolithiasis amongst the communities of the world. A low socioeconomic status has been linked to endemic bladder calculi seen in many poor countries with people subsisting on a deficient diet. The incidence of upper urinary tract calculi increases with prosperity and more nutritious diets. Replacement of open surgery with minimally invasive techniques (ESWL, PCNL, URS) for treating stones in the urinary tract has greatly reduced the patients' morbidity and mortality and the period of hospitalization and convalescence. This change in treatment has also led to less days of absence from work and could minimize the loss to national economy. Minimally invasive surgery is more cost effective in developed countries because of the short hospital stay. However, in developing countries open surgery still appears to be cost-effective in certain subset of the patients.

CONCLUSIONS

There is a need for proper health care and a medical insurance system to take care of the financial burden, especially in developing countries, of a disease with a high magnitude of recurrence and morbidity. The need and type of medical treatment should be appraised continually to accommodate advances in techniques of stone removal. Lastly, the quest for etiology, cost-effective treatment and prevention still continues and even today we cannot stay better than Frère Jacques, 'I have removed the stone, it is up to God to cure the patient'.

Evaluation of fragmentation with single or multiple pulse setting of Lithoclast for renal calculi during percutaneous nephrolithotripsy and its impact on clearance

OBJECTIVES

To evaluate the impact of single or multiple pulse settings of Lithoclast to fragment renal calculi, and its effect on fragment size and clearance.

MATERIAL AND METHODS

In a prospective study 153 patients, who had been treated over a period of 35 months for renal stone disease by percutaneous nephrolithotomy, were evaluated. In 69 cases the single and in 84 cases the multiple pulse modes were used to fragment the stone intracorporeally using the pneumatic lithoclast. The 2 groups were similar with regard to patient characteristics, stone location and size.

RESULTS

Most stones were staghorn. The lithoclast was effective with good fragmentation in all cases. The mean operating and fluoroscopy times in the single and multiple pulse mode were 124.1 and 5.8, and 141.2 and 7.4 min, respectively (both differences statistically significant, p < 0.001). Immediate postoperatively residual stone fragments were seen in 16 cases with the single and 35 cases with the multiple pulse mode setting (difference statistically significant, p < 0.05). Relook procedures were required in 14 cases with the single and 22 cases with the multiple pulse setting (difference not statistically significant). No specific complication was seen related to the use of either of the two modes. On follow-up 1 patient in the multiple pulse setting developed stone recurrence after 19 months.

CONCLUSIONS

The single pulse mode was associated with controlled fragmentation of the stone, formation of larger fragments which were easier to pick up, less stone scatter, shorter operating time and less exposure to fluoroscopy. The single pulse mode was also associated with statistically less chances of postoperative residual fragments.

Simple method of residual stone retrieval through the nephrostomy catheter after PCNL: point of technique

A simple technique of removal of residual stone fragments in patients who have undergone percutaneous nephrolithotripsy (PCNL) and have a nephrostomy tube in situ is described. Under local anesthesia and sedation a rigid 8.5 F ureteroscope is passed through the nephrostomy tube and the stones retrieved. This technique is indicated in patients who have 1-3 residual fragments, none larger than 5 mm, and located in the same calyx or pelvis as the tip of the nephrostomy tube.

Chemoprevention of carcinoma prostate: a review

PURPOSE

Chemoprevention of prostate cancer is the administration of agents to prevent, inhibit, or delay progression of prostate cancer. Opportunities exist for testing various types of chemopreventive interventsion.

MATERIAL AND METHODS

The authors reviewed the relevant articles published in the last twenty years and studied the biology of the prostate cancer. An attempt is made to identify intermediate markers and surrogate endpoint markers. The various interventions and initial clinical trial results are described. End points for evaluation are mainly based on changes in PSA, changes of histological precursors, or time of onset of clinical disease.

RESULTS

Nutritional factors such as reduced fat intake, vitamin A, vitamin E, vitamin C, vitamin D, Lycopene and selenium may have a protective effect against prostate cancer.

CONCLUSION

Numerous studies implicate dietary and nutritional factors in the onset and progression of prostate cancer. Hence, it is possible that bioactive compounds (anti-oxidants) like vits. A, C, D, E, minerals like selenium and carotenoids like lycopene can be a part of chemopreventive strategies for prostate cancer. Ongoing studies on nutrition and prostate cancer may bring the required evidence to support what is still only a hypothesis at present. However, absolute recommendation will have to await the results of long term prospective clinical trials.

Conservative management of spontaneous rupture of a sigmoid colon neobladder

A case of successful management of spontaneous perforation of an orthotopic sigmoid colon neobladder 18 months following radical cystectomy for muscle-invasive transitional cell carcinoma is described. Conservative management of such perforations has rarely been described in the literature; however, this is the first case report of sigmoid colon neobladder perforation and of its successful conservative management, to the best of our knowledge.

Symptomatic and complicated adult and adolescent primary obstructive megaureter--indications for surgery: analysis, outcome, and follow-up

OBJECTIVES

Primary obstructive megaureter is an uncommon presentation in adult patients. Although not reported frequently in published studies, the anomaly exists and warrants aggressive surgical management in contrast to its presentation in children.

METHODS

This study was composed of 55 patients (47 with unilateral and 8 with bilateral megaureters) with adult primary obstructive megaureter who were treated from January 1989 to December 2001. Their clinical presentation, renal function, radiologic data, treatment, complications, and follow-up were studied.

RESULTS

Of the 55 patients, 36 were male and 19 were female (age range 13 to 52 years). All patients were symptomatic except two. Forty-four patients (50 renoureteral units) required ureteral reimplantation, with tailoring in 33. Five patients were treated with endoscopic techniques (ureteral meatotomy in 3 and ureteroscopic retrieval of ureteral calculi in 2). Four patients required nephroureterectomy for nonfunctioning kidneys. Associated renal calculi were managed by extracorporeal shock wave lithotripsy and pyelolithotomy and ureteral calculi by endoscopic methods or calculi removed at the time of ureteroneocystostomy. All but 4 patients showed improvement in hydroureter and hydronephrosis and developed no complications during the follow-up period of 1 to 12 years (mean 7). Five patients with bilateral megaureters had uremia. Only one improved after surgery with adequate drainage and 2 patients died despite reimplantation.

CONCLUSIONS

Most adult patients with megaureter are symptomatic. Complications such as stone formation and deranged function of the affected kidney are common and almost all require surgical intervention. Surgery in those with bilateral megaureters with advanced renal failure is mostly unrewarding.

Molecular screening for Yq microdeletion in men with idiopathic oligozoospermia and azoospermia

Infertility affects 15% couples attempting pregnancy and in 40-50% of these cases the male partner has qualitative or quantitative abnormalities of sperm production. Microdeletions in the azoospermia factor (AZF) region on the long arm of the Y chromosome are known to be associated with spermatogenic failure and have been used to define three regions on Yq (AZFa, AZFb and AZFc) which are critical for spermatogenesis and are recurrently deleted in infertile males. Semen analysis was carried out on one hundred and twenty five infertile males with oligozoospermia and azoospermia. Cytogenetic analysis was done for all the cases and in all cytogenetically normal cases (n = 83) microdeletion analysis was carried out on DNA extracted from peripheral blood using PCR. The sequence tagged sites (STS) primers sY84, sY86 (AZFa); sY127, sY134 (AZFb); sY254, sY255 (AZFc) were used for each case. Eight of the eighty three cases (9.63%) showed deletion of at least one of the STS markers. Correlation of phenotype with microdeletion was done in each case to determine any phenotype association with deletion of particular AZF locus. Based on the present study, the frequency of microdeletion in the Indian population is 9.63%. This study emphasizes the need for PCR analysis for determining genetic aetiology in cases with idiopathic severe testiculopathy.

Laparoscopy in diagnosis and management of urinary incontinence caused by small ectopic dysplastic kidney

We describe a case of urinary incontinence which was caused by a small ectopic dysplastic kidney where all preoperative investigations including ultrasound, intravenous urography, micturating cystourethrogram, technetium-99m ((99m)TC) diethylenetriamine penta-acetic acid renal scan, spiral CT scan and angiography failed to reveal the offending kidney. Only a (99m)Tc dimercaptosuccinic acid scan suggested the presence of a small left kidney located in the iliac region. The patient underwent laparoscopy and the offending kidney was identified and excised.

Ectopic ureter with urinary incontinence. An unusual presentation of Mayer-Rokitansky-Kuster-Hauser syndrome

Ectopic ureter occurs most commonly in association with ureterocele or duplication of the ureter. It is caused by a delay in or failure of separation of the ureteric bud from the mesonephric duct during embryologic development. Vaginal agenesis is the second most common cause of primary infertility in women after gonadal dysgenesis. Agenesis of the vagina in karyotypic females may be accompanied by other defects of the urogenital system [1]. We describe a rare combination of Mayer-Rokitansky-Kuster-Hauser syndrome and ectopic ureter with urinary incontinence.

Is incidental appendectomy necessary during radical cystectomy?

OBJECTIVE

To find out the incidence of acute appendicitis leading to acute abdominal pain and necessitating appendectomy in the follow-up of patients after radical cystectomy and urinary diversions.

METHODS

A prospective 160 consecutive radical cystectomy patients with urinary diversion in whom appendectomy was not done between January 1991 and June 2001 were reviewed for the incidence of acute appendicitis. Ages ranged between 26 and 73 years. There were 143 males and 17 females. 120 patients had ileal conduit, 20 sigmoid neobladder, 5 continent urinary diversion, and 15 ureterosigmoidostomy as urinary diversion. Each patients was followed up regularly till death or last follow-up. The follow-up ranged between 4 months and 10 years (mean 6 years).

RESULTS

Intestinal obstruction (11%) and acute pyelonephritis (16%) were the most common causes of acute abdominal pain. The remaining causes include sigmoid neobladder perforation (0.6%), parastomal hernia (0.6%), urinary retention due to mucus (1.8%) and renal colic (1.8%). In all patients, diagnosis was easily made and they were managed accordingly. None of the patients had acute appendicitis requiring appendectomy on follow-up.

CONCLUSION

Incidental appendectomy is not required during radical cystectomy as the risk of subsequent appendicitis is extremely low.

Chronic renal infarct simulating renal mass: diagnostic challenge

A 36-year-old male presented with symptomatic left renal mass simulating renal cell carcinoma. He underwent left radical nephrectomy and histopathology revealed chronic renal infarct with calcifications. The case description warrants the inclusion of focal chronic renal infarcts in the differential diagnosis of renal masses, especially following history of previous trauma.

Efficacy and outcome of surgical intervention in patients with nephrolithiasis and chronic renal failure

AIM

To prospectively evaluate the efficacy and outcome of surgical intervention in patients with renal stones and chronic renal insufficiency.

METHODS

The study was carried out from January 1999 till January 2001. Only patients with chronic renal failure without medical renal disease were taken up for study. All patients were subjected to an ultrasound assessment of the kidney, ureter and bladder. In case of obstructed and infected systems a preliminary percutaneous nephrostomy was carried out. After correction of dyselectrolytemia, acid base imbalance and dialysis (if indicated) patients were subjected to surgical intervention (open surgery or percutaneous nephrolithotomy). ESWL was offered for stones persisting after surgery. The stone burden, composition, therapeutic procedures required to render patients stone free were assessed. The outcome of stone removal on renal function was also evaluated by serial renal dynamic scans and creatinine clearance estimations.

RESULTS

Out of 90 patients operated for staghorn or calyceal calculi, complete follow up data was available in 70. Pyelo-nephrolithotomy and percutaneous nephrolithotomy was carried out in 63 and 7 patients respectively. Out of 15 patients with residual stones ESWL was successfully performed in 9 cases. Mixed, calcium oxalate monohydrate, calcium oxalate dihydrate, and struvite stones were encountered in 48%, 14%, 17% and 21% respectively. The average pre operative serum creatinine was 4.76 (1.9-16) mg%. The maximum duration of follow up was 9 months. By the 9th post operative month the average fall in serum creatinine values was 1.53 mg/dl (32%) and the average functional improvement by renal dynamic scans stood at 20.665%. 41 patients were saved from further dialysis.

CONCLUSION

Patients with mild to moderate renal failure showed maximal improvement in renal function forestalling or reducing the need for dialysis/renal replacement therapy.

Laser endoscopic incision: a viable alternative to treat adult ureterocele

AIM

To prospectively evaluate the safety. efficacy, feasibility and outcome of Nd-Yag laser endoscopic incision in adult symptomatic patients with intravesical uretroceles.

METHODS

We present our experience with the use of Nd-Yag laser for endoscopic incision of the adult ureterocele in a group of five symptomatic adult patients.

RESULTS

All the five patients showed excellent decompression with relief from flank pain and hydronephrosis and none demonstrated a post-op vesicoureteric reflux (VUR).

CONCLUSION

Laser endoscopic management of intravesical ureteroceles is new emerging modality, which is being increasingly employed to decompress ureteroceles. Laser endoscopic incision is a precise and bloodless procedure enabling a clean accurate controlled cut through the endoscope as opposed to the traditional bugbee electrode.

Vapor resection: a good alternative to standard loop resection in the management of prostates >40 cc

BACKGROUND AND PURPOSES

The morbidity of transurethral vesection of the prostate (TURP) necessitates constant attempts at modifications to the standard equipment and technique. Patients with larger prostates (>40 cc) need a longer time for the procedure, and the blood loss, requirement for irrigation fluid, and incidence of postoperative complications tend to be greater. We report on the safety and efficacy of TURP with the thick vapor resection loop compared with the standard wire loop in comparable groups of patients with prostates >40 cc.

PATIENTS AND METHODS

We randomized 100 patients with benign prostatic hyperplasia (BPH) into two groups of 50 each which were similar in age. The inclusion criteria included an indication for prostatectomy and prostate size >40 cc. Patients who were on finasteride preoperatively (six) and those who had histopathologic adenocarcinoma of the prostate (three) were excluded. Preoperative evaluation included assessment of International Prostate Symptom Score (IPSS), prostate volume by abdominal ultrasonography, maximum flow rate (Q(max)), and residual urine volume. The two groups were similar in the signs and symptoms of BPH. Patients in Group 1 underwent transurethral vapor resection of the prostate (TUVRP) using the vapor resection loop (Wing trade mark; Richard Wolf, Germany), while patients in Group 2 underwent TURP using a standard wire loop. All procedures were performed by consultant urologists with equivalent experience. We used a Martin ME 401 (Gebruder Martin, Tuttlingen, Germany) electrosurgical generator with settings of 120 to 150 Watts and 50 to 70 W for cutting and coagulating, respectively, for the thick loop and 70 to 80 W and 40 to 50 W for the standard loop. Operating time, resected tissue weight, duration of catheterization, nursing contact time, hospital stay, hemoglobin change, serum sodium concentrations, and any complications were noted and analyzed using the Kruskal-Wallis paired variables test, and P values were calculated. P value <0.04 was considered significant. The IPSS, Q(max), and residual urine volume were reevaluated at 6 months and 1 year after the procedure and compared for the two groups.

RESULTS

The median prostate volume was 63 cc and 54 cc in Groups 1 and 2, respectively, and the median resected weight was 20 and 19 g, respectively (P = NS). The differences in operating time (median 45 v 60 minutes; P < 0.0001), intraoperative irrigant use (15 v 21 L; P < 0.0001), and intraoperative blood loss (median 52.5 v 150 mL; P < 0.0001) in the two groups were statistically significant. Peroperative blood loss was estimated by the indicator dilution method of Freedman et al in three 5-mL samples of the irrigant fluid and arriving at the average of the three values and adjusted for the volume of irrigant fluid used. The differences in postoperative irrigant (P < 0.01) and catheter duration (P = 0.04) were also significant. Two patients received blood transfusion in Group 2 and none in Group 1. The difference in the change in hemoglobin and serum sodium postoperatively in the two groups was not statistically significant. The complications were dysuria in six patients lasting for a month and one capsular perforation in Group and incontinence lasting for 6 months in two patients and stricture in one patient in Group 2. The efficacy, assessed with IPSS, Q(max), and residual urine volume, was comparable at 6 months and at 1 year.

CONCLUSION

The use of a thick vapor resection loop for TURP coupled with higher generator settings as recommended for them, especially for prostates >40 cc, is beneficial, as it significantly reduces operating time, blood loss, irrigant requirement, nursing contact time, and duration of catheterization, besides providing clear vision during surgery and ease of resection. There was no reduction in efficacy or increase in complications.

Is infundibuloureteropelvic angle (IUPA) a significant risk factor in formation of inferior calyceal calculi?

INTRODUCTION

Many studies confirm the fact that radiographic anatomy of inferior calyx has a significant role in the clearance of a stone lodged in it [Br. J. Urol. 50 (1978) 449; Invest. Urol. 18 (2) (1980) 167; BJU Int. 83 (Suppl) (1999) 24; J. Urol. 132 (1984) 1085]. Acutely angled and narrow infundibular neck of a inferior calyx has a poorer stone clearance in comparison to that with a less acute angled and wider infundibular neck [Br. J. Urol. 50 (1978) 449; Invest. Urol. 18 (2) (1980) 167; Br. J. Urol. 82 (1998) 12; BJU Int. 83 (Suppl) (1999) 24]. Incidence of bilateral stones in clinical practice is significantly less than unilateral stones. This study was taken up to define the significance of radiographic anatomy of the inferior calyx as a risk factor predisposing to stone formation in a patient and compared the anatomy of inferior calyx of the stone forming and contralateral kidney. The fact that inspite of the similar known etiological factors (intrinsic and extrinsic) of stone formation, why stone forms unilaterally?

MATERIAL AND METHODS

100 consecutive cases of non-obstructed unilateral inferior calyceal calculus with non-metabolically active stones were studied. The infundibuloureteropelvic angle (IUPA) and infundibular width of the stone forming and non-stone forming contralateral side were compared.

RESULTS

IUPA of stone forming side was more acute than the non-stone forming side, in 74% of the cases, more obtuse in 18% of the cases, and same in 8% of the cases. The difference in the IUPA of the stone forming and that of non-stone forming contralateral side was statistically significant (p<0.0002). The infundibular width of the stone forming side ranged from 1 to 16 mm and that of non-stone forming side from 2 to 11 mm. There was no statistically significant difference between the infundibular width of both the sides. Exactly, how and more importantly under what influences the macromolecules in the urine transforms into a calculus in the pelvicalyceal system is still not known till date but from our observations we conclude that IUPA is a significant risk factor which predisposes to calculus formation in inferior calyx.

CONCLUSION

IUPA is a significant risk factor, which predisposes to urolithiasis in inferior calyx.