Corrigendum to "RPN (Radius, Position of tumour, iNvasion of renal sinus) Classification and Nephrometry Scoring System: An Internationally Developed Clinical Classification To Describe the Surgical Difficulty for Renal Masses for Which Robotic Partial Nephrectomy Is Planned" [Eur. Urol. Open Sci. 54 (2023) 33-42]

[This corrects the article DOI: 10.1016/j.euros.2023.05.007.].

Effect of rumen-protected choline on dairy cow metabolism, immunity, lactation performance, and vaginal discharge microbiome

Rumen-protected choline (RPC) promotes benefits in milk production, immunity, and health in dairy cows by optimizing lipid metabolism during transition period management and early lactation. However, the RPC success in dairy cows depends on choline bioavailability, which is affected by the type of protection used in rumen-protected choline. Therefore, our objectives were to determine the effects of a novel RPC on dry matter intake (DMI), identify markers of metabolism and immunity, and evaluate lactation performance. Dry Holstein (n = 48) cows at 245 ± 3 d of gestation were blocked by parity and assigned to control or RPC treatment within each block. Cows enrolled in the RPC treatment received 15 g/d of CholiGEM (Kemin Industries, Cavriago RE, Italy) from 21 d prepartum and 30 g/d of CholiGEM from calving to 21 d postpartum. During the transition period, DMI was measured daily, and blood was sampled weekly for energy-related metabolites such as β-hydroxybutyrate (BHB), glucose, and nonesterified fatty acids (NEFA), as well as immune function markers such as haptoglobin (Hp) and lipopolysaccharide-binding protein (LPB). Vaginal discharge samples were collected at the calving and 7 d postpartum and stored in microcentrifuge tubes at -80°C until 16S rRNA sequencing. The main responses of body condition score, body weight, DMI, milk yield, milk components, and immune function markers were analyzed using the GLIMMIX procedure of SAS with the effects of treatment, time, parity, and relevant covariates added to the models. The relative abundance of microbiome α-diversity was evaluated by 3 indexes (Chao1, Shannon, and Simpson) and β-diversity by principal coordinate analysis and permutational multivariate ANOVA. We found no differences in DMI in the pre- and postpartum periods. Cows fed RPC increased the yields of energy- and 3.5% fat-corrected milk and fat yield in primiparous and multiparous cows, with an interaction between treatment and parity for these lactation variables. However, we found no differences in milk protein and lactose up to 150 DIM between treatments. Glucose, NEFA, and BHB had no differences between the treatments. However, RPC decreased BHB numerically (control = 1.07 ± 0.13 vs. RPC = 0.63 ± 0.13) in multiparous on the third week postpartum and tended to reduce the incidence of subclinical ketosis (12.7% vs. 4.2%). No effects for Hp and LPB were found in cows fed RPC. Chao1, Shannon, and Simpson indexes were lower at calving in the RPC treatment than in the Control. However, no differences were found 7 d later for Chao1, Shannon, and Simpson indexes. The vaginal discharge microbiome was altered in cows fed RPC at 7 d postpartum. Fusobacterium, a common pathogen associated with metritis, was reduced in cows fed RPC. Rumen-protected choline enhanced lactation performance and health and altered the vaginal discharge microbiome which is a potential proxy for uterine healthy in dairy cows. The current study's findings corroborate that RPC is a tool to support adaptation to lactation and shed light on opportunities for further research in reproductive health.

Perioperative and functional outcomes following robot-assisted partial nephrectomy: Descriptive analysis of Indian study group on partial nephrectomy database

Introduction

There is an unmet need for high-quality data for Robot-assisted partial nephrectomy (RAPN) in the Indian population. Indian study group on partial nephrectomy (ISGPN) is a consortium of Indian centers contributing to the partial nephrectomy (PN) database. The current study is a descriptive analysis of perioperative and functional outcomes following RAPN.

Methods

For this study, the retrospective ISGPN database was reviewed, which included patients who underwent RAPN for renal masses at 14 centers across India from September 2010 to September 2022. Demographic, clinical, radiological, perioperative, and functional data were collected and analyzed. Ethics approval was obtained from each of the participating centers.

Results

In this study, 782 patients were included, and 69.7% were male. The median age was 53 years (interquartile range [IQR 44-62]), median operative time was 180 min (IQR 133-240), median estimated blood loss was 100 mL (IQR 50-200), mean warm ischemia time was 22.7 min and positive surgical margin rates were 2.5%. The complication rate was 16.2%, and most of them were of minor grade. Trifecta and pentafecta outcomes were attained in 61.4% and 60% of patients, respectively.

Conclusions

This is the largest Indian multi-centric study using the Indian Robotic PN Collaborative database to evaluate the outcomes of robot-assisted PN, and has proven its safety and efficacy in the management of renal masses.

Cyanoacrylate Glue Masquerading as an Obstructive Calculus: Rare Sequelae of Angioembolization for Renal Pseudoaneurysm

Renal pseudoaneurysm is a well-known albeit rare vascular complication following renal trauma, percutaneous interventions, renal biopsy, and partial nephrectomy. Angioembolization has become an effective treatment option for pseudoaneurysm using Cyanoacrylate glue, Gel-foams, Micro-coils, polyvinyl alcohol, etc. We herein present a 20-year-old gentleman with infected left hydroureteronephrosis secondary to an impacted foreign body in a ureter, specifically, down-migrated cyanoacrylate glue. This is two weeks following glue angioembolization for a left upper polar segmental renal artery pseudoaneurysm secondary to stab injury. He underwent a successful left-side ureteroscopic extraction of this polymerized glue, following which his symptoms subsided. These complications of glue migration following angioembolization are infrequent, and reports of it are scarce in the literature. Stringent follow-up and timely intervention are essential to mitigate disastrous outcomes.

Novel use of levodopa in human immunodeficiency virus encephalopathy-mediated parkinsonism in an adult

We report a case of a 36-year-old man with a medical history of human immunodeficiency virus (HIV) infection who presented with hypomimia, hypophonia, bradykinesia, rigidity, and freezing of gait. His clinical presentation and magnetic resonance imaging were consistent with HIV encephalopathy with involvement of the bilateral basal ganglia and diffuse leukoencephalopathy. We initiated a trial of carbidopa-levodopa. The dose was escalated to 1050 mg levodopa daily. Amantadine was also started. The patient was closely monitored for behavioral, neurological, or systemic side effects. He tolerated therapy well without adverse effects. The patient's neurological status significantly improved with levodopa, including hypomimia, hypophonia, bradykinesia, and fluidity of gait. This case demonstrates that carbidopa-levodopa can be safely utilized to manage parkinsonism in an adult patient with HIV encephalopathy.

Spectrum of hyperosmolar hyperglycaemic state in neurology practice

Background & objectives:

Hyperosmolar hyperglycaemic state (HHS) is a medical emergency, but there is a paucity of studies reporting the spectrum of neurological manifestations of HHS. We, therefore, report the neurological spectrum, triggering factors and outcome of HHS in general neurology practice.

Methods:

The records of the patients with HHS were extracted from computerized hospital information system and those managed currently were prospectively included. The demographic, clinical manifestations, duration of diabetes and precipitating events such as infection, stress and stroke were noted. Patients with HHS were categorized into seizure, movement disorder and encephalopathy groups. Their electroencephalography, magnetic resonance imaging (MRI) findings and outcome were noted.

Results:

There were 17 patients with HHS (age range 40 and 75 yr) and seven were females. Seven patients were diabetic for five years, one for four years, one for one year and four were diagnosed after the occurrence of HHS. Four patients had epilepsia partialis continua persisting for 72-360 h, one patient had focal seizures and his MRI revealed T2 hyperintensity in frontal region in one patient and cerebellar vermian hyperintensity in another. All the five patients improved, but two had neurological deficits on discharge. Nine patients had encephalopathy which was precipitated by stroke in six patients, urinary infections in two and meningitis in one. Three females had hemichorea-hemiballismus syndrome, which was triggered by infections. Abnormal movements lasted 5-10 days and responded to correction of hyperosmolarity. Nine out of 17 patients improved completely whereas the remaining eight had partial recovery, these patients had stroke, ventilator-related complications or meningoencephalitis.

Interpretation & conclusions:

The most common presentation of HHS was encephalopathy (9) followed by seizure (5) and hemichorea-hemiballismus syndrome (3) which responded to the correction of hyperosmolar state.

Impact of learning curve on the perioperative outcomes following robot-assisted partial nephrectomy for renal tumors

INTRODUCTION

Robot-assisted partial nephrectomy (RAPN) is an established, minimally invasive technique to treat patients with renal masses. The aim of this study was to assess the learning curve (LC) of RAPN, evaluate its impact on perioperative outcomes following RAPN and to study the role of surgeon experience in achieving "trifecta" outcomes following RAPN.

METHODS

We prospectively analyzed the clinical and pathological outcomes of 108 consecutive patients who underwent RAPN for renal tumors from January 2012 to December 2016 by a laparoscopy trained surgeon with no prior robotic experience. We used warm ischemia time (WIT) <20 min, operative time <120 min, and blood loss <100 ml as endpoints for plotting the LCs. Trifecta was analyzed in relation to our LC.

RESULTS

Surgeon experience was found to correlate with WIT, operative time, and blood loss. Overall 18.5% of patients developed complications. Complication rate reduced with increasing surgeon experience. LC was 44 cases for WIT ≤20 min, 44 cases for operative time <120 min, and 54 cases for blood loss <100 ml. Trifecta outcome was achieved in 67.6% patients overall and was found to correlate with increasing surgeon experience. Improvement in trifecta outcomes continued to occur beyond the LC.

CONCLUSIONS

RAPN is a viable option for nephron-sparing surgery in patients with renal carcinoma. For a surgeon trained in laparoscopy, acceptable perioperative outcomes following RAPN can be achieved after an LC of about 44 cases. Increasing surgeon experience was associated with improved "trifecta" achievement following RAPN.

Metabolomics approach discriminates toxicity index of pyrazinamide and its metabolic products, pyrazinoic acid and 5-hydroxy pyrazinoic acid

Pyrazinamide (PYZ)-an essential component of primary drug regimen used for the treatment and management of multidrug resistant or latent tuberculosis-is well known for its hepatoxicity. However, the mechanism of PYZ-induced hepatotoxicity is still unknown to researchers. Studies have shown that the drug is metabolized in the liver to pyrazinoic acid (PA) and 5-hydroxy pyrazinoic acid (5-OHPA) which individually may cause different degrees of hepatotoxicity. To evaluate this hypothesis, PYZ, PA, and 5-OHPA were administered to albino Wistar rats orally (respectively, at 250, 125, and 125 mg kg^-1 for 28 days). Compared to normal rats, PYZ and its metabolic products decreased the weights of dosed rats and induced liver injury and a status of oxidative stress as assessed by combined histopathological and biochemical analysis. Compared to normal controls, the biochemical and morphological changes were more aberrant in PA- and 5-OHPA-dosed rats with respect to those dosed with PYZ. Finally, the serum metabolic profiles of rats dosed with PYZ, PA, and 5-OHPA were measured and compared with those of normal control rats. With respect to normal control rats, the rats dosed with PYZ and 5-OHPA showed most aberrant metabolic perturbations in their sera as compared to those dosed with PA. Altogether, the study suggests that PYZ-induced hepatotoxicity might be associated with its metabolized products, where 5-OHPA contributes to a higher degree in its overall toxicity than PA.

CRTC1 nuclear localization in the hippocampus of the pilocarpine-induced status epilepticus model of temporal lobe epilepsy

cAMP response-element binding protein (CREB)-dependent genes are differentially expressed in brains of temporal lobe epilepsy (TLE) patients and also in animal models of TLE. Previous studies have demonstrated the importance of CREB regulated transcription in TLE. However, the role of the key regulator of CREB activity, CREB-regulated transcription coactivator 1 (CRTC1), has not been explored in epilepsy. In the present study the pilocarpine-induced status epilepticus (SE) model of TLE was used to study the regulation of CRTC1 during and following SE. Nuclear translocation of CRTC1 is critical for its transcriptional activity, and dephosphorylation at serine 151 residue via calcineurin phosphatase regulates cytoplasmic to nuclear transit of CRTC1. Here, we examined the localization and phosphorylation (Ser151) of CRTC1 in SE-induced rat hippocampus at two different time points after SE onset. One hour after SE onset, we found that CRTC1 translocates to the nucleus of CA1 neurons but not CA3 or dentate granule neurons. We further found that this CRTC1 nuclear localization is independent of Ser151 dephosphorylation since we did not detect any difference in dephosphorylation of Ser151 between control and SE animals at this time point. In contrast, 48 h after SE CRTC1 shows increased nuclear localization in the dentate gyrus (DG) of the SE-induced rats. At 48 h after SE, FK506 treatment blocked CRTC1 nuclear localization and dephosphorylation of Ser151. Our results provide evidence that CREB cofactor CRTC1 translocates into the nucleus of a distinct subset of hippocampal neurons during and following SE and this translocalization is regulated by calcineurin at a later time point following SE. Nuclear CRTC1 can bind to CREB possibly altering transcription during epileptogenesis.

Transperitoneal laparoscopic left versus right live donor nephrectomy: Comparison of outcomes

Introduction:

Although laparoscopic donor nephrectomy (LDN) is being performed at many centers, there are reservations on the routine use of laparoscopy for harvesting the right kidney due to a perception of technical complexity and increased incidence of allograft failure, renal vein thrombosis and the need for more back-table reconstruction along with increased operative time.

Materials and Methods:

We performed a prospective non-randomized comparison of transperitoneal laparoscopic left donor nephrectomy (LLDN) with laparoscopic right donor nephrectomy (RLDN) from August 2008 to May 2013. The operative time, warm ischemia time, intraoperative events, blood loss and post-operative parameters were recorded. The renal recipient parameters, including post-operative creatinine, episodes of acute tubular necrosis (ATN)  and delayed graft function were also recorded.

Results:

A total of 188 LDN were performed between August 2008 and May 2013, including 164 LLDN and 24 RLDN. The demographic characteristics between the two groups were comparable. The operative duration was in favor of the right donor group, while warm ischemia time, estimated blood loss and mean length of hospital stay were similar between the two groups. Overall renal functional outcomes were comparable between the two donor groups, while the recipient outcomes including creatinine at discharge were also comparable.

Conclusions:

RLDN has a safety profile comparable with LLDN, even in those with complex vascular anatomy, and can be successfully performed by the transperitoneal route with no added morbidity. RLDN requires lesser operative time with comparable morbidity.

SIU/ICUD Consultation on Urethral Strictures: Evaluation and follow-up

For the 2010 International Consultation on Urethral Strictures, all available published data relating to the evaluation and follow-up of patients with anterior urethral stricture or posterior urethral stenosis were reviewed and evaluated. Selected manuscripts were classified by Level of Evidence using previously established criteria. Consensus was achieved through group discussion, and formal recommendations were established and graded on the basis of levels of evidence and expert opinion. Retrograde urethrography remains the de facto standard for the evaluation of patients with urethral stricture. It can readily be combined with voiding cystourethrography to achieve a synergistic evaluation of the entire urethra, and this approach is currently recommended as the optimal method for pretreatment staging. Cystoscopy is recommended as the most specific procedure for the diagnosis of urethral stricture and is a useful adjunct in the staging of anterior urethral stricture, particularly to confirm abnormal or equivocal findings on imaging studies. Cystoscopy is also an important modality for assessing the bladder neck and posterior urethra in the setting of a pelvic fracture-related urethral injury. Although urethrography and cystoscopy remain the principle forms of assessment of the patient with urethral stricture, additional adjuncts include uroflowmetry, symptom scores, quality of life assessments, ultrasonography, computed tomography, and magnetic resonance imaging. These modalities might be helpful to further evaluate patients in select circumstances or provide a less invasive approach to monitoring outcomes after surgical treatment. Further research is needed to establish consensus opinion as to the definition of success after urethroplasty and to develop standardized patient outcome measures.

SIU/ICUD Consultation on Urethral Strictures: Pelvic fracture urethral injuries

The posterior urethra pierces the perineal diaphragm in close relationship to the pubic arc elements of the bony pelvis to which it is tethered by attachments to the puboprostatic ligaments and the perineal membrane. Because of these relationships, it is not surprising that fracture disruptions of the pelvic ring can be associated with injuries to the urethra at this level. Although the relationship between pelvic fracture and posterior urethral injury has been recognized for >1 century, considerable controversy exists on almost any aspect of these injuries, from the anatomy and classification of the injuries to the strategies for acute management, reconstruction, and treatment of complications, to mention just a few. What it is not controversial and well known is that these injuries can result in significant morbidity in the long run--mainly strictures, erectile dysfunction, and urinary incontinence--which can cause lifelong disability. It also well known that, just as in many other areas of trauma, the severity and duration of the complications can be reduced considerably if the injury is diagnosed and treated promptly and efficiently. This chapter summarizes the most relevant published evidence about the management of pelvic fracture urethral injuries. This comprehensive review, performed by an international panel of experts, will provide valuable information and recommendations to help urologists worldwide improve the treatment and outcomes of their injured patients.

Single incision laparoscopic distal pancreatectomy with splenectomy for neuroendocrine tumor of the tail of pancreas

Laparoscopic resection is becoming the standard of care for tumors located in the body and tail of pancreas. We herein report a patient with neuroendocrine tumor in the tail of pancreas who underwent single incision laparoscopic distal pancreatectomy with splenectomy without the use of a commercial port device.

Transumbilical laparoendoscopic single-site donor nephrectomy: Without the use of a single port access device

Introduction:

Laparoendoscopic single-site donor nephrectomy (LESS-DN) is a procedure in evolution. Currently described techniques utilize single port access devices and articulating, flexible, and bent working instruments. We describe a modified technique of transumbilical LESS-DN with conventional laparoscopic instruments in five kidney donors.

Materials and Methods:

Three standard laparoscopic ports (10 mm × 1, 5 mm × 2) were placed through a 4.5 cm vertical transumbilical incision. A 10 mm 45°, long bariatric lens (Karl Storz) was used. Renal mobilization was performed using conventional rigid laparoscopy instruments. A port closure needle loaded with a blunt plastic needle cap was used for traction. After hilar clamping, an incision was made connecting the three ports, and the kidney was extracted using a preplaced suture over the lower pole fat. All data were prospectively recorded.

Results:

LESS-DN was performed successfully in all five patients. The mean operative time was 157.2 minutes (range, 134–184) and the mean warm ischemia time was 3.2 minutes (range, 3–4). All donors were discharged on postoperative day 3 and were able to resume normal physical activity by 2 weeks after the procedure. All donors had an excellent cosmetic outcome. The mean serum creatinine (recipient) at discharge was 1.14 mg% (range, 0.9–1.4).

Conclusions:

Transumbilical LESS-DN can be cost-effectively performed using conventional laparoscopy instruments and without the need for a single port access device. Warm ischemia times with this technique are comparable with that during conventional multiport laparoscopic donor nephrectomy.

The current role of direct vision internal urethrotomy and self-catheterization for anterior urethral strictures

Introduction:

Direct visual internal urethrotomy (DVIU) followed by intermittent self-dilatation (ISD) is the most commonly performed intervention for urethral stricture disease. The objective of this paper is to outline the current scientific evidence supporting this approach for its use in the management of anterior urethral strictures.

Materials and Methods:

A Pubmed database search was performed with the words “internal urethrotomy” and “internal urethrotomy” self-catheterization. All papers dealing with this subject were scrutinized. Cross-references from the retrieved articles were also viewed. Only English language articles were included in the analyses. Studies were analyzed to identify predictors for success for DVIU.

Results:

Initial studies showed excellent outcomes with DVIU with success rates ranging from 50% to 85%. However, these studies reported only short-term results. Recent studies with longer followup have shown a poor success rate ranging from 6% to 28%. Stricture length and degree of fibrosis (luminal narrowing) were found to be predictors of response. Repeated urethrotomies were associated with poor results. Studies involving intermittent self-catheterization following DVIU have shown no role in short-term ISD with one study reporting beneficial effects if continued for more than a year. A significant number of studies have shown long-term complications with SC and high dropout rates.

Conclusions:

DVIU is associated with poor long-term cure rates. It remains as a treatment of first choice for bulbar urethral strictures <1 cm with minimal spongiofibrosis. There is no role for repeated urethrotomy as outcomes are uniformly poor. ISD, when used for more than a year on a weekly or biweekly basis may delay the onset of stricture recurrence.

Radio-median cubital / radiocephalic arteriovenous fistula at elbow to prevent vascular steal syndrome associated with brachiocephalic fistula: Review of 320 cases

Aim:

Radiocephalic arteriovenous fistula (AVF) at wrist is the vascular access of choice for dialysis. In the absence of a suitable vein at the wrist, a brachiocephalic fistula at elbow is usually constructed. In order to avoid the complication of vascular steal syndrome associated with the brachiocephalic fistula, an alternative operative technique involving the creation of radio-median cubital vein / radiocephalic fistula at elbow was evaluated.

Settings and Design:

Retrospective study.

Materials and Methods:

Between January 1990 and October 2005, 320 patients underwent creation of radio-median cubital vein / radiocephalic AVF at elbow as a primary procedure or following failure of a fistula at the wrist. A transverse skin incision was made 4cm below the elbow crease, centering in line with the brachial artery pulsation. The median cubital vein / cephalic vein was anastomosed to the radial artery in end to side fashion. The surgical complications and patency of the fistulae were analyzed in the immediate and late postoperative period.

Results:

Mean operative time was 55 ± 7.15 min. There were no major intraoperative complications. Immediate patency and a palpable distal radial pulse were present in all the patients. Mean time to fistula maturation was 26 ± 5.2 days. No patient developed a vascular steal syndrome at a median follow-up of 54 months (range 12–168 months) Early fistula failure was seen in 16 (5%) patients whereas eight (2.5%) fistulas failed at a later date. Pseudoaneurysm of the arterialized vein at the fistula site developed in only one (0.3%) patient. Pseudoaneurysm proximal to the anastomosis developed in three (0.9%) patients. Sixteen (5%) patients requested for closure of the fistula following successful renal transplant due to unsightly dilated veins and continuous noisy murmur disturbing their sleep.

Conclusions:

The radio-median cubital vein / radiocephalic AV fistula at elbow is safe and is a better vascular access procedure for hemodialysis than brachiocephalic fistula because it leads to the dilatation of both the cephalic and the basilic veins with no incidence of vascular steal phenomenon in our experience. Patency and flow rates are similar to brachiocephalic fistula.

Minimal invasive treatment of ureteropelvic junction obstruction in low volume pelvis: A comparative study of endopyelotomy and laparoscopic nondismembered pyeloplasty

OBJECTIVE

To evaluate the role of nondismembered laparoscopic pyeloplasty and percutaneous endopyelotomy for ureteropelvic junction obstruction (UPJO) with low volume renal pelvis.

MATERIAL AND METHODS

Retrospective acquired data of 34 patients of laparoscopic nondismembered pyeloplasty was compared with 26 patients of UPJO with pelvic volume less than 50 ml undergoing antegrade endopyelotomy and analyzed for clinical parameters, operative outcomes and success of procedures. All patients were followed up clinically and with diuretic renogram at regular intervals.

RESULTS

Mean age, renal pelvic volume and preoperative glomerular filtration rate (GFR) was 25 years, 43.6 ml and 42.5 ml/min, respectively in endopyelotomy group and 21 years, 34.4 ml and 39.9 ml/min, respectively in laparoscopic pyeloplasty group. Mean operative time, postoperative analgesic requirement and mean hospital stay was 100min, 250 mg and 4 days, respectively in endopyelotomy group and 210 min, 300 mg and 4 days, respectively in laparoscopic pyeloplasty group. Only operative time was significantly different between two groups (P < 0.05). Mean follow-up was 36 and 39 months and success rates were 91.2% and 88.8% in laparoscopy and endopyelotomy group, respectively (P < 0.05). No significant complication was seen in endopyelotomy group while two patients had hematuria (one requiring blood transfusion) and three had increased drain output for more than 3 days in laparoscopy group.

CONCLUSION

Percutaneous endopyelotomy is associated with significantly less operative time and postoperative complication rate and provides equivalent success in comparison to nondismembered laparoscopic pyeloplasty in patients with UPJO and low volume pelvis. It can be a preferred minimally invasive treatment modality for such patients.

Congenital posterior urethral diverticula causing bladder outlet obstruction in a young male

We present a case of 26-year-old male presenting with mild renal failure. Ultrasound findings were suggestive of posterior urethral valve, but micturating cystourethrogram and endoscopic evaluation confirmed the diagnosis of posterior urethral diverticulae. Transurethral resection of diverticulae was performed. Patient is voiding well and his renal function has stabilized.

Closure versus nonclosure of buccal mucosal graft harvest site: A prospective randomized study on post operative morbidity

Objective:

To prospectively compare the postoperative morbidity of closure versus non closure of the buccal mucosal graft (BMG) harvest site.

Methods:

Patients who underwent BMG harvest for urethroplasty were randomized into 2 groups; in group 1 donor site was closed and in group 2 it was left open. Self made questionnaires were used to assess post-operative pain, limitation to mouth opening, loss of sensation at graft site. The time to resumption of liquid and solid diet were also noted.

Results:

Fifty patients were studied, 25 in each group from July 2003 to July 2005. BMG was harvested from single cheek in most of the patients. Mean post operative pain score was 4.20 and 3.08 at day 1 in group 1 and group 2, respectively (P < 0.05). Return to oral intake in terms of liquid and solid diet was comparable between the groups. Difficulty with mouth opening was maximal during the first week with no difference among the two groups. Two patients in group 1 and one in group 2 had persistent peri-oral numbness at 6 months. None of the patients in both the groups had changes in salivation or retention cysts.

Conclusion:

Pain appears to be worse in the immediate post operative period with suturing of the harvest site. There is no difference in long term morbidity whether the graft site is closed or left open. It may be best to leave buccal mucosa harvest sites unsutured.

Management of vesicovaginal fistula: An experience of 52 cases with a rationalized algorithm for choosing the transvaginal or transabdominal approach

Purpose:

We aim to present our experience for the repair of vesicovaginal fistula (VVF) with special reference to surgical approach.

Materials and Methods:

From January 1999 to June 2005, 52 VVF patients with mean age of 32 years underwent operative treatment. Fistulas were divided into two groups, simple and complex, depending on site, size, etiology and associated anomalies. Simple VVFs were approached through the vaginal route and complex VVFs via the transabdominal route. Patients were evaluated at two to three weeks initially, three-monthly twice and later depending on symptoms.

Results:

Thirty-two (61.5%) had simple fistulas and 20 (38.5%) complex fistulas. The most common etiology was obstetric trauma in 31 (59.6%) patients, while the second most common cause was post hysterectomy VVF. Thirty-two (61.5%) patients were managed by transvaginal route, of which 17 had supratrigonal and 15 trigonal fistulas. Twenty (38.5%) patients with complex fistulas were managed by abdominal route. The mean blood loss, postoperative pain and mean hospital stay were shorter in transvaginal repair. Eleven (21.2%) patients required ancillary procedures for various other associated anomalies at the time of fistula repair. Three patients failed repair giving a success rate of 94.2%. At a mean follow-up of three years 48 women were sexually active, of these 10 (19.2%) complained of mild to moderate dyspareunia.

Conclusion:

Most of the simple fistulas irrespective their locations are easily accessible transvaginally while in complex fistulas we recommend the transabdominal approach. Depending on the clinical context both the approaches achieved comparable success rates.

Single-centre experience of laparoscopic nephrectomy: Impact of learning curve on outcome

Aim:

To present our experience of laparoscopic nephrectomies done for benign and malignant conditions; and the impact of learning curve on outcome.

Settings and Design:

Retrospective study.

Materials and Methods:

Between January 2000 and September 2006, 396 laparoscopic nephrectomies were performed at our institute for various benign and malignant conditions. These included 250 simple nephrectomies, 48 nephroureterectomies, 95 radical nephrectomies, two partial nephrectomies and one hemi-nephrectomy. For the purpose of self-evaluation, we have divided our experience into two groups. Group 1 (learning phase) comprised the first 100 cases; Group 2 (consolidation phase) comprised cases performed after the initial learning phase. Retrospective evaluation of the case records was done to evaluate the differences in the operative and postoperative outcome.

Statistical Analysis Used:

Student's ‘t’ test using SPSS 14.0 software.

Results:

Demographic profile of the patients and relative indications of procedures performed were similar in the two groups. Mean operative time in Group 1 was 262 ± 37 min, which reduced to 184 ± 44 min in Group 2 (P<0.001). Mean operative blood loss was 310 ± 58 ml and 198 ± 88 ml (P<0.001); and blood transfusion was required in 38% and 13.5% of patients (P<0.001) of Group 1 and Group 2 respectively. There was a significant reduction in the intraoperative and postoperative complications from 16% in Group 1 to 3.4% in Group 2 (P<0.001). Similarly, conversion to an open procedure was required in 17% cases of Group 1 and 5.4% cases of Group 2 (P<0.01).

Conclusions:

Laparoscopic nephrectomy is a viable option which can be performed safely with increasing experience.

Urethrocutaneous fistula after hypospadias repair: outcome of three types of closure techniques

OBJECTIVE

To evaluate the outcomes of three surgical techniques for the closure of urethrocutaneous fistula (UCF) after hypospadias repair.

MATERIALS AND METHODS

Fifty-one patients (mean age 6.5 years) who underwent UCF closure between June 1998 and February 2008 were divided in to three groups depending on fistula size; group I had <2 mm and (n = 17, 33.4%), group II had 2-4 mm (n = 21, 41.2%) and group III had >4 mm or multiple fistulas (n = 13, 25.4%). Group I patients were treated by excision and simple closure. Patients in group II and III were treated with flip flap technique along with the wrapping of repaired area with scrotal dartos flap and tunneled tunica vaginalis flap (TVF), respectively.

RESULTS

Mean surgical time was 45 min (range 30-55), 60 min (range 50-75) and 80 min (range 60-100) in three techniques, respectively. The mean follow-up was 3.5 years (range 6 months-10 years). No patient had recurrence of fistula in group III, while 2 (9.5%) and 4 (25.4%) patients in groups II and I, respectively, had recurrent UCF. No postoperative complications were encountered in the testis or the scrotum. No patient had torsion or deviation of penis.

CONCLUSION

Simple fistula closure carries a higher risk of recurrence even in small sized fistulas. The application of scrotal dartos or TVF for wrapping the repaired area gives excellent results and they are easy to harvest with no harmful effects on the scrotum or testis.

Status of birth preparedness & complication readiness in Rewa District of Madhya Pradesh

OBJECTIVE

To assess status of birth preparedness & complication readiness among recently delivered and pregnant mothers in Rewa district of Madhya Pradesh.

METHODS

A cross-sectional descriptive study was conducted during September-November 2008 among a sample of 2022 study subjects (pregnant women in second/third trimester and/or mothers who have delivered within one year) selected through 30 cluster sampling technique. Investigators collected data using pre-designed schedule by house to house visit. 7 indicators were derived from elements of birth preparedness (BP)/complication readiness (CR). Mean of 7 indicators was taken as BP/CR Index.

RESULTS

Among 2022 women, 632 were pregnant and 1390 were recently delivered. BP/CR index was found to be 47.5. BP/CR index was significantly high in above poverty line families (50.9), higher educational level (63.6) and in service and business group (59.3). BP/CR were significantly higher in primi-para (50.9) as compared to multipara (40.1). Some indicators for example knowledge of danger sign (18.6%), about transportation facilities (18.6%) and 1st trimester ANC (24.1%) was very low.

Post-renal transplant surgical complications with newer immunosuppressive drugs: mycophenolate mofetil vs. m-TOR inhibitors

PURPOSE

To compare the incidence of immediate surgical complications after renal transplantation between mycophenolate mofetil (MMF group)-based and mTOR inhibitors (mTOR group)-based immunosuppressive regimens.

METHODS

The preoperative parameters in the recipients, rejection rates and surgical complications within 12 months in the recipients were analyzed in 80 patients who had live related renal transplantation. The immunosuppressive regimen was based on MMF (MMF, prednisolone, cyclosporine) in 40 patients and mTOR inhibitors (sirolimus/everolimus, prednisolone, cyclosporine) in 40 patients.

RESULTS

The baseline characteristics were comparable between the two groups. Infective complications (urinary tract infections, pulmonary infections and superficial wound infection) occurred in 27.5% (11/40) and 12.5% (5/40) of patients from MMF and mTORI groups, respectively (P = 0.096). Patients in mTORI group had significantly more wound dehiscence (8/40 i.e., 20%) than in MMF group (1/40 i.e., 2.5%) (P = 0.014). There was no significant difference in the occurrence of clinically significant or symptomatic lymphoceles that needed intervention (3 vs. 2). The hospital stay was significantly prolonged in mTORI group mainly because of wound-related problems (35 vs. 24 days).

CONCLUSION

In the post-renal transplant setting, use of mTORI results in significantly higher wound complications compared to that of MMF leading to prolonged hospital stay. There is no significant difference in infective complications or lymphocele incidence between these two immunosuppressive regimens.

The routine use of prostate-specific antigen for early detection of cancer prostate in India: Is it justified?

BACKGROUND

The use of prostate-specific antigen (PSA) for early detection of prostate cancer is a widely debated issue. The average Indian urologist is faced with the dilemma of whether PSA testing should be routinely offered to men over 50 years of age. The Urological Society of India is yet to issue any guidelines on PSA testing. This article attempts to explore scientific evidence dealing with this controversial subject.

MATERIALS AND METHODS

A MEDLINE search was performed using the words 'PSA screening', 'prostate cancer statistics', and 'PSA screening guidelines'. The relevant articles were then analysed for evidence regarding the utility of PSA screening.

RESULTS

Prostate cancer does not qualify to be categorized as a major health problem in India. The natural history of screen-detected cancer is not known. Prostate-specific antigen testing for early detection of prostate cancer has questionable benefits and has a potential to cause harm to asymptomatic individuals. There is no consensus amongst learned medical societies as to what should be the best approach for PSA testing. Most organizations caution against widespread PSA screening and emphasize on informed consent and patient counseling with regard to PSA testing. Randomized prospective trials are ongoing to assess to the true impact of screening on prostate cancer mortality.

CONCLUSIONS

There is no scientific rationale to advocate routine use of PSA for early detection of prostate cancer in Indian males. Results of randomized screening trials are awaited to clarify on this issue.

Posttraumatic posterior urethral strictures in children--management and intermediate-term follow-up in tertiary care center

OBJECTIVES

To evaluate the management and intermediate-term follow-up of posttraumatic posterior urethral strictures in children.

METHODS

From March 2000 to November 2006, the surgical records of 28 children (< or = 18 years) who had been admitted for treatment of posttraumatic posterior urethral strictures were retrospectively reviewed. The patients had been followed up for a median of 36 months (range 3-58). The cause of trauma, extent of urinary tract injury, radiologic examination findings, previous treatment, and its effect on the final outcome, treatment complications,, and failures were evaluated.

RESULTS

The mean age of the patients was 12.1 years (range 5-18) at the injury. The estimated radiographic mean stricture length before surgery was 3.41 cm (range 2-6). Of the 28 patients, 27 were treated with transperineal anastomotic urethroplasty, with a success rate of 75%. All treatment failures were at the anastomotic site and occurred within the first year of anastomotic urethroplasty. The failed repairs (7 cases) were successfully managed endoscopically in 4 patients and by redo urethroplasty in 3, for a final success rate of 100%. Of the 28 patients, 15 (80%) with urethral manipulation before anastomotic urethroplasty had a satisfactory result compared with 69.3% of patients without previous surgical treatment. The difference was not statistically significant.

CONCLUSIONS

Most posttraumatic posterior urethral strictures in children can be managed through the perineal route. The transpubic approach should be reserved for more complex posterior strictures. Previous urethral manipulations did not affect the intermediate-term results of anastomotic urethroplasty.