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   Table of Contents - Current issue
Coverpage
October-December 2018
Volume 10 | Issue 4
Page Nos. 347-422

Online since Friday, October 12, 2018

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SYSTEMATIC REVIEWS AND META-ANALYSIS  

Redo laparoscopic pyeloplasty among children: A systematic review and meta-analysis Highly accessed article p. 347
Hamdan Hammad Alhazmi
DOI:10.4103/UA.UA_100_18  
Laparoscopic pyeloplasty (LP) is more beneficial than open procedures. However, studies on laparoscopic management of cases with secondary ureteropelvic junction obstruction (SUPJO) after previous failed pyeloplasty in the pediatric population are lacking. This meta-analysis aimed to assess the difference between redo LP (RLP) and redo open pyeloplasty (ROP) for children with SUPJO, focusing on certain criteria. All recent studies on RLP and ROP in children with SUPJO were searched. Search engines such as Medline, PubMed, and The Cochrane Library of Systematic Reviews were used. Sixty citations were specified. Two reviewers extracted data independently, screened the titles, and assessed the quality of each citation. Continuous data reported as a weighted mean difference (WMD) (95% confidence interval) and dichotomous data reported as relative risk were used. We measured the length of hospital stay (LOS) and operative time using weighted mean and success and complication rates using risk difference and odds ratio (OR). A random effects model was used to pool OR that was tested for heterogeneity. We specified six publications that minutely met our eligibility standards. Meta-analysis of given data resulted in the following: ROP showed reduction in operative time by 12 min (WMD: 12.7 min; P = 0.14). RLP had shorter LOS than ROP (WMD: 0.6 days; P < 0.01). No difference was observed in complication and success rates (OR: 0.8; P = 0.50 and OR: 1.2; P = 0.51, respectively). In conclusion, RLP seems to be better than ROP in terms of LOS reduction; however, both are comparable with respect to success and complication rates, especially postoperative urine leakage.
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ORIGINAL ARTICLES Top

Meatal stenosis after surgical correction of short frenulum: Is the “pull-and-burn” method the way to go? Highly accessed article p. 354
Kostis I Gyftopoulos
DOI:10.4103/UA.UA_25_18  
Background and Objectives: The surgical correction of a short frenulum includes several procedures that vary in complexity of the technique and the use of stitches, lasers, or skin grafts. However, little is known about the effect of these procedures on meatal stenosis. A possible association of frenular artery trauma during circumcision and subsequent meatal stenosis has raised concerns regarding the importance of frenulum preservation. We hereby report our experience over 15 years of applying the “pull-and-burn” method for short frenulum correction. Patients and Methods: A total of 236 patients underwent the “pull-and-burn” procedure for short frenulum under local anesthesia on an outpatient basis between November 2002 and November 2017. The method is suture free and involves tearing the frenulum superficially and vertically by the aid of a low-power, high-frequency hyfrecator, avoiding the underlying frenular vessels. Patients were advised for a regular follow-up visit at 2–3 months postoperatively and were reviewed for symptoms and signs suggestive of meatal stenosis. Results: Follow-up files were available for 228 patients (96.6%). No symptoms suggestive of meatal stenosis (dysuria and stream pattern abnormalities) were reported by any patient. Examination of the urethral meatus revealed normal appearance, with no signs of edema or scarring in all the 228 patients. Conclusions: The “pull-and-burn” method is a simple and safe procedure for the correction of short frenulum that respects anatomically the delicate vasculature of the frenular area, resulting in the preservation of the integrity of the urethral meatus.
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Percutaneous retropelvic endopyelotomy for treatment of ureteropelvic junction obstruction p. 358
Khalid M Alotaibi
DOI:10.4103/UA.UA_61_18  
Purpose: A new minimally invasive approach for endopyelotomy for the treatment of ureteropelvic junction obstruction (UPJO) is described. The results are compared with those of other lines of treatment. Materials and Methods: A total of 39 patients with UPJO underwent percutaneous retropelvic endopyelotomy. Retrograde percutaneous renal access, using the Lawson catheter and deflecting guidewire, was done for creation of the nephrostomy tract. Using holmium laser through a 28-Fr nephroscope, a small window was made in the posterolateral surface of the renal pelvis. The nephroscope was advanced from the renal pelvis to the retropelvic space through that window. Crossing vessels were easily detected and were either coagulated or avoided. The window incision was extended distally, and the narrow ureteropelvic junction (UPJ) was incised using holmium laser. Results: The entire procedure was done in the supine position within 1 h. The presence of secondary stones, hugely dilated renal pelvis, high insertion of the UPJ, and whether UPJO was primary or secondary, did not alter the results. The only factor that affected the results was split function of the obstructed renal unit. The success rate was 100% when the split function exceeded 35%. When the split function was <35%, the success rate dropped to 56%. Conclusion: Percutaneous retropelvic endopyelotomy is a promising approach for the treatment of UPJO that gave favorable results. The use of the nephroscope provided a wide visual field. The wide-field facilitated detection of crossing blood vessels with no incident of vascular injury. It also facilitated endopyelotomy with high precision. Ureteral injury was not a risk factor.
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Management of urethral strictures: A nationwide survey of urologists in the Kingdom of Saudi Arabia p. 363
Raed M Almannie, Waleed H Alkhamis, Abdulaziz I Alshabibi
DOI:10.4103/UA.UA_58_18  
Context: urethral strictures commonly occur and considered difficult to manage due to high recurrence rate and wide variety of management approach. Aims: This study aims to identify how urologists in Saudi Arabia manage new and recurrent urethral stricture cases and to investigate their opinions regarding urethroplasty. Settings and Design: A cross-sectional study (Online Survey) among urologists. Subjects and Methods: A nationwide survey of urologists registered with the Saudi Commission for Health Specialties was performed through a mailed questionnaire. A total of 603 urologists were selected from all five regions of Saudi Arabia, of whom 216 (35.8%) completed the questionnaire. Statistical Analysis Used: SPSS software version 23 was used for data entry and analysis. Results: Most urologists (40.3%) had treated 1–5 urethral strictures in the past year. The most common procedures used to manage urethral strictures were visual urethrotomy (82.4%), cystoscopy and dilatation (62.2%), and excision and primary anastomosis (20.8%). Minimally invasive procedures were used more frequently than any open urethroplasty techniques. Most urologists (63%) did not perform urethroplasty surgery, and 21.8% were not aware of any adult reconstructive urologists in Saudi Arabia. When used, however, the most commonly performed urethroplasty surgeries were excision and primary anastomosis, dorsal buccal graft augmented urethroplasty, and ventral buccal graft augmented urethroplasty. Conclusions: Minimally invasive methods are easy to perform and have good short-term outcomes. As such, they are more commonly used for the management of urethral strictures. On the other hand, urethroplasty surgeries are challenging procedures that require greater experience and skill.
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Use of ileum for complex ureteric reconstruction: Assessment of long-term outcome, complications, and impact on renal function p. 369
Yash Pamecha, Umesh Shelke, Bhushan Patil, Sujata Patwardhan, Siddharth Kini
DOI:10.4103/UA.UA_5_18  
Introduction: Defect in ureteral continuity can be due to various etiologies. The surgical options for management of complex long-segment ureteric defects are limited. Use of ileum is indicated in these cases; however, the technique is challenging and outcomes need to be assessed in detail. Material and Methods: It is an observational study conducted over 4 years. After preoperative optimization, ureteric reconstruction was performed using standard techniques of ileal interposition in cases of unilateral and bilateral long-segment ureteric defects. Patients were followed up at regular interval to assess outcomes and see for complications. Results: A total of 14 patients were studied. Two most common indications for performing ileal ureter were iatrogenic injury and radiation-induced strictures (5–5 cases). Most common site of ureteric involvement was lower and midureter seen in 6 cases. The mean length of the ileum used was 11.2 cm. Mean preoperative nadir creatinine level was 1.57 mg/dL in this study. Average postoperative creatinine level at 4-week follow-up was 1.75 mg/dL and 1.45 mg/dL and 1.37 mg/dL, at 3 and 12 months, respectively. The most common short-term complication was paralytic ileus and long-term complication was recurrent urinary tract infection UTI. There was no mortality. Conclusion: Ileal ureter is found to be relatively easy and safe surgery even in patients with borderline high creatinine. There was no worsening of renal function attributable to the conduit in this study. In patients with limited surgical options, it is a suitable alternative, rather than keeping patient on permanent percutaneous nephrostomy or regular stent change. Metabolic acidosis and mucous-associated complications such as pain, infection, and stone formation can be minimized by adherence to strict protocol.
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The use of S-curved coaxial dilator for urethral dilatation: Experience of a tertiary department p. 375
Panagiotis Kallidonis, Constantinos Adamou, Adamantia Koutava, Panteleimon Ntasiotis, Dimitrios Kotsiris, Abdulrahman Al-Aown, Evangelos Liatsikos
DOI:10.4103/UA.UA_68_18  
Objective: Urethral strictures can be treated by urethral dilation, optical internal urethrotomy, or open surgical reconstruction (urethroplasty). Urethral dilation is done with filiforms and followers, balloons, or coaxial dilators inserted over a guidewire. The S-curved coaxial dilator (SCCD) was designed to facilitate the passage of the dilator through the stricture and the urethra because it imitates the curved anatomy of the male urethra. This study presents our experience with SCCD. Materials and Methods: We used this kind of dilation in 310 patients. The technique included the insertion of a hydrophilic floppy-tipped guidewire through the urethra directly into the bladder under fluoroscopic control. The SCCDs were then inserted over the guidewire. Dilators of gradually increased size from 8F to 20F were used. The follow-up of the patients includes uroflowmetry and measurement of postvoid residual at 4 weeks, 6 months, or in the case of a recurrence of symptoms. Results: The age of the patients were 69.08 ± 15.77 years. The causes of urethral stricture were iatrogenic (n = 114), traumatic (n = 35), infectious (n = 22), and of unknown origin (n = 139). The stricture length was 1.62 ± 0.85 cm. The mean number of dilations needed per case was 2 (range: 1–15), and the time between the dilations was 212.19 ± 253.9 days. We had seven failures. Conclusion: We propose the S-curved coaxial dilators for urethral dilation as a safe and effective technique because of their similarity to the shape of the male urethra and because of their hydrophilic coating.
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Utilization of scrotal orchidopexy for palpable undescended testes among surgeons p. 380
Fahad A Alyami, Abdulaziz Fahad Bin Yahya, Hamad Fahad Albraidi, Nawaf Abdullah Almarek, Mohammed Abdulaziz Alkhalifa, Hamdan Alhazmi, Mahmoud Salem Trbay, Khalid Fouda Neel
DOI:10.4103/UA.UA_54_18  
Introduction: Scrotal orchidopexy for palpable undescended testicle (UDT) has received attention in the last decade due to its lower morbidity. This study was conducted to determine the frequency and factors related to the use of the scrotal approach in the surgical treatment of palpable UDT among surgeons. Methods: An observational cross-sectional study was carried out using an online survey, which was sent to different pediatric urologists, pediatric surgeons, and urologists groups. The survey consisted of questions on demographics as well as surgeons opinions and experience toward scrotal orchidopexy. Results: Of 163 respondents, 57 (35.0%) were pediatric surgeons, 98 (60.1%) were pediatric urologists, and 8 (4.9%) were urologists. There were 86 respondents (52.8%) who used the scrotal orchidopexy approach for UDT at any time in their practice. Pediatric urologists tended to use the scrotal orchidopexy approach for UDT more significantly than others (P < 0.001). There were significantly more scrotal orchidopexies for UDT performed by the pediatric urologists throughout their practice and per year compared to others, respectively (P < 0.001). Fifty-two respondents (31.9%) claimed that scrotal orchidopexy is not a good option for their patients, while seven respondents (4.3%) claimed that the procedure was hard to perform. Discussion: Based on the results of this study, we believe that there is a discrepancy in the reported advantages and success rate of scrotal orchidopexy in the published literature and the utilization of such an approach among surgeons managing palpable UDT in children. Conclusion: Scrotal orchidopexy is an underutilized approach in the management of palpable UDT in children. Only 52.8% of our respondents used it for UDT. One of the main reasons why scrotal orchidopexy is underutilized is due to the surgeons' perception that scrotal orchidopexy is not the procedure of choice for their patients and their unfamiliarity with the procedure.
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Robotic cold ischemia achieves comparable functional outcomes to open cold ischemia during partial nephrectomy for complex kidney tumors p. 386
Ryan J Nelson, Julien Dagenais, Matthew J Maurice, Jaya Sai S. Chavalia, Daniel Ramirez, Peter A Caputo, Paurush Babbar, Nitin K Yerram, Jihad H Kaouk
DOI:10.4103/UA.UA_91_17  
Objectives: To compare the perioperative and functional outcomes after open and robotic partial nephrectomy performed with cold ischemia. Methods: A retrospective chart review was completed of consecutive patients who underwent partial nephrectomy with renal hypothermia between January 2011 and September 2016. The study cohort included both open (Open Cold Ischemia, OCI; n=170) and robotic (Robotic Cold Ischemia, RCI; n=31) patients with complex renal masses (R.E.N.A.L. score &gt;7) who did not meet exclusion criteria. A modified intracorporeal technique 1 was utilized for the introduction of ice slush at the time of hilar clamping in the RCI group. Statistical testing was performed to compare key perioperative and functional outcomes after ensuring equilibration of both groups by clinicodemographic criteria. Results: Both groups were statistically equivalent with respect to baseline characteristics. Median GFR preservation postoperatively was 86.7% for the open group and 86.6% in the robotic group (p=0.49). Cold ischemia time (CIT) in the open group was 35 minutes compared to 28 minutes (p = 0.03) in the robotic group. LOS was significantly shorter by 2 days (p &lt; 0.01) in the robotic group. Positive margins was noted to be 17 (10%) in the open group and 2 (6.5%) patients in the robotic group (p=0.48). Conclusions: We demonstrate an effective and simplified method of intracorporeal ice cooling during robotic partial nephrectomy. Our data suggests that results with this approach compare favorably to open cold ischemia technique. Intracorporeal ice cooling can be considered when performing complex partial nephrectomies with ischemia times expected to exceed 25 minutes.
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Management of hypospadias in Saudi Arabia: A national survey p. 391
Ossamah Saleh Alsowayan
DOI:10.4103/UA.UA_88_18  
Introduction: Hypospadias is one of the most common congenital anomalies of the penis. Different methods of hypospadias management are described in the literature. We try in this study to evaluate the national trends and to compare them with international practices. Materials and Methods: A multiple choice survey was distributed among a sample of national practitioners using a weblink between September and December 2017. It included questions about participants demographics, number of cases operated on per year, perioperative care and preferences, long-term follow-up, and complications. Data were analyzed and compared with international practices. Results: Results of 47 practitioners were evaluated and analyzed in this study. The majority of the participants were pediatric urologists (48.9%) and from the central province (44.7%). Most of the participants prefer to operate on patients between the ages of 1 and 2 years (48.9%) and operate at ≥20 cases per year (76.6%). Tubularized incised plate (TIP) is the preferred technique for distal penile hypospadias repair whereas staged repair is preferred for proximal cases. All participants use a form of a second layer and a stent for their repairs. The majority reported an overall complication rate of ≤10% for distal penile hypospadias (76.1%) and >10% for proximal penile cases (59.6%). Conclusion: This study helped us identify national trends in hypospadias management, which were comparable to the international trends. TIP repair is the preferred technique for distal penile hypospadias repair whereas staged repair is preferred for more complex proximal variants. Although data in this study come from reports of personal experience, it can serve as a backbone for the future prospective studies on this topic.
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Assessment of quality of life in patients of urethral stricture on clean intermittent catheterization following direct vision internal urethrotomy p. 395
Ankur Jhanwar, Ashok Kumar Sokhal, Kawaljit Singh, Satyanarayan Sankhwar, Durgesh Kumar Saini
DOI:10.4103/UA.UA_34_17  
Context: Clean intermittent catheterization (CIC) after direct vision internal urethrotomy (DVIU) Aims: The aim is to assess the quality of life (QOL) in patients with urethral strictures on CIC following DVIU. Settings and Design: Prospective study. Materials and Methods: This prospective study was conducted between August 2013 and July 2015 in the Department of Urology at KGMU, Lucknow. We included patients above the age of 18 years with stricture urethra, who were on CIC following direct visual internal urethrotomy. Patients below the age of 18 years, noncompliance, concomitant neurogenic voiding dysfunction, multiple strictures, pan anterior strictures, and posterior stenosis were excluded from the study. A 16 French Foley catheter was used for CIC following DVIU. Patients were evaluated at follow-up visit at 3, 6, and 12 months. At each follow-up visits, patients were assessed using CIC-QOL questionnaire, maximum urine flow rate and complications related to CIC if any. Statistical Analysis Used: Unpaired t-test was used to compare continuous data, and Fisher's exact test was used to analyze categorical data. Results: Among total 144 male patients evaluated, we included 97 patients, who underwent DVIU. Mean age of the study population was 37.7 ± 14.03 years. Most urethral strictures were idiopathic (64.02%) followed by postinflammatory (24.25%). A significant number of patients reported difficulty in performing CIC, which hampered daily activities. No major procedure related complications were reported. Patients who were compliant to CIC reported no stricture recurrence till 6 months follow-up. Conclusions: CIC following DVIU remains a reasonable adjunctive option. All the parameters of CIC-QOL questionnaire had improved on continuing CIC. Young men on CIC had greater impairment of QOL when compared to aged patients.
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Retroperitoneoscopic partial nephrectomy for renal cell carcinoma: A single-center Indian experience p. 400
Suresh Kumar, Pranjal R Modi, Bipin C Pal, Vivek Kothari, Amit Mishra
DOI:10.4103/UA.UA_20_18  
Objective: Retroperitoneoscopy, by avoiding peritoneal breach and injury to intra-abdominal organs, provides a more direct and rapid access to the kidney and the renal hilum. Laparoscopic partial nephrectomy by retroperitoneal route (LPNR) is less commonly performed than transperitoneal route for early stage renal cancer. The objective of this study is to carry out the outcomes of partial nephrectomy using retroperitoneal approach. Materials and Methods: Patients, who underwent LPNR from period 2008 to 2014, were retrospectively analyzed. Outcomes of interest included demographic data, preoperative data, perioperative variables, surgical complications, recurrence of disease, and mortality, if any, during their follow-up. Results: Among 24 patients, 16 were male, and 8 were female. Mean age and mean body mass index, respectively, were 49.16 years (range: 25–75) and 25.35 kg/m2 (17.84–34.25). Among renal masses, the right-sided to left-sided distribution was 13:11. The proportions of low-risk and intermediate-risk nephrometry score (NS) cases were 13 (54.17%) and 11 (45.83%), respectively, as assessed by renal NS. Mean operative duration, mean warm ischemia time, mean estimated blood loss, and mean hospital stay, respectively, were 132.5 min (90–170), 21.83 min (15–44), 106 ml (25–300) ml, and 5.25 days. During the postoperative period, complications encountered were lung atelectasis in one, bleeding in two, and urinary leakage in one. Histopathology revealed malignancy in 23 patients and leiomyoma in the remaining one. All patients but two experienced a disease free survival during a median follow- up period of 33 months. Conclusion: Overall outcomes for LPNR is comparable to the outcomes for open and transperitoneal laparoscopic partial nephrectomy mentioned in the literature and is equally safe for the right-sided and left-sided lesions.
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CASE REPORTS Top

A case of splenogonadal fusion accompanied by accessory spleen in a 4-year-old boy p. 406
Aria Shakeri, Arash Shakeri, Reza Rasolmali, Saeed Shakeri
DOI:10.4103/UA.UA_194_17  
Splenogonadal fusion (SGF) is a rare benign malformation in which spleen is aberrantly attached to the gonads or mesonephric derivatives. This entity often presents with scrotal mass, inguinal hernia, or cryptorchidism. Herein, we report our experience with a boy who presented with a scrotal enlargement which later turned out to be SGF. Moreover, an accessory spleen was unexpectedly found in the left inguinal canal. To the best of our knowledge, this is the first report of SGF and accessory spleen in the literature. Although rare, SGF should be included in the complete differential diagnosis list of scrotal masses, especially in children. The use of frozen section pathology if available would aid the surgeon in avoiding unnecessary orchiectomy in small testicular masses of benign origin.
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Extracorporeal shock wave lithotripsy for bilateral renal stones: A case report with serious complications that could be avoided p. 409
Mohamed Mohamed Elawdy, Samer El-Halwagy, Salim Al-Khanbashi, Anas Akbar Aga, Yasser A Razek
DOI:10.4103/UA.UA_69_18  
22-year-old male patient with irrelevant medical history presented with bilateral renal stones; multiple stones in right renal pelvis measured 10, 11, and 11mm and another one on the left side measured 12mm. Extra corporeal shock wave lithotripsy (ESWL) was done first on the left side, but after 400 shocks and total energy of 20 Storez Medical Lithotripsy Index only, the stone wasn't visible. Then, the operator switched to the right side and a he completed the session. A day after, the patient presented with bilateral renal colic, gradual rising of renal function and imaging showed bilateral steinstrasse with bilateral hydroureteronephrosis. Patient was managed with insertion of bilateral ureteric stents and had another session of ESWL on the right side. We concluded that bilateral simultaneous ESWL for bilateral renal stones doesn't affect the renal function on the long-term outcome, but still carries the risk of bilateral obstruction and acute renal injury.
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Primitive neuroectodermal tumor transformation of testicular teratoma p. 413
Anastasios Karatzas, Vasileios Papadopoulos, Vagianna Katsiouli, Louis Pisters, Christos Papandreou, Vassilios Tzortzis
DOI:10.4103/UA.UA_182_17  
Malignant transformation of teratoma develops in a small subset of testis cancer patients. Primitive neuroectodermal tumor represents a highly malignant component of testicular germ cell tumors. It is a rare clinical entity which is characterized by a high risk of disease progression and death. Surgical resection plus chemotherapy appears to be the therapy of choice.
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Extragastrointestinal stromal tumor of prostate p. 416
Sarah A Almagharbi, Yara A Fayoumi, Taha A Abdel-Meguid, Ahmed Abdelsalam, Rana Y Bokhary, Raed A Azhar
DOI:10.4103/UA.UA_26_18  
Gastrointestinal stromal tumors (GISTs) that originate outside the GI tract are extremely uncommon. In this case report, we describe a GIST of primary origin in the prostate gland of an 84-year-old male who presented with severe urinary retention at King Abdulaziz University Hospital in Saudi Arabia. Diagnosis was based on patient history, radiological studies, pathologic findings, and immunohistochemical data. Digital rectal examination revealed a hugely enlarged prostate encroaching upon the rectal lumen with a smooth and firm surface. Transrectal ultrasound showed a markedly enlarged prostate with an estimated volume of 360 ml; prostate-specific antigen was 5.4 ng/ml. Immediate preoperative cystoscopy demonstrated only a moderate enlargement of the prostate, which was disproportionate to its actual size. Postoperative abdominal computed tomography showed residual prostatic tissue with an estimated weight of 78 g, multiple diffuse colonic diverticulosis, and scattered subcentimeter mesenteric lymph nodes. Histopathological examination of the prostatic tissue showed cellular spindle cell neoplastic proliferation which was diffusely positive for CD117 (c-kit), DOG1, and CD34. GISTs must be considered in the differential diagnosis of spindle cell tumors detected in the prostate.
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COMMENTARY Top

Fosfomycin for management of persistent female lower urinary tract infection p. 420
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/0974-7796.243209  
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INVITED COMMENTARY Top

Isolated native renal hydatidosis in a renal transplant patient: The case for an aggressive approach p. 421
Muhammed Mubarak
DOI:10.4103/0974-7796.243205  
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