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   Table of Contents - Current issue
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July-September 2020
Volume 12 | Issue 3
Page Nos. 205-299

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REVIEW ARTICLE  

Novel imaging in prostate cancer Highly accessed article p. 205
Orestis Porfyris, Abdulrahman Al-Awon, Evangelos Liatsikos, Panagiotis Kallidonis
DOI:10.4103/UA.UA_37_20  
Imaging of prostate cancer (Pca) presents many challenges as imaging tools aim to improve cancer detection, assessment in biochemical relapse, and disease progression in advanced metastatic stages. Current imaging modalities have strengths but also weaknesses, such as the lack of ability to diagnose micrometastases, to differentiate significant from nonsignificant cancer, and to diagnose advanced disease at low prostate-specific antigen values. Some of the modalities appear promising in increasing the sensitivity and specificity rate, particularly in recurrent and advanced disease (e.g., prostate-specific membrane antigen–positron emission tomography). Others can prove valuable in delivering focal therapy for Pca. Finally, the combination of two modalities could provide improved results in the diagnosis of Pca. Despite promising results, most guidelines still recommend traditional imaging modalities, such as 99mTc bone scintigraphy and computed tomography, for the estimation of metastatic spread in bones and lymph nodes, and the routine use of the novel techniques is not considered. Prospective studies clarify the value of the modalities and determine their role in clinical practice.
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ORIGINAL ARTICLES Top

Study of ureteral and renal morphometry on the outcome of ureterorenoscopic lithotripsy: The critical role of maximum ureteral wall thickness at the site of ureteral stone impaction Highly accessed article p. 212
Amit Kumar Mishra, Santosh Kumar, Lalgudi Narayan Dorairajan, Ramanitharan Manikandan, G Ramkumar, KS Sreerag, Jayesh Kumar Mittal
DOI:10.4103/UA.UA_95_19  
Purpose: The purpose is to study the association of stone, ureteral, and renal morphometric parameters with the relevant outcome variables, i.e., complication rate, stone-free rate (SFR), and operating time of ureterorenoscopic lithotripsy. Although a safe procedure, it still occasionally has major complications. Computed tomography (CT) scan is often performed to diagnose ureteral calculi, providing opportunities for ureteral morphometry that may have a bearing on the outcome of the procedure. Materials and Methods: Ureteric, renal, and stone morphometric parameters were measured from CT of the abdomen and pelvis of the 110 patients with ureteral calculi who underwent ureteroscopic lithotripsy (URSL). Data were collected retrospectively in 25 patients and prospectively in 85 patients. Association of these parameters with the outcome variables of the procedure mentioned above was studied. Results: On univariate analysis, body mass index, stone size, and maximum ureteral wall thickness (MUWT) were found to have a significant association with URSL complications, SFR, and duration of surgery. On multivariable analysis, only MUWT was found to be an independent risk factor for URSL complications. In 90% of total patients with residual stones, MUWT was found to be >4.8 mm. Conclusion: Ureteral wall thickness of >4.8 mm is associated with prolonged duration of surgery and lower SFR. Patients with ureteral wall thickness of >4.8 mm at the site of ureteral stone who are planned for URSL must be counseled about the higher chances of residual stones and the need for additional procedure.
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The perception and competency of undergraduates in urology: Is the clinical exposure necessary? p. 220
Abdulmalik M Addar, Manerh A Bin Mosa, Ali S Alothman, Abdulrahman Alabdulkareem, Fares Al Jahdali, Sultan S Alkhateeb
DOI:10.4103/UA.UA_39_19  
Objective: The objective of this study is to investigate medical students' perception, choices of future career, and competency in urology. Methods: A cross-sectional survey was distributed among 5th, 6th, and 7th (interns) year medical students at King Saud bin Abdulaziz University for Health Sciences using both hard copies and soft copies. Major outcomes were medical students' perception, future career decision, and core skills in urology. Results: The overall response rate was 51.3%. A total number of 163 responses (122 were males and 41 females) were collected. Only 8% indicated that they would pursue a surgical career in urology and 42% thought that they had received a good clinical exposure to urology. Of the participants, 67.5% viewed urology as a male-dominated field. Only 17% of the respondents either agreed or strongly agreed that they were considering a future career in urology. Female students were less likely to consider a urological career (P < 0.01). About 32.5% were confident at urethral catheterization. About 66.9% felt that a workshop day to enhance urological skills and knowledge will be beneficial. Females were more confident at assessing a urological case in an acute setting (P < 0.05). Conclusion: Most of the students agreed that their urology exposure was inadequate and their confidence at urethral catheterization was low. As in many different global studies, urology is still regarded as a specialty with a male dominance. This report is consistent with the global decline in formal urological education.
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Management of urolithiasis in patients with chronic kidney disease p. 225
Vikram P Satav, Sonu Sharma, Rohit Kapoor, Vilas P Sabale, Avreen Singh Shah, Ashwani Kandari
DOI:10.4103/UA.UA_122_19  
Context: Management of urolithiasis in patients with chronic kidney disease. Aims: To ascertain the best method surgical or noninvasive. Settings and Design: This was a single-institute study. Subjects and Methods: A total of 50 patients of CKD with urolithiasis were enrolled in this comparative study. Clinical evaluation, biochemical evaluation, and radiological imaging were done. The management strategies were individualized to patient need. Following procedure, imaging and biochemical assessment were done to assess the stone clearance and improvement in the renal parameters. Intraoperative and postoperative complications are also noted. The patients were followed up to 6 months. Statistical Analysis Used: Statistical Package for the Social Sciences version 21.0 software was used for statistical analysis. Results: The mean age of the patients was 55.22 ± 10.76 years (range 28–76). Majority were male (76%) and had unilateral involvement. The mean preoperative hemoglobin (Hb), urea, creatinine, and total leukocyte count (TLC) were 9.49 ± 0.84 g%, 71.13 ± 24.09 mg/dl, 4.71 ± 2.45 mg/dl, and 8.67 ± 1.81 thousands/cumm, respectively. Percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (URSL) were the most common procedures performed in 23 (46%) and 12 (24%) patients, respectively. In 5 (10%) patients, PCNL with URSL was used. The clearance rate for different techniques ranged from 40% (PCNL with URSL) to 91.7% (URSL alone). The overall clearance rate was 78.3%. Fever (40%) and deranged renal function test requiring hemodialysis (16%) were the most common postoperative complications. Postoperatively, a significant decline in the mean Hb, serum (S.) urea, and S. creatinine was observed. The mean TLC levels showed a significant increase. During follow-up, S. creatinine levels showed consistent decline. Auxiliary procedures were needed in six (12%) cases. There were two (4%) mortalities. Conclusions: The management of urolithiasis among CKD patients requires individualized approaches. The selection of appropriate strategy results in good outcome and minimum complications.
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A comparative study of robot-assisted laparoscopic intracorporeal versus open urinary diversion p. 229
Mahmoud I Khalil, Ehab Eltahawy, Jonathan Bauer-Erickson, Ahmed Farouk, Sherif Mourad, Rodney Davis, Mohamed H Kamel
DOI:10.4103/UA.UA_54_19  
Aims: Robot-assisted laparoscopic intracorporeal urinary diversion (ICUD) has several potential benefits of a smaller incision and reduced pain over extracorporeal urinary diversion (ECUD). We compared the perioperative outcomes of patients who have undergone these procedures with or without cystectomy. Subjects and Methods: This study is a retrospective chart review of patients who underwent ICUD and ECUD in a single tertiary referral hospital. Patient demographics, perioperative outcomes, and the 90-day postoperative complications were collected. Statistical Analysis Used: The statistical analyses were performed using the Chi-square test for categorical variables which are specified as frequency (percentage). Results: Thirty-five patients who underwent urinary diversion procedure were identified for inclusion in the study. Of these patients, 14 underwent ICUD and 21 underwent ECUD. The mean operative time was longer in the ICUD group compared to that of the ECUD (457.14 ± 103.91 and 388.29 ± 110.17, respectively, P = 0.07). The median blood loss was statistically significantly lower in the ICUD group (250 ml) than in the ECUD group (450 ml, P = 0.05). The mean hospital stay was marginally longer for the ECUD group (8.1 days) as compared to the ICUD group (6.3 days, P = 0.17). There was no difference in the readmission or reoperation rates after 30 days. The 90-day complication rate was not statistically significantly different between the two groups, but a trend favoring ICUD (64%) over ECUD (71%,P= 0.656) was noted. Conclusions: Robot-assisted ICUD is associated with decreased blood loss, and there is a trend toward fewer postoperative complications and shorter hospital stays.
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Differentiation of renal cell tumors with morphological cocktails using a minimal panel of immunohistochemical markers p. 236
B Vishal Rao, Tejomayi Regulavalasa, Daphne Fonseca, Sudha S Murthy, Rakesh Sharma, K V. V. N. Raju, T Subramanyeshwar Rao, Challa Sundaram
DOI:10.4103/UA.UA_131_18  
Context: Morphological cocktails in renal cell carcinoma (RCC). Aims: Minimal immunohistochemistry (IHC) panel to resolve the diagnosis of renal cell cacinoma (RCC) with morphological overlaps. Settings and Design: RCC is the most common malignancy in kidney accounting for 90% of all kidney cancers. Clear cell RCC is the most common histological type followed by papillary RCC. However, many of the RCCs show morphological cocktails which may pose diagnostic difficulties in small biopsies and even in the resection specimens. Accurate diagnosis has both prognostic and therapeutic implications; hence, correct differentiation is necessary. Subjects and Methods: This retrospective study includes all renal cell tumors diagnosed on core biopsies, radical and partial nephrectomies between January 2015 and September 2017 were studied. The demographic, clinical, and gross findings were noted. The cases that had morphological overlap among the subtypes were subjected to a panel of IHC markers, including CD10, CK7, alpha-methyl acyl-coenzymeA racemase (AMACR), and CD117. Results: There were 128 RCC in the study period, and morphological overlap was seen in 36 (27.9%) specimens including 13 core biopsies, 16 radical, and 7 partial nephrectomies. IHC resolved 35/36 (97.2%) cases rendering a diagnosis of clear cell (11), papillary (15), chromophobe (4), and oncocytoma (5). However, in one case where the provisional diagnosis was oncocytic tumor, all IHC markers were negative rendering IHC noncontributory. Conclusions: Difficulty in diagnosis was encountered in many core biopsies, resection specimens which when subjected to IHC panel of CD10, CK7, AMACR, and CD117 helped in resolving the diagnosis of subtypes of RCC.
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Epidemiology of parvovirus B19 and anemia among kidney transplant recipients: A meta-analysis p. 241
Charat Thongprayoon, Nadeen J Khoury, Tarun Bathini, Narothama Reddy Aeddula, Boonphiphop Boonpheng, Ploypin Lertjitbanjong, Kanramon Watthanasuntorn, Napat Leeaphorn, Supavit Chesdachai, Aldo Torres-Ortiz, Wisit Kaewput, Jackrapong Bruminhent, Michael A Mao, Wisit Cheungpasitporn
DOI:10.4103/UA.UA_89_19  
Background: Persistent anemia has been described in kidney transplant (KTx) recipients with parvovirus B19 virus infection. However, the epidemiology of parvovirus B19 and parvovirus B19-related anemia after KTx remains unclear. We conducted this systematic review (1) to investigate the incidence of parvovirus B19 infection after KTx and (2) to assess the incidence of parvovirus B19 among KTx patients with anemia. Materials and Methods: A systematic review was conducted in EMBASE, MEDLINE, and Cochrane databases from inception to March 2019 to identify studies that reported the incidence rate of parvovirus B19 infection and/or seroprevalence of parvovirus B19 in KTx recipients. Effect estimates from the individual studies were extracted and combined using random-effects, generic inverse variance method of DerSimonian and Laird. The protocol for this systematic review is registered with PROSPERO (no. CRD42019125716). Results: Nineteen observational studies with a total of 2108 KTx patients were enrolled. Overall, the pooled estimated seroprevalence of parvovirus B19 immunoglobulin G was 62.2% (95% confidence interval [CI]: 45.8%–76.1%). The pooled estimated incidence rate of positive parvovirus B19 DNA in the 1st year after KTx was 10.3% (95% CI: 5.5%–18.4%). After sensitivity analysis excluded a study that solely included KTx patients with anemia, the pooled estimated incidence rate of positive parvovirus B19 DNA after KTx was 7.6% (95% CI: 3.7%–15.0%). Among KTx with anemia, the pooled estimated incidence rate of positive parvovirus B19 DNA was 27.4% (95% CI: 16.6%–41.7%). Meta-regression analysis demonstrated no significant correlations between the year of study and the incidence rate of positive parvovirus B19 DNA (P = 0.33). Egger's regression asymmetry test was performed and demonstrated no publication bias in all analyses. Conclusion: The overall estimated incidence of positive parvovirus B19 DNA after KTX is 10.3%. Among KTx with anemia, the incidence rate of positive parvovirus B19 DNA is 27.4%. The incidence of positive parvovirus B19 DNA does not seem to decrease overtime.
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Pattern and outcome of management of Fournier's gangrene in a resource-constraint setting p. 248
Ngwobia Peter Agwu, Abubakar Sadiq Muhammad, Abdulwahab-Ahmed Abdullahi, Bello Bashir, Jacob Ndas Legbo, Ismaila Arzika Mungadi
DOI:10.4103/UA.UA_62_19  
Introduction: Fournier's gangrene (FG) is a necrotizing fasciitis of the external genitalia and perineum but may involve upper thigh and anterior abdominal wall. Patients and Methods: This is a retrospective study of 47 patients managed for FG at Usmanu Danfodiyo University Teaching Hospital from January 2001 to June 2017. Data were entered into a semi-structured pro forma and analyzed using SPSS version 20.0. Results: The mean age of the patients was 42.7 ± 19.4 years, with age range of 7 weeks to 72 years. All the patients were male. The patients had underlying urologic conditions in 27.6%, 15.0% were postoperative, 4.2% had anorectal diseases, 10.6% had medical conditions, and 42.6% were idiopathic. After resuscitation, all the patients had serial debridement, Hypertonic saline bath, broad spectrum antibiotics and wound dressing. The wound healed by secondary intention in 34.0% and 32.3% of the patients had wound closure ± skin graft. The treatment was successful in 68.0% of the patients, 15.0% left against medical advice, and 17.0% died of severe sepsis. Conclusion: FG mainly affects men with existing urologic conditions in our environment. Aggressive debridement, hypertonic saline sitz bath, broad-spectrum antibiotics, and appropriate wound care are associated with good outcome.
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Outcomes of percutaneous nephrolithotomy in elderly versus young patients under regional anesthesia: A comparative study p. 254
Rahul Gupta, Arti Mahajan
DOI:10.4103/UA.UA_69_19  
Introduction: Surgical management of elderly patients with renal calculi is inherently challenging. We compared the efficacy and safety of percutaneous nephrolithotomy (PCNL) performed under regional anesthesia between elderly patients (age >65 years) and patients aged <65 years. Materials and Methods: Between July 2015 and June 2016, fifty patients aged >65 years with renal stones (size >1.5 cm) were treated with PCNL under regional anesthesia (elderly group). We retrospectively compared the outcomes with those obtained in an equal number of patients aged <65 years (younger group) who underwent PCNL under regional anesthesia. Patients with staghorn stones and pyonephrosis and falling under the American Society of Anesthesiologists (ASA) Grade IV were excluded. Data pertaining to demographic characteristics, body mass index, stone bulk, operative time, tract size, number of tracts required, blood loss, clearance rates, complications, and length of hospital stay were analyzed. Results: The mean age at presentation in the elderly and younger groups was 66.8 ± 2.1 years and 38.7 ± 11 years, respectively; 56% of the patients in the elderly age group had ASA Grade II, whereas 58% in the younger age group had ASA Grade I. The mean stone size and the number of tracts were comparable in both the groups, whereas operative time was slightly longer in the elderly group (58.54 ± 18 vs. 51.98 ± 18 min;P < 0.05). Postoperative complications and stone-free rates (94% vs. 92%, respectively) were comparable in the two groups. Conclusions: Age itself should not deter the treatment of elderly patients with renal stones as PCNL under regional anesthesia is safe and effective in elderly patients; outcomes in elderly and younger patients were comparable in this study.
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Objective assessment of mouth opening after buccal mucosal graft urethroplasty: A prospective study p. 259
Kaushal Patel, Jaisukh Kalathia, Venkatesh Krishnamoorthy
DOI:10.4103/UA.UA_84_19  
Introduction and Objectives: Buccal mucosal graft (BMG) is frequently used for the reconstruction of urethral strictures with acceptable donor-site morbidity after graft harvest. There are only a few prospectively designed studies with a small number of patients reporting oral complications, particularly the mouth opening in the long terms. We did an objective assessment of mouth opening before and after 6 months of BMG urethroplasty as well as pain scores. Materials and Methods: Fifty-eight patients who underwent BMG urethroplasty were included in the study between May 2013 and December 2014. Preoperative mouth opening (reference point between two incisors with the highest of three readings taken as final) was measured using a Vernier caliper. Harvest site was left open to heal by secondary intentions. Postoperatively, mouth opening and pain scores using self-administered (Visual Analog Scale [VAS]) assessed on day 1 and day 3, and follow-up at 1 week, 1 month, and 6 months. Data were analyzed as mean (standard deviation [SD]), proportion, and median (inter-quartile range [IQR]) with two-tailedP < 0.05 as statistically significant. Results: The mean age was 39.6 years. The graft was harvested from a single cheek in 50% of patients. In remaining, it was taken from both cheeks, both cheeks with lip, and both cheeks with the tongue in 29.31%, 17.24%, and 3.5%, of patients, respectively. Preoperative mouth opening (5.13 cm [0.08]) was statistically significantly more than mouth opening on day 1 (4.34 cm [0.09]), day 3 (4.48 [0.09]), and day 7 (4.69 cm [0.09]). Mean difference became insignificant at the interval of 1 month (4.91 cm [0.09]) with 6 months' values showing marginal improvement over preoperative values (5.14 cm [0.07]). Pain was tolerable and patients reported low median VAS 2 (2–4) on day 1 and day 3 each. Reported median VAS became 0 (0–0) on day 7. Conclusion: Mouth opening restriction after BMG urethroplasty is a definite entity in the initial postoperative period, which becomes nonsignificant by 6 months. The pain has no effect on mouth opening.
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Recipient outcomes in total laparoscopic live donor nephrectomy with multiple renal vessels p. 266
John Fitzpatrick, Jakub Chmelo, Arjun Nambiar, Oliver Fuge, Toby Page, Gourab Sen, Naeem Soomro, David Rix, Alistair Rogers, David Talbot, Rajan Veeratterapillay
DOI:10.4103/UA.UA_96_19  
Introduction: In kidney transplantation, total laparoscopic live donor nephrectomy (TLLDN) in the presence of multiple renal arteries (MRA) is technically challenging and has traditionally been associated with higher complication rates. We report our experience of using MRA grafts procured by TLLDN. Materials and Methods: Patients undergoing TLLDN at our center (2004–2014) was identified from a prospectively maintained database and divided into single renal arteries (SRA) or MRA groups. Recipient perioperative parameters, postoperative complications, and long-term graft survival were analyzed. Results: Of 465 patients, 106 had MRA and 359 had an SRA. There were six vascular complications in the SRA group and two in the MRA group (1.7% vs. 1.8%). There were eight ureteric complications requiring intervention in the SRA group compared to three in the MRA group (4% vs. 3%; P = 0.45). Acute rejection was observed in 12% of the SRA group compared to 9% in the MRA group (P = 0.23). One-, 5- and 10-year graft survivals were 98.2%, 91.3%, and 89.8% in the MRA group versus 98.0%, 90.4%, and 77.5% in the SRA group (log-rank P = 0.13). Conclusion: The use of MRA grafts procured by TLLDN has comparable complication rates to SRA grafts and should not preclude selection for renal transplantation.
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Relation of baseline prostate volume to improvement of lower urinary tract symptoms due to tamsulosin monotherapy in benign prostatic hyperplasia: An exploratory, multicenter, prospective study p. 271
Mahmoud Shoukry El-Adawy, Ahmed Yehia Abdelaziz, Ahmed Salem, Waseem Aboul Ela, Ayman Salah Moussa, Rabee Ibrahim, Fouad Zanaty, Mohamed H Abdelhamid, Hussien Aldaqadossi, Ahmed M Ragheb, Hossam A Shaker, Sameh Kotb
DOI:10.4103/UA.UA_91_19  
Aims: The aim of the study was to investigate the relation between baseline prostate volume (PV) and the improvement of lower urinary tract symptoms (LUTS) induced by tamsulosin monotherapy after 2-year follow-up in Egyptian benign prostatic hyperplasia (BPH) patients. Settings and Design: This was a prospective comparative multicenter study. Subjects and Methods: Three hundred and eighty-one BPH patients were included in the study from January 2014 to January 2017. The patients were divided according to their PV into two groups. Group A included patients with small-sized prostate (≤40 ml) and Group B included those with PV larger than 40 ml. Full evaluation was done at presentation. The patients are followed up at 6, 12, and 24 months of continued medical treatment with tamsulosin 0.4 mg once daily. Statistical Analysis Used: Data were coded and entered using the Statistical Package for the Social Sciences version 24. Data were summarized using mean and standard deviation in quantitative data. Comparisons between quantitative variables were done using unpaired t-test or the nonparametric Mann–Whitney test. A comparison between paired measurements in the same person was done using paired t-test (Chan, 2003).P < 0.05 was considered as statistically significant. Results: The mean age was 60.1 ± 7.2 years. The mean value of the International Prostate Symptom Score (IPSS) was recorded for the 381 patients at presentation. In Group A, the mean value of IPSS was 20.44 ± 3.18, whereas in Group B, the mean value of IPSS was 21.23 ± 3.5. There was a significant improvement in symptoms (Qmax-IPSS) in both groups, but we found that this improvement was significantly better in Group A (P = 0.017). Conclusions: PV is an important prognostic factor affecting the improvement of the LUTS by α1-blocker monotherapy. Tamsulosin monotherapy may not be enough for large prostate (>40 mg) to maintain adequate symptom relief, and it is better to start with other medical options such as combined therapy or early nonmedical therapy. Starting α1-blocker monotherapy in smaller prostates may be of benefit in symptomatic patients without considering watchful waiting.
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Prospective evaluation of using multiparametric magnetic resonance imaging in cognitive fusion prostate biopsy compared to the standard systematic 12-core biopsy in the detection of prostate cancer p. 276
Li Yi Lim, Guan Hee Tan, Zulkifli Md Zainuddin, Xeng Inn Fam, Eng Hong Goh, Othman Syazarina Syaris, Azyani Yahaya, Praveen Singam
DOI:10.4103/UA.UA_98_19  
Purpose: There is mounting evidence to suggest that multiparametric magnetic resonance imaging (mpMRI)-guided biopsy is better than systematic biopsy for the diagnosis of prostate cancer (PCa). Cognitive fusion biopsy (CFB) involves targeted biopsies of areas of suspicious lesions noted on the mpMRI by transrectal ultrasound (TRUS) operator. This study was undertaken to determine the accuracy of mpMRI of the prostate with Prostate Imaging–Reporting and Data System (PI-RADS) version 2 in detecting PCa. We also compare the cancer detection rates between systematic 12-core TRUS biopsy and CFB. Materials and Methods: Sixty-nine men underwent mpMRI of the prostate followed by TRUS biopsy. In addition to 12-core biopsy, CFB was performed on abnormal lesions detected on MRI. Results: Abnormal lesions were identified in 98.6% of the patients, and 59.4% had the highest PI-RADS score of 3 or more. With the use of PI-RADS 3 as cutoff, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI for the detection of PCa were 91.7%, 57.8%, 53.7%, and 92.8%, respectively. With the use of PI-RADS 4 as cutoff, the sensitivity, specificity, PPV, and NPV of mpMRI were 66.7%, 91.1%, 80%, and 83.7%, respectively. Systematic biopsy detected more PCa compared to CFB (29% vs. 26.1%), but CFB detected more significant (Gleason grade ≥7) PCa (17.4% vs. 14.5%) (P < 0.01). CFB cores have a higher PCa detection rate as compared to systematic cores (P < 0.01). Conclusions: mpMRI has a good predictive ability for PCa. CFB is superior to systematic biopsy in the detection of the significant PCa.
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CASE REPORTS Top

Solitary incidental primary Kaposi's sarcoma of the glans penis in a patient with no risk factors p. 283
Abdulaziz Baazeem
DOI:10.4103/UA.UA_172_19  
Kaposi's sarcoma (KS) is an endothelial neoplasm, originally reported by Moritz Kaposi in 1872. It most commonly involves the lower extremities. Its clinical presentation and course can be quite variable. We present a rare case of solitary incidental primary KS of the glans penis in a circumcised, immunocompetent male who is human immunodeficiency virus seronegative. The lesion was discovered incidentally when the otherwise asymptomatic male presented to our outpatient department for an unrelated issue and was given a physical examination. To our knowledge, this is the first incidentally discovered case of primary penile KS.
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Bladder teratoma with pilimiction in a male adolescent p. 286
Ankit Vaishnav, Debansu Sarkar, Dilip Kumar Pal
DOI:10.4103/UA.UA_125_19  
Teratomas are tumors consisting of two or three germ layers, seen commonly during childhood. Mature teratomas are benign and demonstrate well differentiated tissues such as sebaceous glands, hair, and teeth. Bladder is a very rare extragonadal site for teratoma, moreover so in adults. Presentation may vary from with irritative lower urinary tract symptoms or urinary retention to pilimiction (passage of hair in the urine). We hereby present a case of mature teratoma of the urinary bladder, with a classical symptom of pilimiction, in a 22-year-old male patient, which to our knowledge is the first male case reported in the literature.
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The antegrade continence enema procedure in the setting of acute appendicitis p. 289
Dawn Deacy, Feargal Quinn
DOI:10.4103/UA.UA_174_18  
The antegrade continence enema (ACE), known as the ACE procedure, has gained popularity over the past two decades in the treatment of refractory fecal incontinence. This case report describes an acutely inflamed appendix being used for an ACE procedure. To my knowledge, this has not previously been documented in the literature.
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Mucinous cystadenomas of urachus: A case report and literature review p. 291
Arun Kumar Agnihotri, Vipul D Yagnik, Smriti Agnihotri, Bhargav Yagnik
DOI:10.4103/UA.UA_118_19  
Urachal epithelial neoplasms are rare tumors that arise from the vestiges of the urachus. Mucinous cystadenomas are considered as a benign glandular tumors of the urachus. Cystadenomas are commonly found in the ovary, appendix, and pancreas. Mucinous cystadenomas of the urachus are extremely rare in the urachus, and only nine cases reported so far. We reported the 10th case of Mucinous cystadenomas of the urachus detected incidentally at the time of diagnostic laparoscopy for investigation of genitourinary tuberculosis.
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Mixed epithelial and stromal tumor of the kidney treated with minimally invasive surgery p. 295
Can Aykanat, Seref Coser, Aynur Albayrak, Altug Tuncel
DOI:10.4103/UA.UA_163_19  
Mixed epithelial and stromal tumor of the kidney (MESTK) is a rare kidney tumor that tends to occur in middle-aged and older women and is characterized by a distinctive histological appearance. Most of them were incidentally detected. A 26-year-old female patient was referred to in our clinic due to intermittent left lower back pain for 2 months and left renal mass. Abdominal computed tomography showed a cystic enhanced heterogenic left renal mass about 5 cm in the largest diameter was extending from the renal pelvis to the ureter and causing gross hydronephrosis of the left kidney. The mass treated with transperitoneal laparoscopic nephroureterectomy and bladder cuff resection. Histopathological evaluation revealed MESTK. In our patient, MESTK successfully and without any complication be treated by minimally invasive surgery. We believe that the fact that the tumor can mimic the urothelial-cell carcinoma of the kidney in radiological appearance, as seen in our case, should be taken into consideration.
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LETTER TO EDITOR Top

Response to: Importance of time in management of fracture penis: A prospective study p. 298
Satyendra Persaud, Vijay Naraynsingh
DOI:10.4103/UA.UA_3_20  
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