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   Table of Contents - Current issue
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April-June 2018
Volume 10 | Issue 2
Page Nos. 123-236

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REVIEW ARTICLES  

Saudi oncology society and Saudi urology association combined clinical management guidelines for renal cell carcinoma 2017 p. 123
Abdullah Alsharm, Shouki Bazarbashi, Abdullah Alghamdi, Sultan Alkhateeb, Ali Aljubran, Ashraf Abusamra, Hulayel Alharbi, Mohammed Alotaibi, Mubarak Almansour, Hussein Alkushi, Imran Ahmed, Esam Murshid, Amin Eltijani, Danny Rabah
DOI:10.4103/UA.UA_175_17  
In this report, we update the previously published Saudi guidelines for the evaluation and medical and surgical management of renal cell carcinoma. It is categorized according to the stage of the disease using the tumor node metastasis staging system 7th edition. The recommendations are presented with supporting evidence level.
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Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for urothelial cell carcinoma of the urinary bladder 2017 p. 133
Hulayel Alharbi, Sultan Alkhateeb, Esam Murshid, Mohammed Alotaibi, Ashraf Abusamra, Danny Rabah, Mubarak Almansour, Abdullah Alghamdi, Ali Aljubran, Amin Eltigani, Hussein Alkushi, Imran Ahmed, Abdullah Alsharm, Shouki Bazarbashi
DOI:10.4103/UA.UA_176_17  
This is an update to the previously published Saudi guidelines for the evaluation and medical/surgical management of patients diagnosed with urothelial cell carcinoma of the urinary bladder. It is categorized according to the stage of the disease using the tumor node metastasis staging system, 7th edition. The guidelines are presented with their accompanying supporting evidence level, which is based on comprehensive literature review, several internationally recognized guidelines, and the collective expertise of the guidelines committee members (authors) who were selected by the Saudi Oncology Society and Saudi Urological Association. Considerations to the local availability of drugs, technology, and expertise have been regarded. These guidelines should serve as a roadmap for the urologists, oncologists, general physicians, support groups, and health-care policymakers in the management of patients diagnosed with urothelial cell carcinoma of the urinary bladder.
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Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for prostate cancer 2017 p. 138
Ali Aljubran, Ashraf Abusamra, Sultan Alkhateeb, Mohammed Alotaibi, Danny Rabah, Shouki Bazarbashi, Hussain Alkushi, Mubarak Al-Mansour, Hulayel Alharbi, Amin Eltijani, Abdullah Alghamdi, Abdullah Alsharm, Imran Ahmad, Esam Murshid
DOI:10.4103/UA.UA_177_17  
This is an update to the previously published Saudi guidelines for the evaluation and medical and surgical management of patients diagnosed with prostate cancer. Prostate cancer is categorized according to the stage of the disease using the tumor node metastasis staging system 7th edition. The guidelines are presented with supporting evidence levels based on a comprehensive literature review, several internationally recognized guidelines, and the collective expertise of the guidelines committee members (authors) who were selected by the Saudi Oncology Society and Saudi Urological Association. Local factors, such as availability, logistic feasibility, and familiarity of various treatment modalities, have been taken into consideration. These guidelines should serve as a roadmap for the urologists, oncologists, general physicians, support groups, and health-care policymakers in the management of patients diagnosed with adenocarcinoma of the prostate.
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ORIGINAL ARTICLES Top

Increased burden on metropolitan urological services: The era of the Australian National Emergency Access Targets (NEAT or the “4-h target”) Highly accessed article p. 146
Marlon L Perera, Neiraja Gnaneswaran, Matthew J Roberts, Nathan Lawrentschuk, Peter Ritchie, Steven TF Chan
DOI:10.4103/0974-7796.164843  
Background: The National Emergency Access Targets (NEAT) was introduced in Australia in 2011 and guides the clearance of presentations within 4-h of initial presentation from the Emergency Department (ED). We aim to assess the impact of the introduction of NEAT on acute urological services at a large metropolitan center. Methods: A retrospective cohort study was performed and data were collected from electronic patient management systems. The control group was represented by ED presentations between June and September 2011, 1 year prior to the introduction of NEAT. The two study groups consisted of ED presentations between June and September 2012 and 2013, respectively. Outcome measures included time to the ureteric stent and scrotal exploration, inpatient length of stay (IPLOS), out-of-hours operating, and hospital mortality rates. Results: Across the three study periods, a total of 76,935 patients were assessed by the EDs of the health service. 225 urological inpatient episodes were included across all periods with a trend showing increasing numbers of admissions (P = 0.003). For patients admitted under the urological service: Waiting room time and ED length of stay decreased significantly (P < 0.001). Proportion of operative cases decreased insignificantly (P = 0.275). Time from emergency presentation to emergency ureteric stent remained unchanged, however, proportions of procedures performed out-of-hours showed an increasing trend (P < 0.001). A significant increase in inter-unit transfer was observed, however, median IPLOS and mortality for operative and nonoperative cases remain unchanged. Conclusions: Concerning urological admissions, the implementation of NEAT has been associated with improvement in ED key performance indicators. Such changes have been correlated with reductions in operative cases and increases in out-of-hours emergency operating. Further research is required to evaluate the direct effect of NEAT on urological patient care.
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Incremental value of 68-gallium-prostate-specific membrane antigen positron emission tomography/computed tomography in patients with abnormal prostate-specific antigen and benign transrectal ultrasound biopsy p. 150
Manoj Gupta, Partha Sarathi Choudhury, Sudhir Rawal, Gurudutt Gupta
DOI:10.4103/UA.UA_55_17  
Introduction: Bladder outlet obstruction due to prostate enlargement is a common health problem in male and frequently investigated with prostate-specific antigen (PSA) and transrectal ultrasound (TRUS). TRUS-guided biopsy is critical to differentiate benign prostatic hyperplasia (BPH) or prostate cancer (PCa) even though it has been associated with false negative with reported 3%–16% incidence of PCa in BPH specimens. Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT), a targeted molecular imaging for PCa, has showed promising results in recurrence and staging. We analyzed its role in patients with abnormal PSA and benign TRUS biopsy. Material and Methods: Of 558 68Ga-PSMA PET/CT performed from July 2014 to February 2017, we found six patients with abnormal PSA (range 8.2–24.2 ng/ml, median: 13.3 ng/ml) with benign 12 cores TRUS biopsy as indication. These cases were reanalyzed in detail. Spearman's rank test was used entire correlation using SPSS version 21. Results: 68Ga-PSMA PET/CT showed mild diffuse tracer uptake in prostate in all patients with no focality and maximum standard uptake value normalized to body weight (SUVmax) range was 3.2-5.8 (median: 3.9). Two patients with PSA <10 ng/ml had normal 68Ga-PSMA PET/CT and underwent medical management. In other four patients with PSA >10 ng/ml, two showed metastatic disease in pelvic lymph node in both and in lung in one; hence, 68Ga-PSMA PET/CT changed these patients' management. Spearman's rank test showed no correlation with baseline PSA and SUVmaxof prostate (rs −0.0287, P = 0.9571) while strong positive correlation was seen with baseline PSA and 68Ga-PSMA PET/CT scan positivity for extraprostatic disease (rs = 0.828, P = 0.042). Conclusions: 68Ga-PSMA whole-body PET/CT can provide useful incremental information in patient with high PSA and negative TRUS biopsy and has a potential to guide management in this subgroup of PCa patients.
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Prospective study to evaluate the clinical outcome of intralesional interferon-α2b in the management of Peyronie's disease p. 154
Ashok Kumar Sokhal, Nilesh Kumar Jain, Ankur Jhanwar, Kawaljit Singh, Durgesh Kumar Saini
DOI:10.4103/UA.UA_65_17  
Context: Interferon (IFN)-α2b in Peyronie's disease (PD). Aims: This study aims to evaluate clinical efficacy of the IFN-α2b in both subjective and objective manner for the treatment of PD and compared with previously used intralesional verapamil in terms of cost-benefit analysis. Settings and Design: Prospective study. Materials and Methods: A prospective study conducted from January 2013 to July 2016 in the Department of Urology, Government Medical College, Kota, Rajasthan, India. We included patients with identifiable Peyronie's plaque with or without pain, curvature ranging between 30 and 90 degrees. We excluded patients with a calcified plaque and the ventral location of the plaque, any infective foci over the penis, erectile dysfunction due to other etiologies and patients who had received previous intralesional therapy. Patients were evaluated by clinical history, physical examination including plaque location, size, consistency, and penile curvature. Patients received intralesional IFN-α2b in a dose of 3 × 106 IU. Patients completed the visual analogue pain (VAS) score for pain, and International Index of Erectile Function-5 (IIEF-5) questionnaire at first visit as well as at follow-up of 1 month and 3 months. Statistical Analysis Used: Comparisons were performed using the paired Student's t-test and Chi-square tests as appropriate. Patient's objective and subjective clinical characteristics were described as a means (standard deviation). Results: We included 86 patients in this study. Patients had a mean age of 48.6 years, mean plaque volume 256 mm3, and disease duration of 15.2 years. After 1 month of treatment, there was a significant change in plaque volume 256–60.8 mm3; P < 0.01) and penile curvature 34.8–24.6°; P < 0.01). The patients reported significant improvement in pain score VAS and IIEF-5. Conclusions: IFN-α2b, as minimal invasive (intralesional) options for the treatment of PD, demonstrated significant improvement in plaque volume, penile curvature with minimal complications. Patients subjectively reported significant improvement in pain on erection and sexual activities. IFN-α2b and verapamil had an almost similar clinical outcome, but verapamil at much lower cost.
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Role of clinical and radiological parameters in predicting the outcome of shockwave lithotripsy for ureteric stones p. 159
Hemant Goel, Sumit Gahlawat, Malay Kumar Bera, Dilip Kumar Pal, Onam Aggarwal
DOI:10.4103/UA.UA_84_17  
Introduction: Shockwave-lithotripsy (SWL) provides a noninvasive and effective option for the management of ureteric calculi. Several factors may affect the success of SWL. Identification of these predictive factors will both increase the efficacy and decrease the cost. This study was designed to identify factors affecting the outcome of SWL for ureteral stones. Materials and Methods: This study was conducted from March 2012 to November 2014 in patients with solitary ureteric calculi who were managed with SWL. Data were analyzed to identify clinical and radiological factors associated with treatment outcome. Success after SWL was described as complete stone clearance or clinically insignificant residual fragments <3 mm at 3 months after SWL. Results: A total of 110 patients with ureteric calculi were divided into two groups depending on the outcome of SWL, Group A (successful - 76%) and Group B (failed - 24%). Stone size, Skin to stone distance (SSD), secondary signs of obstruction, and presence of double J (DJ) Stent, all were significantly associated with the outcome of SWL on univariate analysis. On multivariate analysis, stone size, hounsfield unit, SSD, and DJ stent were the independent factors affecting the outcome of SWL. On Receptor-Operator Characteristic curve analysis, a cutoff value of 8.2 mm for the stone size was found which best predicts a successful outcome, with a sensitivity of 54% and specificity of 96%. Conclusion: The findings of this study suggest that Stone size, SSD, the presence of DJ stent, and stone attenuation values are the significant factors that influence the outcome of SWL in patients with ureteral stones.
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Miniaturized percutaneous nephrolithotomy versus retrograde intrarenal surgery in the treatment of renal stones with a diameter <15 mm: A 3-year open-label prospective study p. 165
Sunil Mhaske, Mehul Singh, Abhirudra Mulay, Sharadkumar Kankalia, Vikram Satav, Vilas Sabale
DOI:10.4103/UA.UA_156_17  
Aim: The aim of this study is to compare the outcomes of miniaturized percutaneous nephrolithotomy (mini-perc) and retrograde intrarenal surgery (RIRS) in management of renal stones with a diameter <15 mm. Materials and Methods: This was an open-label prospective study that included a total of 80 cases underwent mini-perc (n = 40) and RIRS (n = 40) between July 2014 and August 2017. The primary outcome objective was stone-free rate, retreatment rate, complications, hospital stay, operative time, and reduction in hemoglobin level. Data were analyzed using SPSS version 16.0 Software. Results: Overall, 80 patients were enrolled in this study. The mean age was 40.12 and 38.20 years, and the mean stone size was 1.15 and 1.30 cm in mini-perc and RIRS group, respectively. Majority of the study participants were males. Overall, mini-perc and RIRS had stone clearance rates of 100% and 95.4%, respectively. Two patients required retreatment in RIRS group. The duration of hospital stay and the rate of complication was similar in both the groups. Operative duration was more in RIRS group. Decrease in hemoglobin level was more in mini-perc group. Conclusions: Results demonstrated that both modalities were associated with high stone clearance rates with minimal complications. RIRS was associated with less reduction in hemoglobin and could be used as standard treatment modality for small renal calculi.
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Primary urethral carcinoma: A Surveillance, Epidemiology, and End Results data analysis identifying predictors of cancer-specific survival p. 170
Ilija Aleksic, Soroush Rais-Bahrami, Michael Daugherty, Piyush K Agarwal, Srinivas Vourganti, Gennady Bratslavsky
DOI:10.4103/UA.UA_136_17  
Objectives: Primary urethral carcinoma (PUC) is rare, accounting for <1% of genitourinary malignancies. Current knowledge regarding is founded upon tertiary care centers reporting their experiences. We aim to identify factors predictive of outcomes using a nationwide registry database. Materials and Methods: The Surveillance, Epidemiology, and End Results-18 registries database was queried for cases of PUC ranging between 2004 and 2010. To identify PUC cases, ICD-O site code C68.0 was used as a filter, hence identifying PUC with histologic subtypes including urothelial carcinoma (UC), squamous cell carcinoma (SCC), and adenocarcinoma (AC). Tumor characteristics were compared using log-rank analysis, and survival outcomes were compared using Cox proportional hazards models. Results: A total of 419 PUC cases were identified, 250 (59.7%) male and 169 (40.3%) female patients. The most common histology in men was UC (134, 53.6%), followed by SCC (87, 34.8%) and AC (29, 11.6%). The most common histology in women was AC (79, 46.7%), followed by SCC (43, 25.4%) and UC (42, 24.9%). Log-rank analysis illustrated significant difference in cancer-specific survival (CSS) for T-stage, N-stage, M-stage, and stage of PUC with all histological variants combined (P < 0.001). Multivariate Cox proportional hazards model demonstrated that stage and age were significant for survival, with a risk ratio of 1.033 (95% confidence interval [CI], 1.020–1.046)/year of increased age (P < 0.001) and 3.71 (95% CI, 2.72–5.05) for patients with regional or distant spread. Conclusions: Knowledge of patient and tumor characteristics that influences survival is paramount in dictating management. The present study illustrates that age and stage are factors significantly associated with CSS in PUC.
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Outcome of anastomotic posterior urethroplasty with various ancillary maneuvers for post-traumatic urethral injury. Does prior urethral manipulation affect the outcome of urethroplasty? p. 175
Shahbaz Mehmood, Omer Abdulaziz Alsulaiman, Waleed Mohammad Al Taweel
DOI:10.4103/UA.UA_168_17  
Purpose: We present our success rate and complications of delayed anastomotic urethroplasty (DAU) in patients with post-traumatic posterior urethral injury. Materials and Methods: This was a retrospective study of patients aged ≥17 years that underwent DAU for post-traumatic posterior urethral injury during 2010–2014. Stricture length was measured by ascending and descending urethrogram. Success of procedure was considered when the patient was free of stricture-ralated obstruction and needed no further intervention. Primary group includes patients who underwent first time delayed urethroplasty while secondary group included patients who had some sort of urethral manipulation in local hospital. Results were analyzed using unpaired t-test, Chi-square test, binary logistic regression, Kaplan–Meier curves, and log-rank test. Results: Of the 80 male patients, 73 (91.25%) patients underwent primary DAU while 7 (8.75%) patients had secondary DAU. Median age, stricture length, and follow-up were 27.0 ± 12.7, 1.6 ± 0.9, and 3.2 ± 0.9, respectively. Overall, success rate was 83.75% while success rate in primary group was 89.04% and secondary group was only 28.57% (P = 0.0059). Regarding ancillary maneuvers, urethral mobilization alone was done in 29 (36.25%) patients with success rate (72.41%), corporeal body separation in 36 (45%) patients with success rate (91.66%), inferior wedge pubectomy in 13 (16.25%) with success rate (84.61%), supracrural rerouting in 1 (1.25%) with success rate (100%), and abdominoperineal approach in 1 (1.25%) with success rate of 100% (P = 0.193). Patients who had prior urethral manipulation affect the outcome of definitive anastomotic urethroplasty. Conclusion: DAU has durable success rate with less morbidity. Ancillary elaborated maneuvers are frequently needed in patients with complex and elongated post-traumatic posterior urethral defect with successful outcome.
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Clinical, radiological, cytological, and microbiological assessment of painful extratesticular lesions p. 181
Vivek Agrawal, Ashesh Kumar Jha, Devender Dahiya
DOI:10.4103/UA.UA_62_17  
Introduction: Most of the painful extratesticular scrotal lesions are erroneously diagnosed and treated in our clinical practice. Therefore, this study was undertaken to analyze the usefulness of a combination of clinical, radiological, cytological, and microbiological assessment in establishing the accurate diagnosis of this lesion. Aim: To study the Clinical, Radiological, Cytological and Microbiological assessment of painful extra-testicular lesions and their correlation with each other in establishing the accurate diagnosis of these lesions. Objectives: The objectives of the study were to assess the diagnostic significance of clinical, radiological, cytological, and microbiological methods and their correlation in establishing the accurate diagnosis of painful extratesticular lesions. Materials and Methods: This cross-sectional study was carried out in Departments of Surgery, Radiology, Pathology, and Microbiology, University College of Medical Sciences and GTB Hospital over the period of 2 years. During this period, we were able to accommodate 75 patients in the study, who presented with pain and swelling in the scrotum and clinically found to have extratesticular swellings. Radiological assessment was done on the 1st day of visit, using Grayscale ultrasonography along with Color Doppler of these lesions. For cytological assessment, ultrasound-guided fine-needle aspiration cytology and microbiological assessment were done from the aspirate remaining after making cytology slide. Statistical Analysis: Data analysis was done using SPSS statistical software. Kappa statistics were used to find the degree of agreement or concordance between clinical, radiological, cytological, and microbiological findings. Results: Clinically 71 patients were found to have tender extratesticular swellings, whereas in four patients, these swellings were nontender on clinical examination. Radiologically, epididymitis was found in 32 patients. Only in 37 patients out of 75, a definite diagnosis could be made on cytology. The microbiological examination did not give any positive results. Conclusion: Painful extratesticular scrotal lesion often poses a diagnostic dilemma in the mind of treating physician. Clinical findings of these lesions may be corroborated through radiological, cytological, and microbiological assessment in an endeavor to arrive at a definitive diagnosis with a defined etiology.
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Long-term outcomes of sigmoid vaginoplasty in patients with disorder of sexual development – our experience p. 185
Ved Bhaskar, Rahul J Sinha, Seema Mehrotra, CN Mehrotra, Vishwajeet Singh
DOI:10.4103/UA.UA_88_17  
Introduction: To report our experience with sigmoid vaginoplasty in patients with different forms of disorder of sexual development and their long-term follow-up. Materials and Methods: This is a retrospective study of patients who underwent sigmoid vaginoplasty between July 2004 and June 2015 at our center. Follow-up included a physical examination to assess vaginal length and width, cosmetic appearance of the neovagina, and occurrence of any complications. Results: The current study included eight patients with mean age 19.5 years. The mean operative time was 164 min. No significant intraoperative or immediate postoperative complications occurred. Follow-up period ranges from 21 months to 12 years with mean of 7.5 years. In all patients, the neovagina was found to have a satisfactory cosmetic appearance. Seven patients are sexually active and satisfied. Conclusion: Sigmoid vaginoplasty is safe and acceptable procedure in patients having vaginal agenesis. Sigmoid vaginoplasty has acceptable cosmetic results and complication rate.
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Can preoperative clinicoradiological parameters predict the difficulty during laparoscopic retroperitoneal simple nephrectomy? – A prospective study p. 191
Sumit Gahlawat, Rajeev Sood, Umesh Sharma, Nikhil Khattar, Arif Akhtar, Praveen Kumar Pandey, Akhila Prasad, Swati Jain
DOI:10.4103/UA.UA_141_17  
Introduction: Urologists tend to prefer retroperitoneal approach for open nephrectomy and transperitoneal route for laparoscopic nephrectomy. Urologists consider retroperitoneal laparoscopic approach difficult to learn and perform. There is a need to objectively define predictors of difficulty during laparoscopic retroperitoneal simple nephrectomy (LRSN) for the proper preoperative selection. To the best of our knowledge, this is the first study to prospectively assess the factors associated with difficulty during LRSN. Materials and Methods: All adult patients of nonfunctioning kidneys (due to benign causes) planned for simple nephrectomies from November 2014 to January 2017 were included in the study. Various clinical and radiological parameters were noted along with intraoperative difficulty parameters (difficulty score, total operative time, and estimated blood loss). Renal and perirenal parameters were assessed and noted on computed tomography scan. Difficulty scale was calculated based on the three difficulty parameters and was used to objectively categorize the patients in easy and difficult group. Results: A total of 44 patients were included in the study. There were 23 patients in Group I (Easy) and 21 patients in Group II (Difficult). Various preoperative clinical and radiological parameters were analyzed and compared between these two groups. History of pyonephrosis and presence of nephrostomy tube were the only two statistically significant factors associated with difficult cases (Group II). None of the factors were statistically significant in multivariate analysis. Conclusion: Based on the findings of our study, history of pyonephrosis and presence of nephrostomy are the most significant factors predicting difficulty during LRSN.
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Knowledge and attitude about sexually transmitted diseases among youth in Saudi Arabia p. 198
Hossam S El-Tholoth, Fahad D Alqahtani, Abdullah A Aljabri, Khalid H Alfaryan, Fares Alharbi, Albaraa A Alhowaimil, Ali Alkharji, Abdulrahman Alrwaily, Ali Obied, Tala Al-Afraa
DOI:10.4103/UA.UA_14_17  
Background: Sexually transmitted diseases (STDs) are one of the most serious diseases in the world. Our aim was to explore the knowledge and attitude about STDs among the youth. Patients and Methods: This cross-sectional survey was conducted from August 1 to August 13, 2016. Male and female youth between 18 and 25 years were invited to participate in the survey using social media open to all Internet users consisting of questions and statements about STDs, and then the data were analyzed Results: We received 5040 responses to the survey; out of these participants 76.6% were females and 23.4% were males with a mean age 21.5 and most of them were single (85.1%). We noticed that most of the respondents selected the Internet (71.7%) as the main source of their knowledge about STDs followed by school, television, and others, respectively. In spite of, 94.08% knew that human immunodeficiency virus/AIDS is an STD, only 43.61% knew that herpes simplex virus is an STD, and only 31.03% knew that Chlamydia is an STD. A high percent (93.1%) agreed that sexual intercourse transmits STDs. Only 59.6% agreed that condom does not provide complete protection from STDs. To our surprise, only 55% considered themselves capable of protecting themselves against STDs. About 95.8% of the participants agreed that STDs should be taught in schools, while 4.2% disagreed. Conclusion: We noticed a lack of participant's knowledge regarding the types, mode of transmission, and the ways of protections from STDs and their desire to find out information about STDs. Hence, awareness programs about STDs should be started that aim at encouraging youth to follow our religion and culture.
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Incidence of metastasis and prostate-specific antigen levels at diagnosis in Gleason 3+4 versus 4+3 prostate cancer p. 203
Mohamed H Kamel, Mahmoud I Khalil, Wilson M Alobuia, Joseph Su, Rodney Davis
DOI:10.4103/UA.UA_124_17  
Aims: The aim is to assess for a difference in the incidence of metastasis (IM) and prostate-specific antigen (PSA) levels at diagnosis in patients with Gleason score (GS) 3+4 versus 4+3 prostate cancer using a large veterans affairs database. Subjects and Methods: A retrospective review of 1402 medical records from 5 VA hospitals was conducted. The study period was from 2009 to 2014. Primary endpoints were IM and PSA levels at diagnosis. A secondary endpoint was overall survival. Statistical Analysis Used: Chi-square tests for categorical variables, Student's t-test for continuous, normally distributed variables, and rank sum tests for continuous nonnormally distributed variables. Results: There were 1050 patients with GS3+4 and 352 with GS4+3. There were no differences in sociodemographic and clinical characteristics of the study population. PSA at the time of diagnosis was significantly higher in the GS4+3 patients compared to GS3+4 (18.0 vs. 11.4, respectively; P < 0.001). The IM at diagnosis was higher in the GS4+3 patients (10/352) compared to GS3+4 (9/1041) (2.8% vs. 0.9%; P = 0.005). In an adjusted model, GS4+3 was associated with higher PSA, higher IM at diagnosis. There was no difference in overall survival between the 2 groups though a 23% reduction in overall survival in the GS4+3 was noted (P = 0.53). Conclusions: Our results indicate that patients with GS4+3 prostate cancers have higher PSA levels at diagnosis. GS4+3 is associated with 3-fold increased risk of IM at diagnosis than GS3+4 though the overall incidence is low. Further research is needed to assess whether GS4+3 patients need routine staging imaging investigations at the time of diagnosis similar to patients with higher Gleason scores (GS ≥8).
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Study of Proliferating cell nuclear antigen expression and Angiogenesis in Urothelial neoplasms: Correlation with tumor grade and stage p. 209
Poojan Agarwal, Achin Kumar Sen, Minakshi Bhardwaj, Veronique Dinand, Arvind Ahuja, Rajeev Sood
DOI:10.4103/UA.UA_167_17  
Background: Urinary bladder carcinoma ranks ninth in worldwide cancer incidence. About 74,000 new cases were diagnosed in 2015 alone and 16,000 persons died of the disease. Since histopathology is considered gold standard for diagnosis, it is prudent to look for potential tumor proliferation and predictive markers in such a prevalent malignancy so as to alert surgical and medical oncologists for timely intervention and provide better patient-tailored therapy. Aims: This study is to analyze the role of potential biomarkers-proliferating cell nuclear antigen (PCNA) and angiogenesis using CD31 in urothelial neoplasms in relation to tumor grade and stage. Methods: Histopathology slides were prepared from transurethral resection of bladder tumor chips and assessed by three independent observers as per the WHO/International Society of Urologic Pathology criteria 2016. Representative sections were subjected to immunohistochemistry. PCNA labeling index (PCNA LI) and mean vessel density (MVD) were calculated. Statistical Analysis: Tests of analysis were applied as appropriate. A statistical P < 0.05 was considered significant. Results: Forty-nine patients were analyzed. PCNA LI increased with grade and stage. PCNA was significantly higher in noninvasive papillary urothelial carcinoma high grade (NIPUCHG) than in noninvasive papillary urothelial carcinoma low grade (NIPUCLG) and in infiltrating urothelial carcinoma as compared to NIPUCLG. MVD also increased with tumor grade and stage; however, a significant difference was observed only between infiltrating urothelial carcinoma and papillary urothelial neoplasm of low malignant potential. A cutoff value of 73% for PCNA and 49 vessels/high-power field for CD 31 showed 100% accuracy to differentiate between noninvasive papillary urothelial carcinoma high grade and NIPUCLG. No association was observed between tumor recurrence and PCNA or CD31 expression. Conclusion: PCNA and CD31 when used together are valuable markers to help classify urothelial neoplasms in limited tumor material. However, larger prospective studies are required for better prognostication.
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The impact of stone composition on renal function p. 215
Anmar Nassir, Hesham Saada, Taghreed Alnajjar, Jomanah Nasser, Waed Jameel, Soha Elmorsy, Hattan Badr
DOI:10.4103/UA.UA_85_17  
Background: Nephrolithiasis is a common condition that has various classifications according to stone composition. Stone formation can affect renal function; it can be a strong risk factor for chronic kidney disease (CKD). The main objective of this study is to explore the association between creatinine clearance and different stone compositions. Methods: This is a retrospective cohort study conducted in a tertiary center in Jeddah, Saudi Arabia, between 2005 and 2014. Renal function was assessed by the estimating glomerular filtration rate (eGFR) by the Cockcroft-Gault equation. Stone composition was determined by urinary calculi analysis with infrared spectrometry. Results: Stones of 365 patients, with a mean age of 48.2 ± 13.6 years and a male to female ratio of 3.2:1, were analyzed. Stage 2 CKD has been documented. It involved oxalate, struvite, cystine, and uric acid stones. The worst eGFR was reported for stones containing uric acid. The eGFR was least affected with apatite stones followed by brushite stones. Conclusion: Stone disease can affect renal function. Different stone compositions show factor for renal impairment, and this should be considered in patient management. A special precaution should be considered for higher risk groups. Multidisciplinary patient care and immediate referral to a nephrologist are strongly advised.
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Urachal cyst with xanthogranulomatous cystitis: A rare case report p. 219
Aakash Singh, HL Kishan Prasad, K Jayaprakash Shetty, Nigi Ross Philip, Ruhi Salma, Anitha Chakravarthy
DOI:10.4103/0974-7796.229555  
An urachal cyst is a sinus remaining from the allantois during embryogenesis which is rarely manifested in adults. The urachus is an embryologic remnant which degenerates after the birth. Defective obliteration of the urachus leads to urachal abnormalities. Urachal cyst is a rare pathology in adult women, and this pathology should be considered in the differential diagnosis of acute abdomen. Xanthogranulomatous cystitis (XC) is a benign disease of unknown etiology. The clinical manifestations of these are nonspecific such as lower abdominal pain, umbilical discharge with occasional hematuria. Urachal lesions present with persistent umbilical drainage in infants and newborn. However, in 35% cases, enclosed urachal cyst or infected urachal cyst (abscess) manifests without having umbilical discharge. Computed tomography scan and magnetic resonance imaging are of little help to the identification of these preoperatively. Here, we present a rare case of urachal cyst with XC in 30-year-old female which has produced diagnostic dilemma.
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A case of penile strangulation after placement of metallic rings p. 222
Iraklis C Mitsogiannis, Nikolaos Kostakopoulos, Lazaros Lazarou, Evangelos Karagiotis
DOI:10.4103/UA.UA_195_17  
Penile strangulation following placement of metallic rings is a rare clinical entity that needs urgent attention to avoid potentially severe clinical consequences. Careful handling and occasionally a multidisciplinary approach are the keys to a successful outcome.
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Embolization with Onyx® of an arterial pseudoaneurysm with an arteriovenous fistula complicating a percutaneous nephrolithotomy: A case report and review of literature p. 225
Ana Isabel Simões Ferreira, Filipe Veloso Gomes, Tiago Bilhim, Élia Coimbra
DOI:10.4103/UA.UA_29_17  
Percutaneous nephrolithotomy (PCNL) has proven very effective in the management of renal stones. However, complications are not so rare, and bleeding is one of the most worrisome; it has a reported incidence of 1%–3% and may happen during track dilatation. In addition, arterial pseudoaneurysms and/or arteriovenous fistulas (AVF) may occur. We report the case of a patient with an intrarenal pseudoaneurysm associated with an AVF, after PCNL. Superselective endovascular embolization with Onyx® was successfully performed, achieving exclusion of the pseudoaneurysm and AVF with preservation of the remaining vascularization of the kidney. We review the literature regarding endovascular management of kidney vascular lesions after PCNL. Selective renal embolization is a minimally invasive procedure, highly effective with a low incidence of complications. Currently, it is considered the most appropriate technique in the treatment of arterial iatrogenic complications following percutaneous renal procedures. Onyx® is an effective, easy to handle, and safe alternative embolic agent for these procedures.
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Renal cell carcinoma in renal allograft: Case series and review of literature p. 229
Gaurav Vasisth, Anil Kapoor, Kevin Piercey, Shahid Lambe
DOI:10.4103/UA.UA_66_17  
Renal cell carcinoma (RCC) in transplanted kidneys has been reported sporadically with incidence of about 0.5%. There are currently no standard guidelines on the management of allograft RCC in renal transplant recipients. Our objective was to study effectiveness of nephron-sparing surgery (NSS) for allograft RCC. We performed a retrospective analysis of patients with RCC in renal allografts managed with NSS in our institution from January 2000 to December 2015. Patient demographics, interval between transplant and RCC diagnosis, operative parameters, perioperative complications, final pathology, and renal function were evaluated. Three females underwent successful NSS for allograft RCC. Cause of end-stage renal disease was IgA nephropathy in all; mean time between renal transplant and diagnosis of RCC was 23 years. We were able to stay extraperitoneal in all the cases. In the final pathology, two had papillary and one had clear cell RCC. One patient developed pyelocutaneous fistula which was managed by stenting. Long-term functional outcomes of NSS are excellent; none of our patients is dialysis dependent.
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Organ preservation in leiomyosarcoma bladder: Case report and review of literature p. 233
Arun Ramdas Menon, Rajeev Thekke Puthalath, Nivedita Suresh, Suraj Hegde
DOI:10.4103/UA.UA_109_17  
Leiomyosarcomas (LMSs) account for <0.1% of all bladder malignancies. Due to the infrequent occurrence of these tumors, established guidelines for management are lacking. Conventionally, radical extirpative surgery has been advocated. We present our experience with organ preservation in a young male presenting with LMS bladder. A brief review of literature supporting organ preservation in selected cases has also been presented.
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