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   Table of Contents - Current issue
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July-September 2018
Volume 10 | Issue 3
Page Nos. 237-346

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COMMENTARIES  

Trends in percutaneous renal biopsy: The evolving diagnostic pathway for the small renal mass p. 237
Marlon Perera, Nathan Papa, Joseph Ischia, Daniel Christidis, Damien Bolton, Nathan Lawrentschuk
DOI:10.4103/0974-7796.236516  
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Urological concern after nuclear accidents p. 240
Sergei V Jargin
DOI:10.4103/0974-7796.236525  
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ORIGINAL ARTICLES Top

Laparoscopic ureteroneocystostomy for mid and lower ureteric strictures: Experience from a tertiary center p. 243
Manmeet Singh, Gaurav Garg, SN Sankhwar, Manoj Kumar
DOI:10.4103/UA.UA_137_17  
Purpose: The purpose of this study is to evaluate our experience of laparoscopic ureteroneocystostomy for mid and lower ureteral stricture in a tertiary center in North India. Materials and Methods: A total of 20 laparoscopic ureteroneocystostomy were performed with or without bladder flap procedures in 20 patients (13 females and 7 males) with various etiologies such as ureteric stricture, ureterovaginal fistula, endometriosis, and distal ureteric tumor at our hospital in a time frame from August 2013 to January 2017. Eight cases each presented after laparoscopic/open hysterectomy and postureterorenoscopic stone removal while two cases each presented secondary to endometriosis and distal ureteric tumor. Simple laparoscopic ureteroneocystostomy in 4, psoas hitch in 9, and Boari flap was done in 7 cases. Results: The mean patient age was 44.2 years (range 19–65), mean surgical time was 184.25 min (115–250 min.), mean amount of bleeding was 153.25 mL (90–250 mL), and mean hospital stay was 3.05 days (2–7 days). Female-to-male ratio was 1.3:0.7. There was one conversion to open during laparoscopic Boari reimplant because of inadvertent injury to external iliac vein. The mean follow-up was 22.35 months (6–45). All the patients were asymptomatic with the resolution of hydronephrosis on ultrasound and without any significant obstruction on renal scan. Conclusions: Laparoscopic ureteroneocystostomy with or without bladder flap (Boari) provides good functional outcomes with excellent success rates and minimal morbidity comparable to open surgery in patients with ureteric stricture.
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Characterization and outcomes of local treatment for primary bladder lymphoma: A population-based cohort analysis p. 249
David P Sellman, W Greg Simpson, Zachary Klaassen, Rita P Jen, John M DiBianco, Lael Reinstatler, Qiang Li, Rabii Madi, Martha K Terris
DOI:10.4103/UA.UA_106_17  
Introduction: Primary bladder lymphoma (PBL) is rare, representing 0.2% of extranodal lymphoma and less than 1% of all tumors originating in the bladder. Since the initial description of the disease, low-grade mucosa-associated lymphoid tissue (MALT) lymphoma has been reported as the most common subtype while high-grade disease was thought to represent only 20% of the reported cases. Materials and Methods: One hundred and ninety five patients with PBL from the Surveillance, Epidemiology, and End Results (SEER) registry from 1998-2010 were reviewed. Tumors were classified as high or low grade based on histologic subtype of lymphoma based on revised European-American Lymphoma classification system. Socio-demographic and clinical variables were reported, as well as survival outcome analyses using the Kaplan-Meier method and log-rank test. Cox proportional hazard analysis was used to generate hazard ratios for risk factors associated with mortality. Results: Eighty-three patients (42.6%) with low-grade and 112 patients (57.4%) with high-grade bladder lymphoma were studied. There were no differences between the low and high-grade groups for socio-demographic or clinical variables. Median overall survival or patients with low-grade disease was 38 months versus 15 months for patients with high-grade disease (p<0.001). Analysis demonstrated worse survival outcomes for patients with high-grade disease compared to low-grade disease (p<0.001). On multivariable analysis, increasing age and high-grade disease were associated with worse disease specific mortality (p<0.001). Conclusion: Patient with high-grade primary bladder lymphoma had worse survival outcomes compared to those with low-grade disease. While transurethral resection provides tissue for diagnosis, immunotherapy/chemotherapy remains the mainstay of treatment for bladder lymphoma. Consolidation chemotherapy has been recommended in young patients not achieving complete remission with immunotherapy/chemotherapy.
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Laparoscopic pyelolithotomy as a monotherapy for the management of intermediate-sized renal pelvic stones p. 254
Musliyarakath Mujeeburahiman, Chembili Vipin
DOI:10.4103/UA.UA_80_17  
Introduction: Renal calculi are one of the major reason leading to kidney failure or urinal obstructions. Percutaneous nephrolithotomy is considered as the major management option for intermediate to large renal pelvic stones. In the present study we compare Percutaneous nephrolithotomy vs laparoscopic pyelolithotomy procedures in the management of intermediate sized renal pelvic stones. Methods: The time duration of study was between July 2012 and Jan 2014, 20 patients with solitary intermediate sized renal pelvic stones were selected and randomly divided into two groups; group one included 10 patients who were treated by laparoscopic pyelolithotomy and group two included 10 patients who were treated by PCNL. The differences in procedure time, blood loss, stone clearance and duration of hospital stay between the two procedures were compared and analyzed. Results: There was no difference between the two groups regarding patient demographics and stone size. There was statistically significant difference between laparoscopic pyelolithotomy and PCNL regarding mean estimated blood loss (<50 mL vs. 180–250 mL), hospital stay (3–5 days vs. 4–6 days), mean time of postoperative analgesia (2.2 ± 0.9 days vs. 2 ± 0.9 days), and stone-free rate (100% vs. 95%). The operative time was significantly longer in the laparoscopic pyelolithotomy group (80–150 min vs. 45–75 min). Conclusion: Although PCNL is the gold standard for intermediate-sized renal pelvic stones of 2-4 cm, laparoscopic pyelolithotomy is a suitable surgical technique in selected cases.
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Percutaneous nephrolithotomy of horseshoe kidney: Our institutional experience p. 258
Vikram Satav, Vilas Sabale, Prasun Pramanik, Sharad P Kanklia, Sunil Mhaske
DOI:10.4103/UA.UA_152_17  
Purpose: To review our success in PCNL for managing large horse shoe kidney stones as primary treatment . Method: Between 2012 and 2016, a total of 23patients (24 renal units) underwent percutaneous renal surgery for stone dieses in horseshoe kidneys. Indications were HSK with stone more than 1 cm in size and failed ESWL. Results: Mean age was 35.60 ± 10.10 years out of which 18 were males and 5 females .One patient had stone in both kidneys. Mean stone size was 22.03 ± 10.33 mm . Access site was upper calyceal and subcostal in all patients. In 2 patients an extra middle calyceal puncture were used for total clearance (8.69%). Mean operation time was 67.22 ± 7.63 minutes. One patient with staghorn stone was converted to open surgery because of inaccessibility of the stone and complexity of the renal calyceal system. Post operatively, 2 renal units with residual stone more than 8mm were cleared with ESWL. Complete clearance was achieved in 21 renal units with PCNL (87.50%). There was no significant intra operative complication. Post operatively 2 patients developed fever which was treated conservatively(clavien grade I). Conclusion: PCNL can be recommended as first line of management in the treatment of horseshoe kidneys with large stone burden considering its higher clearance rate and minimal complications.
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Current status of robot-assisted urologic surgery in Saudi Arabia: Trends and opinions from an Internet-based survey p. 263
Raed A Azhar, Ahmed A Mobaraki, Hattan M Badr, Noor Nedal, Anmar M Nassir
DOI:10.4103/UA.UA_8_18  
Objectives: The objective of this study is to assess the current status of urologic robot-assisted surgery (RAS) in Saudi Arabia and evaluate perceptions of its importance and utility. Methods: A 59-item questionnaire was E-mailed to urologists and trainees in Saudi Arabia to assess the demographics and individual and institutional surgical practices of minimally invasive surgery (MIS) with a focus on RAS and urologic subtypes. Results: Ninety-five surveys were completed. Nearly 53%, 46%, and 21% of respondents were formally trained in laparoscopic surgery, MIS, and RAS, respectively. Forty percent had used a robot console during training. Nearly 72% of participants felt that RAS training should be included to accomplish their career goals and stated that it would strengthen the department academically and financially. The absence of a robotic system (45%) and administrative disinterest with lack of support (39%) were the most common deterrents. Robot-assisted radical prostatectomy (RARP), robot-assisted radical cystectomy (RARC), and robot-assisted radical nephrectomy (RARN) were regarded as the gold standard for 34%, 23%, and 17% of respondents, respectively. Respondents would recommend RARP (74%), RARC (50%), and RARN (57%) for themselves or their family. The greatest perceived benefits of RAS were its ease of use and improvement in the patient's quality of life. Conclusion: Urologists in Saudi Arabia recognize the superiority of RAS over traditional surgical methods but lack exposure, training, and access to RAS. This survey reveals increasing acceptance of RAS and willingness to incorporate the technology into practice.
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Validation of radius exophytic/endophytic nearness anterior/posterior location and preoperative aspects and dimensions used for an anatomical nephrometric scores in patients undergoing partial nephrectomy for renal cancer: A single-center experience and literature review p. 270
Sachin Yallappa, Rizwana Imran, Ishtiakul Rizvi, Omar M Aboumarzouk, Rupesh Bhatt, Prashant Patel
DOI:10.4103/UA.UA_11_18  
Introduction: Nephrometric scores are used to predict perioperative and postoperative complications, with no uniform results in the current literature. Materials and Methods: A retrospective study of 141 patients in a single center who underwent open partial nephrectomy between June 2006 and 2016 for T1a and T1b renal tumor was conducted. Univariate and multivariate analyses were used to evaluate the correlations between preoperative aspects and dimensions used for an anatomical (PADUA) and radius exophytic/endophytic nearness anterior/posterior location (RENAL) scores and their components with pre-, peri-, and post-operative parameters. Linear regression (F-tests) and logical regression models were used to test for significance of the association and predictability of outcomes. Results: Total RENAL score (P = 0.032), its components R (P = 0.004), E (P = 0.022), L (P = 0.011), and total PADUA score (P = 0.016) were significantly associated with ischemic time. In postoperative complications, the PADUA components: sinus line location (P = 0.008), lateral/medial rim score (P = 0.029), and collecting system score (P = 0.006) showed significance. None of the variables showed correlation with operation time and change in estimated glomerular filtration rate (eGFR). On multivariate analysis, sinus line location and gender (P = 0.012) showed significance in predicting eGFR changes and RENAL score component: A (P = 0.049) was significant in predicting estimated blood loss. Both RENAL and PADUA components were significantly associated with hospital length of stay. Conclusion: Both RENAL and PADUA scores showed important correlation in predicting outcomes. We further demonstrated the importance of knowing the individual components of the scores, which can independently give outcome predictions. The scoring systems can still be improved and standardized for broad clinical use with larger cohort and multicenter-based studies.
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Clinical and biochemical markers of visceral adipose tissue activity: Body mass index, visceral adiposity index, leptin, adiponectin, and matrix metalloproteinase-3. Correlation with Gleason patterns 4 and 5 at prostate biopsy p. 280
Vincenzo Serretta, Alberto Abrate, Simone Siracusano, Cristina Scalici Gesolfo, Marco Vella, Fabrizio Di Maida, Antonina Cangemi, Giuseppe Cicero, Elisabetta Barresi, Chiara Sanfilippo
DOI:10.4103/UA.UA_188_17  
Context: The correlation between aggressive prostate cancer and obesity mainly based on body mass index (BMI) and pathology after surgery remains controversial. Aims: The aim of the study was to correlate BMI, visceral adiposity index (VAI), and the plasmatic levels of leptin, adiponectin, and matrix metalloproteinase-3 (MMP-3), and biomarkers of adipose tissue function, with the detection of Gleason patterns 4 and 5 at biopsy. Subjects and Methods: Consecutive patients with prostate cancer at 12-core transrectal biopsy were enrolled. BMI, waist circumference (WC), blood samples to evaluate the plasmatic levels of triglycerides (TG) and high-density lipoproteins (HDL), adiponectin, leptin, and MMP-3 were obtained immediately before biopsy. The VAI was calculated according to the formula: WC/(39.68 + [1.88 × BMI]) × TG/1.03 × 1.31/HDL. Results: One hundred and forty-nine patients were entered. The median PSA, BMI, and VAI were 10.0 ng/ml, 27.6 kg/m2, and 4.6, respectively. Gleason patterns 4 or 5 were detected in 68 (45.6%) patients; in 15 (41.7%), 31 (44.9%), and 22 (50.0%) among normal weight, overweight, and obese patients, respectively (P = 0.55). The statistical analysis did not show any significant correlation between BMI, VAI, the plasmatic levels of leptin, adiponectin, MMP-3, and the detection of Gleason patterns 4 and 5 at biopsy. A statistically significant association emerged with older age (P = 0.017) and higher PSA values (P = 0.02). Conclusion: We did not find any association between BMI, VAI, the plasmatic levels of adiponectin, leptin, and MMP-3 and the detection of Gleason patterns 4 and 5 at prostate biopsy.
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Different managements of horseshoe kidney stones, any difference in the outcome? p. 287
Abdulhakim Al Otay, Osama Sarhan, Hossam S El-Tholoth, Ahmed Alhelaly, Hamad Al Akrash, Mustafa Al Ghanbar, Khaled Al Bedaiwi, Ziad Nakshabandi, Ali Obeid
DOI:10.4103/UA.UA_116_17  
Purpose: The aim is to assess the outcomes of different approaches for the management of renal stones associated with horseshoe kidneys (HSKs) in our institution over a 12-year period. Methods: A retrospective review of 144 patients with HSKs who presented from 2000 to 2012 was performed. Twenty-eight patients (19.4%) were found to have renal stones. Demographic data were collected; the method of treatment and the outcomes of stone management were reviewed. We excluded patients with non-functioning moieties and associated genitourinary anomalies, and those with incomplete data. Results: We included 25 patients, of which 16 males (64%) and 9 females (36%), with a mean age of 37 years. Mean serum creatinine level was 66 mmol/L. Eleven patients with a stone size <8 mm were treated expectantly with medical treatment, with only one patient requiring endoscopic intervention. Six patients (24%) with a stone size between 1 cm and ≤2 cm were treated with extracorporeal shock wave lithotripsy (ESWL) with the placement of double J stents, and seven patients (28%) with a stone size of >2 cm were treated with percutaneous nephrolithotomy. One patient with a 10 mm stone was treated using flexible ureteroscopy. No significant perioperative complications were encountered. Conclusions: Indications, methods of treatment, and outcomes of management of stones associated with HSKs were comparable to those for stones associated with normal kidneys. Tailored approach based on stone size is highly recommended. ESWL accompanied with ureteric stenting is a promising strategy for the management of stones associated with HSKs in selected patients requiring intervention.
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Transrectal ultrasound-guided aspiration versus transurethral deroofing of prostatic abscess: A prospective randomized study p. 291
Mohammed Selem, Esam Desoky, Ahmed Eliwa, Amr Fawzi, Ehab Elkady, Maged M Ali, Ahmed Ragab, Ahmed Sakr, Mohamed Omran, Mostafa Kamel
DOI:10.4103/UA.UA_41_17  
Aims: The aim of this study is to compare between transrectal ultrasound (TRUS)-guided aspiration and transurethral (TU) deroofing in the treatment of prostatic abscess regarding safety and efficacy. Settings and Design: This prospective randomized study was done during the period between April 2009 and March 2015 and included 32 patients with prostatic abscess. Subjects and Methods: All patients were enrolled in the study after obtaining a written informed consent and approval of the local ethical committee. The patients were randomly allocated into two groups; Group A treated by TRUS-guided aspiration, saline wash, and local injection of antibiotics and Group B treated by TU deroofing of the abscess. All patients received broad-spectrum antibiotics during the period of treatment, and the follow-up was done on the 5th day by TRUS to ensure complete resolution of the abscess. Statistical Analysis Used: Statistical analysis was done using online social science statistical calculators http://www.socscistatistics.com/Default.aspx using t-test for two independent means, Chi-square test, and Mann–Whitney U-test with P < 0.05 considered statistically significant. Results: The mean age was 59 ± 11.46 and 60 ± 13.65 years for Groups A and B, respectively. Diabetes mellitus was detected in 9 (56.25%) and 6 (37.5%) patients in Groups A and B, respectively, hypertension in 7 (43.75%) and 6 (37.5%) patients in Groups A and B, respectively, and two patients (12.5%) with liver cirrhosis in each group. The mean size of the abscess was 3.36 ± 0.86 and 3.04 ± 0.86 cm in Groups A and B, respectively (P = 0.29). The abscess recurred in five patients (31.25%) and one patient (6.25%) in Groups A and B, respectively (P = 0.08). TRUS-guided aspiration was done for all recurrent cases except for two patients (12.5%) in Group A required trans urethral deroofing of the recurrent abscess. The mean hospital stay was 12.9 ± 4.05 and 7.25 ± 2.40 days for Groups A and B, respectively (P = 0.000). In Group A, one patient (6.25%) was complicated by urethrorectal fistula, whereas in Group B, one patient (6.25%) was complicated by septic shock, three patients (13.75%) with epididymo-orchitis and two patients (12.5%) with urethral stricture. Conclusion: Patients with prostatic abscess treated with TRUS-guided aspiration show less morbidity, higher recurrence rate, and longer hospital stay than those treated with TU deroofing.
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Correlation of ultrasonographical findings of hydronephrosis/atrophy with 99m technetium-dimercaptosuccinic acid in childhood: A single-center experience from Turkey p. 296
Yasar Kandur, Ahmet Salan, Fatih Tuten
DOI:10.4103/UA.UA_120_17  
Introduction: To assess the association of frequently detected abnormalities (hydronephrosis and/or atrophy) on renal ultrasound with dimercaptosuccinic acid (DMSA) scan and the impact of vesicoureteral reflux (VUR) on these abnormalities to find new perspectives in pediatric age group. Materials and Methods: We retrospectively reviewed the DMSA, ultrasonography (US), micturating cystourethrography (MCUG) findings, and medical records of pediatric patients with hydronephrosis and/or atrophy who were at follow-up between January 2013 and December 2016 in our center which is located in the southeast region of Turkey. Results: Among 148 pediatric patients (male/female = 60/88), 66 had hydronephrosis, 72 had atrophy, and 10 patients had both. MCUG study detected VUR in 66 patients. Patients with atrophy were significantly older than patients with hydronephrosis (77.8 ± 58.6 vs. 39.3 ± 38.9 months, P = 0.002). Only 19.4% of our patients with atrophy had VUR. The rate of VUR was higher in the high-grade group than the mild-to-moderate-grade group although the difference was not statistically significant (80% vs. 61%, P = 0.199). Patients with high-grade hydronephrosis had more severe DMSA findings (73% vs. 39%). On the other side, 79% of the patients with high-grade VUR had severe DMSA findings. A total of 10 patients had both atrophy and hydronephrosis all affecting the left side. Six of them had VUR. Severe DMSA findings were more likely in toddlers (age 24–72 months) (48%). This finding was abruptly lowered after 72 months of age. Conclusions: The presence of atrophy and cases of left-sided hydronephrosis should be closely monitored, and DMSA may not be necessary in cases with high-grade hydronephrosis before MCUG.
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Assessment of factors affecting the spontaneous passage of lower ureteric calculus on the basis of lower ureteric calculus diameter, density, and plasma C- reactive protein level p. 302
Ajayraj Hada, Sher Singh Yadav, Vinay Tomar, Shivam Priyadarshi, Neeraj Agarwal, Anil Gulani
DOI:10.4103/UA.UA_89_17  
Introduction: The study aimed to evaluate the factors which affect the spontaneous passage of lower ureteric calculus on the basis of noncontrast computed tomography kidneys, ureters, and bladder (NCCT KUB) stone diameter, stone density, and plasma C-reactive protein (CRP) level. Materials and Methods: We conducted a prospective study of 200 patients with lower ureteric calculus 5–10 mm in size, from October 2015 to December 2016. All patients underwent NCCT KUB region with a 5 mm axial and reformatted coronal section. Edema just above the calculus and rim sign at the level of calculus and density of calculus is evaluated. Only scan with isolated, unilateral, solitary ureteric calculus was included in the final analysis and monitored up to 4 weeks, and plasma CRP is estimated in all patients to determine the clinical outcome. Results: A total of 200 patients (145 males, 55 females; mean age ± standard deviation, 34.73 ± 10.29) were included in the study. Lower ureteric calculus between 5–7 mm passed in 70% and 7–10 mm passed in 40%. There was 18% underestimation of maximum stone diameter in axial plane as compared to coronal plane. For spontaneous passage of calculus, craniocaudal (CC) diameter is more reliable then axial in NCCT. Rim sign and edema is absent in 64% of those passed spontaneous calculus. CRP level more than 2.45 mg/dl has low spontaneous expulsion rate. The stone with different HU passes through the ureter with same rate. Conclusion: Plasma CRP level and CC diameter and absence of rim sign on NCCT KUB are more reliable factors then density for spontaneous passage of ureteric calculus.
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Complications of 411 laparoscopic urological procedures: A single surgeon experience p. 308
Khalid Al-Otaibi
DOI:10.4103/UA.UA_190_17  
Objectives: The aim of this study is to review the complications of laparoscopic urological procedures performed using a single surgeon during a 12-year period. Materials and Methods: From June 2004 to May 2017, a total of 411 abdominal urological procedures were performed using the author. They included 250 varicocele ligations, 94 nephrectomies (simple, partial, radical, and nephroureterectomy), 34 adrenalectomies, 22 renal cyst ablation, and 11 pelvic lymph node dissections. Operative and postoperative complications were reviewed and analyzed. The results were analyzed using Chi-squared tests for statistical analysis. Results: A total of 55 complications out of 411 procedures occurred in 26 patients with a total complication rate of 13.4%, 19 were major (4.6%), and 36 were minor (8.8%). Mortality occurred in two patients (0.5%). Conversion to open surgery was done in 5 patients (1.2%) to manage uncontrolled bleeding. Major intraoperative complications included vascular injuries (2.2%), injuries to the diaphragm (0.5%), bowel (0.7%), and pancreas (0.5%). Major postoperative complications included urine leak (0.2%) and pelvic lymphocele (0.2%). Minor intraoperative complications included bleeding during trocar access (4.4%) and subcutaneous emphysema (0.7%), whereas minor postoperative complications included atelectasis (1.2%) and ileus (2.2%). Conclusions: Even though the complications rate in this series was comparable to those of other studies in the literature, yet it remains higher than that of open surgery. The continuing advances in laparoscopic techniques will reduce the complication rate and will pave the way for laparoscopy to replace most currently practiced open surgical urological procedures.
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Effect of gastrocystoplasty on height and bone density in children p. 313
Amit Singh, G Moorthy, Minu Bajpai
DOI:10.4103/0974-7796.236524  
Introduction: Gastrointestinal tissue in the urinary tract results in numerous metabolic changes. This study investigates the effects of augmentation gastrocystoplasty on the height and bone mineralization in bladder exstrophy patients. Aim and Objective: To analyze the long-term outcome following gastrocystoplasty in terms of height, bone mineral density, acid base changes, and complications. Materials and Methods: Cross-sectional study was done after obtaining institutional ethics committee clearance. Inclusion criteria included retrospective analysis of all cases who had undergone gastrocystoplasty since 1992 and prospective analysis of all cases who are undergoing gastrocystoplasty during the study period from June 2008 to December 2010. Exclusion criteria included follow up period of less than 2 years and cases lost to follow up. Indian standard charts were used for anthropometric measurement, and bone density scan of lumbar vertebrae and upper end of femur were done for bone matrix and mineral density. Results: A total of 23 patients were included in the study. Out of 23 patients, 16 were males and 7 were females. Mean age at gastrocystoplasty was 8.28 years, and mean follow up period was 60 months. The median pre-augmentation and post-augmentation percentile height and weight were 56, 59 and 59, 61 respectively. Mean bone density value was 0.654. Conclusion: Augmentation gastrocystoplasty is a safe and viable option without any adverse effect on height or bone mineral density without altering metabolic or acid base homeostasis.
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Predictors of the international prostate symptoms scores for patients with lower urinary tract symptoms: A descriptive cross-sectional study p. 317
Christian Kofi Gyasi-Sarpong, Emmanuel Acheampong, Francis Agyemamg Yeboah, Kenneth Aboah, Edwin Ferguson Laing, George Amoah
DOI:10.4103/UA.UA_4_17  
Background: Lower urinary tract symptoms (LUTSs) can significantly reduce men's quality of life and may point to serious pathology of the urogenital tract. This study aimed at finding predictors of symptoms score on the International Prostate Symptom Score (IPSS) for patients with LUTS. Materials and Methods: The study was cross-sectional conducted among 225 Ghanaian men visiting the urology clinic at Komfo Anokye Teaching Hospital. Trained interviewers used the IPSS, which adds a quality of life question to the American Urology Association symptom index to determine the extent to which patients are troubled by their symptoms. Five milliliters of blood was collected for total prostate-specific antigen (PSA) measurement. Transrectal ultrasonography was performed to evaluate the prostate volume (PV). Results: The mean age of the participants was 67.96 ± 14.57. The average score obtained from the study participants using the IPSS scale was 17.52 ± 7.83. There was a significant association between bother score and IPSS symptoms grade (P < 0.0001). Regression plot of the participants' points for IPSS in relation to the age, PSA, and PV showed statistically significant positive associations (P < 0.05). However, the coefficients of determination (R2) were 0.156, 0.022, and 0.048, respectively. This means that each unit increase of age, PSA, and PV only influences 15.6%, 2.3%, and 4.8% of the change in the symptom score. There was statistically significant association between age and moderate-to-severe LUTS with age range of 75 years above recording the highest odds (adjusted odds ratio (AOR) = 18.72, (1.15–99.78), P < 0.0001). The PSA range 20.1–50 ng/ml was significantly associated with moderate-to-severe LUTS (AOR = 17.37 (2.19–223.45), P = 0.006). Moreover, other factors, which were significantly associated with moderate-to-severe LUTS, were smoking (AOR = 0.32 (0.11–0.94) P = 0.038) and being widowed (AOR = 0.05 (0.002–0.52), P =0.010) respectively. Conclusion: The study found a statistically significant correlation between age, PSA, PV, and IPSS scores; however, these influences were mild.
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Validation of the WHO 2016 new Gleason score of prostatic carcinoma p. 324
Vishal Rao, Gowri Garudadri, Arya Sahithi Shilpa, Daphne Fonseca, S Murthy Sudha, Rakesh Sharma, T Rao Subramanyeshwar, Sundaram Challa
DOI:10.4103/UA.UA_185_17  
Context: New Gleason Score of Prostate. Aims: The aim of this study is to assign the patients with carcinoma prostate into new prognostic grade groups (PGGs) based on revised Gleason score (GS) and follow-up according to the WHO 2016. Subjects and Methods: All the biopsies/resected specimens of carcinoma prostate from January 2014 to June 2016 were reviewed, and GS was done according to the WHO 2016. Accordingly, cribriform, fused, and glomeruloid glands were assigned GS 4. Thus, two groups were identified with GS 7 (3 + 4 and 4 + 3). The patients were grouped into PGGs 1–5. The number of patients with change in the prognostic group along with follow-up was calculated. Results: There were 143 patients with carcinoma prostate, with a median age of 65 years. The initial GS was revised, and there was a decrease in GS 3 + 4 from 13.9% to 9% and increase in 4 + 3 from 19.6% to 23.8%. There was upgradation of PGG in 11 (7.69%) biopsies; with PGG from 1 to 2 in one; 2to 3 in eight; and 3to 4 in two. Follow-up at 2 years in 22 showed the poor prognoses in the patients who were upgraded to the higher prognostic group. Conclusions: A change in PGG according to the WHO 2016 criteria was assigned in 7.69% biopsies of carcinoma prostate, and it correlated with prognosis.
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Robotic-assisted dual kidney transplantation p. 330
Sharma Himanshu, MK Ramaprasad, R Vishnu, TA Kishore
DOI:10.4103/UA.UA_14_18  
Aim: The aim of this study was to report the feasibility of robotic-assisted dual kidney transplantation (DKT) in a marginal donor. Materials and Methods: The case was a 53-year-old male, who with IgA nephropathy underwent a robotic-assisted robotic DKT. Results: The total operating time was 265 min, total console time was 215 min, and anastomotic time was 39 min for both the kidneys, and blood loss was 220 ml. The total drain output was 150 ml on the 1st day. The drain was removed after 48 h and Foley catheter was removed after 5 days. Nadir creatinine was 1.1 mg/dl and time to nadir creatinine was 7 days. The patient received one unit of blood transfusion. Total postoperative hospital stay was 7 days and bilateral ureteric stents were removed after 14 days. At the end of 3 months, creatinine was 1.0 mg% and epidermal growth factor receptor was 82 ml/min/1.73 m2. Conclusion: Robotic DKT offers solutions to the challenges faced in open DKT.
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CASE REPORTS Top

Massive seminal vesicle cyst with ipsilateral renal agenesis – Zinner syndrome in a Saudi patient p. 333
Azhar Farooqui, Loay AlDhahir, Ali Bin Mahfooz
DOI:10.4103/UA.UA_17_18  
Zinner syndrome is a rare male genitourinary tract disorder associated with seminal vesicle cysts and ipsilateral renal agenesis. Clinical presentation often involves symptoms of the genitourinary tract. We present a case report of a young Saudi male, presenting with nonspecific symptoms of fatigue and malaise. Ultrasound visualized a massive seminal vesicle cyst associated with ipsilateral renal agenesis. The cyst was managed using a laparoscopic technique without any immediate complications and an uneventful postoperative period.
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A rare inflammatory myofibroblastic bladder tumor masquerading urachal carcinoma p. 336
Santosh Kumar, Sriharsha Ajjur Shankaregowda, Abhishek Chandna
DOI:10.4103/UA.UA_159_16  
Inflammatory pseudotumor is a rare benign condition of unknown cause. A 19-year-old female presented with gross hematuria and storage symptoms to the emergency. Contrast-enhanced computed tomography scan revealed a mass of 5 cm × 6 cm involving the dome and anterior wall of the bladder. Urachal carcinoma was kept as a possibility and transurethral biopsy of the aforementioned lesion was performed. The histopathology revealed inflammatory myofibroblastic tumor (IMT) of the bladder. A laparoscopic partial cystectomy was undertaken with adequate resection margins and the histopathology of the lesion confirmed IMT. When evaluating a mass in the genitourinary tract in a young individual, IMT should be considered as a possibility.
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Biphasic renal synovial sarcoma with extensive venous tumor thrombosis: A rare presentation p. 339
Uma Kant Dutt, Ramanathinam Manikandan, Lalgudi Narayanan Dorairajan, Bheemanathi Hanuman Srinivas
DOI:10.4103/UA.UA_9_18  
Primary renal synovial sarcoma (SS) is a very rare soft-tissue tumor arising from the kidney. These tumors histologically closely resemble other sarcoma variants. Immunohistochemical and cytogenetic techniques remain the cornerstone in achieving the correct diagnosis. Radical surgical excision is the primary treatment for local tumor control and alleviation of symptoms. Adjuvant chemotherapy, at present, has only a limited role. We report a unique case of a 21-year-old young male with the diagnosis of a biphasic renal SS with extensive venous system thrombosis involving the inferior vena cava, bilateral iliac, and femoral vessels which was managed by radical nephrectomy and tumor thrombectomy followed by adjuvant chemotherapy.
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Collision metastasis of prostatic adenocarcinoma and urothelial carcinoma of the bladder p. 342
David P Sellman, Leslie Peard, Greg Simpson, Katrina Lancaster, Sravan Kavuri, Martha Terris, Rabbi Madi
DOI:10.4103/UA.UA_97_17  
The incidence of concomitant prostate adenocarcinoma found in patients with muscle-invasive bladder carcinoma is not uncommon, reaching up to 21%–28%. However, the presence of collision metastasis involving prostate cancer and bladder cancer within the same lymph node is exceedingly rare, with only 5 cases reported to date in the literature. We report a case of collision metastasis of prostate adenocarcinoma and urothelial carcinoma of the bladder in a 73-year-old man who underwent cystoprostatectomy with bilateral pelvic lymph node dissection for high-grade muscle-invasive urothelial carcinoma. Final pathology revealed a pT3aN2 high-grade urothelial carcinoma and pT3N1 Gleason 4 + 4 = 8 adenocarcinoma of the prostate with 12/40 pelvic lymph nodes positive for urothelial carcinoma. One node was positive for both urothelial carcinoma and prostate adenocarcinoma, confirmed by positive staining by p40 and prostate specific antigen(PSA), respectively. Immunohistochemistry is the sole method of confirming collision metastasis of two primary cancers. In this case, we describe immunohistochemical markers for urothelial carcinoma and prostate adenocarcinoma and their clinical implications. One month postoperatively, our patient began adjuvant leuprolide therapy and cycle 1 of gemcitabine and cisplatin chemotherapy, which he is tolerating well.
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LETTER TO EDITOR Top

Evaluation of testicular workup for ischemia and suspected torsion score in patients presenting with acute scrotum p. 345
Mohamed Mohamed Elawdy
DOI:10.4103/UA.UA_13_18  
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