Background and Aim : Premature ejaculation (PE) is the most prevalent sexual dysfunction in every country. There are many types of treatment, but the main limitation of medical treatment for premature ejaculation is recurrence after withdrawal of medicine. The prepuce is a specific erogenous zone that contains a rich and complex network of nerves. Circumcision radically desensitizes the penis, but incomplete circumcision may cause premature ejaculation. We evaluate the effect of removal of foreskin remnants in adults on PE. Materials and Methods : The sensitive area of penile skin and the remaining parts of foreskin in adult men were recognized in 47 selective patients. Under local anesthesia, the remnant parts of foreskin were incised and removed. They were asked to fill the investigating questionnaire about the changes of intravaginal latency ejaculatory time (IVELT), patients and their sexual partners' satisfaction with sexual life, control over ejaculation, and penile sensitivity, before and after treatment. Results : There were no signs of inflammation and no serious adverse reactions in all cases after operation. IVELT significantly increased from 64.25 before surgery to 731.49 sec after surgery (P<0.001). The percentage of postoperative satisfaction in both the patient and his partner significantly increased (P<0.001). After surgery, 95.7% of men had better control over their ejaculation. This surgery significantly decreased sensitivity of penis (P<0.001), but it did not change glans penis insensitivity. Conclusions : These results indicate that removal of foreskin remnants in adults is an effective modality in selective patients of PE.

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Aim: To evaluate the effectiveness of transobturator vaginal tape (TOT) in the treatment of female stress urinary incontinence (SUI) and to analyze functional results and quality of life after12 months follow up. Materials and Methods : All women with SUI who underwent TOT procedure from outside to inside under general or regional anesthesia from December 2004 to January 2007 were included in the study. All must have had a minimal follow up of one year. The patients were prospectively evaluated with history including pads use/day, physical examination - pelvic examination, urinalysis, urogenital distress inventory (UDI-6), and analog global satisfaction scale - and urodynamic studies - filling cystometry, pressure-flow studies, and Valsalva leak point pressure. Results: Sixty two consecutive patients who fulfilled the inclusion criteria underwent TOT procedure by one surgeon. The mean age was 52 ± 9 years (range, 34-70 years) and minimal follow up was one year (12-24 months). The mean operative time was 17 ± 4 minutes (15-31) with average amount of bleeding 62 ± 22 cc. We found objectively 89% cure or improvement rate after one year. Conclusion: The out-in transobturator approach is a very effective treatment of SUI with low morbidity and high success rate. However, longer follow up in larger populations should assess the long-term reliability of this attractive procedure.

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Introduction: Resistance to higher antimicrobial agent is commonly seen in gram negative bacilli. This issue is a challenging problem to the medical practitioners in addition to it is financial impact on the health care system. Objectives: To document the prevalence of multi drug resistant gram negative bacilli isolated from urine of patients attending the Urology Department of Tertiary care Hospital of western India in year 2008. Results: Out of total 328 isolates, 118 (35.98%) E.coli, 72 (21.95 %) Klebsiella, 64 (19.51%) Pseudomonas aeruginosa, 30 (9.15%) Acinetobacter, 18 (5.49%) Proteus vulgaris, 18 (5.49%) Proteus mirabilis, 6 (1.83%) Providencia rettgerii, 2 (0.61%) Citrobacter freundii. Out of these isolates, 228 (69.51%) were b-lactamase positive, while 100 (30.51%) were β-lactamase negative. Out of 228 β-lactamase positive, 104 (45.61%) were AmpC β-lactamase positive. Conclusions: Stringent protocol such as Antibiotic policy and Hospital infection control program are mandatory to curb these microbes in a tertiary care hospital.

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Metastatic renal cell carcinoma (RCC) was, until recently, considered a challenging disease to treat with few therapeutic options of limited benefit. The past few years have seen spectacular advances in the treatment of this disease based on understanding the molecular pathways behind tumor growth and angiogenesis. This progress has led to the development of targeted therapies such as the receptor tyrosine kinase inhibitors sunitinib and sorafenib, the anti-vascular endothelial growth factor antibody bevacizumab, and a class of rapamycin analogues that includes temsirolimus and everolimus that have each demonstrated clinical efficacy in patients with metastatic RCC. The goal of this manuscript is to review the current evidence based on large randomized trials and propose a rationale paradigm for the treatment of this disease.

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With few exceptions, most of the current publications on history of urology still ignore the scientific and technological events of the more than a thousand years between the Greco-Roman times and the modern era. This has broken an important link in the globally continuous line of progress and evolution of world civilizations. Another aggravation of that missing-link problem in the history of urology, and history of medicine, in general, is the large number of articles based, only, on copying from secondary sources without checking the primary sources (the edited and published original manuscripts). Such articles easily propagate omissions, deficiencies, misunderstandings, distortions, and unfounded claims. On the other hand, in the Arabic and Islamic world, though many original authentic medical manuscripts written by famous scholars of the Islamic era were authoritatively edited and published during the twentieth century, the number of primary source studies based on them by historians or medical researchers remained few and were limited to individual efforts. Therefore, we focused on this missing-link era and performed several primary source studies of the published medical works of ten scholars who lived and practiced between the ninth and the thirteenth centuries and whose Latinized books were available in Europe as early as the twelfth century with their influence lasting until the eighteenth century. Our results confirm that those scholars of the Islamic era were not mere compilers or sheer transmitters of Greco-Roman medical literature. On the contrary, they critically reviewed the translated heritage of previous civilizations rejecting what is superfluous and accepting only what proves to be true. They added original contributions to the progress of urology and pioneered new fields of medical knowledge and practice such as medical ethics, medical education, medical certification, health education, preventive medicine, hospitals and hospital training, medical-practice quality control, clinical medicine, differential diagnosis, experimental medicine, experimental surgery, beginnings of specialization, pharmacology, use of anesthetics, and many other new discoveries in anatomy, physiology, pathology, therapeutics, surgical instruments, and surgical techniques.

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Tunica vaginalis hydrocele (TVH) is a relatively common entity. The procedure of testicular reposition in a subcutaneous pouch following severe scrotal avulsion injury is also a standard line of care. Though, the occurrence of TVH in such a reposited testis is extremely rare clinical presentation. We herein report a case of 55-year male patient who presented with swelling over medial aspect of left upper thigh which was diagnosed as TVH of reposited testis on detailed assessment. The patient was managed on the usual lines of management protocols of TVH with successful outcome.

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Aim: We assessed the results of laparoscopic transperitoneal ureteroneocystostomy with or without a psoas hitch for management of lower ureteral strictures. Materials and Methods: Between October 2005 and August 2008, 16 patients with lower ureteric strictures underwent laparoscopic ureteroneocystostomy with or without a psoas hitch. Etiology of strictures was gynecological surgery in 11, surgery for stone disease in 3, ureterovaginal fistula in 1 and primary obstructive megaureter in 1. Transperitoneal 3- or 4-port laparoscopic ureteroneocystostomy was performed with or without psoas hitch. Results: All operations were successfully completed without any need for conversion to open. Mean operative time was 171.56 min (range 130 to 260 min), mean blood loss was 93.44 cc (range 30 to 200 cc) and total hospital stay was 3.73 days (range 3 to 6 days). Mean time to resume oral intake was 12.5 h (range 8 to 22 h). Mean follow-up period was 21.83 months (range 6-39 months). Postoperative follow-up investigations revealed successful outcome in all 16 patients, success being defined as relief of symptoms and radiological improvement, irrespective of the refluxing status. Non-refluxing status was achieved in 15 out of 16 patients as determined by micturition cystography. Conclusions: Laparoscopic ureteroneocystostomy is a safe and effective procedure, with inherent advantages of laparoscopic surgery.

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A new indication for testicular tissue cryopreservation is discussed here. We evaluate the feasibility of testicular sperm extraction during bilateral orchiectomy for testicular cancer. A 26-year-old man with a history of right orchidopexy presented with primary infertility. Tests revealed left varicocele and oligospermia. He underwent varicocelectomy but was lost to follow-up. Nine months later, he presented with right-sided solid testicular swelling. Ultrasound examination confirmed the finding of possible neoplasm and revealed contralateral intratesticular lesion. Since the patient turned azoospermic, no semen sample could be cryopreserved. Permanent histopathological sections revealed bilateral classical seminomas. On processing the fresh healthy looking specimen, normal-looking viable sperm were obtained. Future attempts at in-vitro fertilization with intracytoplasmic sperm injection should be possible. This method has been described in metachronous testicular cancer, but to our knowledge, we are the first to use it in synchronous bilateral testicular tumors.

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Robotic surgery is a cutting edge and minimally invasive procedure, which has generated a great deal of excitement in the urologic community. While there has been much advancement in this emerging technology, it is safe to say that robotic urologic surgery holds tremendous potential for progress in the near future. Hence, it is paramount that urologists stay up-to-date regarding new developments in the realm of robotics with respect to novel applications, limitations and opportunities for incorporation into their practice. Robot-assisted surgery provides an enhanced 3D view, increased magnification of the surgical field, better manual dexterity, relatively bloodless field, elimination of surgeon's tremor, reduction in a surgeon's fatigue and mitigation of scattered light. All these factors translate into greater precision of surgical dissection, which is imperative in providing better intraoperative and postoperative outcomes. Pioneering work assessing the feasibility of robotic surgery in urology began in the early 2000's with robot-assisted radical prostatectomy and has since expanded to procedures such as robot-assisted radical cystectomy, robot-assisted partial nephrectomy, robot-assisted nephroureterectomy and robot-assisted pyeloplasty. A MEDLINE search was used to identify recent articles (within the last two years) and publications of specific importance, which highlighted the recent developments and future direction of robotics. This review will use the aforementioned urologic surgeries as vehicles to evaluate the current status and future role of robotics in the advancement of the field of urology.

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Aim: To determine the efficacy and potential complications of double-J ureteric stents in the treatment of persistent or progressive primary obstructive megaureter in pediatric patients within our institution. Materials and Methods: A retrospective case-note review of all patients with double-J ureteric stents, between 1997 and 2004, was performed. In all, 38 stents were inserted in 31 patients aged between 2 months and 15 years of age. Complications and results of follow-up investigations and the need for follow-up investigations were recorded. Patients were followed up clinically and radiologically for a minimum of 2 years following stent insertion. Results: Endoscopic placement of double-J ureteric stents in childhood is straightforward and complications are uncommon (8/38 insertions). In non-resolving or progressive primary non-refluxing megaureter, double-J ureteric stenting alone is effective with resolution of primary non-refluxing megaureter in 66% of cases (25/38 insertions). Conclusions: Ureteric stenting provides an alternative to early surgery in patients with primary non-refluxing megaureter. The youngest patient in our series was 2 months old at the time of endoscopic ureteric double-J stent insertion. Endoscopic placement of ureteric double-J stents should be considered as a first-line treatment in the management of persistent or progressive non-refluxing megaureter leading to progressive hydronephrosis or pyonephrosis.

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Purpose : Penile carcinoma is a common disease in India. This paper shows the results of sentinel node biopsy using methylene blue and discusses the incidence of false-negative rates. Materials and Methods: From September 2005 to March 2008, 22 newly diagnosed penile carcinoma patients (T1, T2, N0) were included in this prospective study. Intraoperative lymphatic mapping was done using methylene blue dye and the sentinel node was identified and removed. Lymphadenectomy was performed for positive inguinal lymph node metastasis. Results : There were 22 patients (mean age 52.7). The tumors were mostly located in the glans (73%). Eighty six percent was T1 lesions and 14% was T2. Ninety one percent of the patients underwent partial penectomy, and 9% underwent total penectomy. Sentinel node was identified in 20 patients (90.9%). In total, 49 sentinel nodes were identified (2.45 nodes per person). Only one patient had a positive pathological lymph node metastasis at the time of the surgery. Additionally, two patients became inguinal lymph node positive at the follow-up. This data yielded a sensitivity rate of 33% and a false-negative rate of 66%. There were no complications due to methylene blue. Conclusion : Sentinel node biopsy using only methylene blue for penile carcinoma has a very low sensitivity and a high false-negative rate. However, methylene blue can be used as a substitute for lymphazurin.

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Renal subcapsular hematoma is not an uncommon complication after extracorporeal short wave lithotripsy, trauma, renal angiographic procedures and spontaneously in patients of malignancy and in patients on anticoagulation. We present a patient who developed renal subcapsular hematoma after ureterorenoscopy, which has not been mentioned in literature ever. Clinical spectrum varies from spontaneous resolution through acute renal failure to Page kidney. Page kidney is the external compression of a kidney usually caused by a subcapsular hematoma associated with high blood pressure and occasional renal failure. It is named after Dr. Irvin Page who first demonstrated in 1939 that wrapping cellophane tightly around animal kidneys could cause hypertension. Various management options are mentioned in literature and depend upon the severity of hematoma. Percutaneous drainage is a successful option for the management of subcapsular hematoma in hemodynamic stable patients.

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Context: There has been a paradigm shift in the management of ureteral calculi in the last decade with the introduction of new less invasive methods, such as ureterorenoscopy and extracorporeal shock wave lithotripsy (ESWL). Aims: Recent studies have reported excellent results with medical expulsive therapy (MET) for distal ureteral calculi, both in terms of stone expulsion and control of ureteral colic pain. Settings and Design: We conducted a comparative study in between watchful waiting and MET with tamsulosin. Materials and Methods: We conducted a comparative study in between watchful waiting (Group I) and MET with tamsulosin (Group II) in 60 patients, with a follow up of 28 days. Statistical Analysis: Independent 't' test and chi-square test. Results: Group II showed a statistically significant advantage in terms of the stone expulsion rate. The mean number of episodes of pain, mean days to stone expulsion and mean amount of analgesic dosage used were statistically significantly lower in Group II (P value is 0.007, 0.01 and 0.007, respectively) as compared to Group I. Conclusions: It is concluded that MET should be considered for uncomplicated distal ureteral calculi before ureteroscopy or extracorporeal lithotripsy. Tamsulosin has been found to increase and hasten stone expulsion rates, decrease acute attacks by acting as a spasmolytic, reduces mean days to stone expulsion and decreases analgesic dose usage.

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Context and Aim: Prostatic abscess is an unusual condition. The prevalence of prostatic abscess is about 0.5% of all prostatic diseases. The purpose of the study is to present and discuss the role of transrectal ultrasound (TRUS) in the management of prostatic abscess. Settings and Design: Retrospective study. Materials and Methods: We retrospectively reviewed the medical records of all eight patients diagnosed and treated for prostatic abscess in the last threeyears. TRUS was used for diagnosis in all cases. Four patients had TRUS guided aspiration for management of prostatic abscess. Data collected regarding etiology, clinical features, investigations and treatment was compared with the available literature. Results: The age of patients ranged from 18-65 yrs (mean 47.12 yrs). Out of the eight patients, six were diabetics. TRUS revealed one or more hypoechoic areas within the prostate in all the patients. Successful treatment of prostatic abscess with TRUS guided needle aspiration was done in all fourpatients in whom it was used. Mean hospitalization time was 9.4 days, and most frequent bacterial agent was S. aureus. Conclusions: TRUS is useful in diagnosis as well as in guidance for aspiration of such abscesses. TRUS guided needle aspiration is an effective method for treating prostatic abscess. Most of the patients are diabetics and usually grow Staphaureus. So an antibiotic with staphylococcal coverage should be used empirically.

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Purpose: To describe a case of acute superior vena cava syndrome during percutaneous nephrolithotomy (PCNL), and to review the associated clinical features, management and complications. Clinical features: A 34-year-old man, diagnosed as right renal calculi and nodal tachycardia, was admitted to receive percutaneous nephroscope laser lithotripsy. Shortly after stone disintegration, he suffered acute hypoxic and hypotension, and showed cyanoderma of face and chest skin, ocular proptosis, jugular filling and ventricular fibrillation. Dopamine and adrenaline was intravenously injected. The patient was turned over to supine position and external cardiac massage and electric defibrillation were carried out immediately. The patient finally cardioverted. His vital signs subsequently became stable and cyanoderma faded. The patient was eventually discharged from the intensive care unit three days following the event. Conclusion: Severe complications such as cardiac arrest could happen during PCNL. Close monitoring the vital signs is essential for early finding and quick response to rescue.

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Acute appendicitis may occasionally become extraordinarily complicated and life threatening yet difficult to diagnose. One such presentation is described in a 60-year-old man who was brought to the hospital due to right lumbar pain and fever for the last 15 days. Ultrasonography showed a right perinephric gas and fluid collection. Abdominal computed tomography with multidetector-row CT (MDCT) revealed gas-containing abscess in the right retroperitoneal region involving the perinephric space, extending from the lower pole of the right kidney up to the bare area of the liver. Inflamed retrocecal appendix was seen on thick multiplanar reformat images with its tip at the lower extent of the abscess. Laparotomy and retroperitoneal exploration were performed immediately and a large volume of foul smelling pus was drained. A ruptured retrocecal appendix was confirmed as the cause of the abscess.

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A case of priapism following the consumption of a single dose of sildenafil is reported. A 25-year-old unmarried healthy man consumed non-prescribed 50 mg sildenafil purchased over the counter. He developed painful priapism 30 min after the drug intake that had lasted for 4 days (96 h) when he sought medical advice as an emergency. The corpus spongiosum and glans was soft and the corpus cavernosa was rigid. Winter's shunt was done. Fifteen milliliters of dark blood was aspirated with 16 G needle. Detumescence was achieved within 30 min. He was discharged after 12 h. On one month follow-up, he had normal morning erections. A genetic basis with cross-reactivity of PDE-3 in addition to PDE-5 resulting in a cumulative erection effect may be possible elucidation for this unwanted side effect in rare cases. However, the number of cases reported with this side effect is still too less to draw further conclusions.

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Dermoid cyst is a mature-type teratoma containing sebaceous material and predominantly tufts of hair or teeth along with skin appendages. It is most commonly observed in the ovary but is rare in the testis, and only a few cases have been reported so far. In most of the reports, the cyst tended to be diagnosed in a younger age group. Here, we report a dermoid cyst of the testis in a 72-year-old man.

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Context: There are different methods of continuous ambulatory peritoneal dialysis (CAPD) catheter placement. Open surgical technique is a widely followed method. The complication rate following catheter placement varies and catheter blockage due to omental plugging is one of the main reasons. Aim: To analyze the need for routine omentectomy during CAPD catheter placement. Materials and Methods: This was a retrospective analysis of 58 CAPD catheter placements performed between July 2002 and June 2007. Tenckhoff double cuffed catheter was used in all. The postoperative complications were analyzed. Results: There were 44 males and 14 females. The mean age was 51 years ranging from 15 to 76 years. Of these, 40 (69%) patients underwent omentectomy (group A) and 18 (31%) did not (group B). Laparoscopic and open techniques were performed in 5 and 53 patients, respectively. Omentectomy was not performed in 13 patients with open technique and all the five in the laparoscopic group. One patient in group A developed hemoperitoneum which was treated conservatively. None from group A developed catheter blockage, whereas five (27.8%) from group B developed catheter blockage postoperatively. The median time interval between the primary procedure and development of catheter blockage was 45 days (ranged from 14 to 150 days). Conclusions: Omentectomy during CAPD catheter placement prevents catheter blockage and secondary interventions.

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Inflammatory pseudotumors (IPTs) are rare, nonepithelial tumors of the urinary bladder that are benign. They are very difficult to distinguish from sarcomas or carcinomas of the urinary bladder in children. Conservative surgical management by either transurethral resection or partial cystectomy is the treatment of choice. We report here a rare case of juvenile urinary bladder IPT that we managed by right partial cystectomy with right ureteric reimplantation because of involvement of the right ureteric orifice. On account of histological similarity of IPT to malignant urinary bladder tumors, it is mandatory to require definite diagnosis and long-term close follow up.

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Adrenal myelolipoma is an unusual, benign and biochemically inactive tumor that is composed of mature adipose and hematopoietic tissue. It is usually diagnosed accidentally and nowadays much more frequently because of widespread use of ultrasonography, computed tomography (CT) and magnetic resonance imaging. Adrenal myelolipoma is usually unilateral and asymptomatic, though known to be associated with obesity, hypertension, endocrinological disorders and some malignancies. We report herein two cases of right-sided giant adrenal myelolipoma diagnosed by multidetector-row CT. One patient was symptomatic because of a large mass in the right upper abdomen, which on imaging with CT was seen to be right adrenal myelolipoma. Another patient had a large left side Bochdalek hernia and right adrenal myelolipoma was incidentally discovered on CT.

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Double inferior vena cava (IVC) is a rare developmental anomaly of IVC with a prevalence rate of 0.2-0.3%. Preoperative identification of major vascular anomalies is of paramount importance for a retroperitoneal surgeon. In addition, more anomalies are to be expected in those situations. Radiological studies in similar cases may be reported as retroperitoneal lymph nodes or masses if the radiologist is unaware. In this case report, a patient with bilateral testicular tumor with double IVC who underwent extensive retroperitoneal and pelvic lymph node dissection is described for rarity of the condition and technical difficulties associated with such a condition.

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Object: The purpose was to highlight the diagnosis and treatment of extra-adrenal para-gangliomas, which often causes catecholamine hypersecretion and hypertension. Methods: 67 cases of extra-adrenal paraganglioma of retroperitoneum proven pathologically from 1999 to 2009 were reviewed and studied after operation. Endocrine secretion examinations, B-US, CT, MRI, 131-MIBG, octreotide and hands microcirculation inspection were used to diagnose the disease. Results: All patients underwent successful surgical resection of the tumors, which proved to be paragangliomas. They were from 3 cm to 25 cm in size. Almost all of them were diffusely positive for cgA, syn, NSE and s-100 by immunohitochemical staining. There were nine cases assayed malignant paraganglioma by the follow-up. Conclusions: 131-MIBG and octreotide have high sensitivity and accuracy in diagosing extra-adrenal paraganglioma. Surgical treatment should be carried out on the basis of correct drug preparation of a-receptor blocker, such as prazosin and phenoxybenzamine. Complete surgical excision is the treatment of choice for extra-adrenal paragangliomas as well as recurrent or metastatic disease, which could be resected laparoscopically. Intimate lifelong follow-up is necessary and important.

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Aims : Although nephron-sparing tumor surgery (NSS) has become a routine procedure for renal tumors under certain precautions in many centers, due to the incidence of multifocality, it still remains controversial. This study examines some clinical and pathological risk factors associated with multifocal renal tumors and also factors contributing to the success or failure of NSS. Materials and Methods: From 2000-2005, 130 patients with renal cell carcinoma (RCC) who had undergone radical nephrectomy were included in this study at one academic center. The clinicopathologic features of these cases were reviewed and categorized to identify risk factors of multifocality including age, gender, size and side of the tumor, presence of vascular invasion, Fuhrman's grade, and clinical and pathological stages. Statistical Analysis: Data were expressed as mean. Statistical significance among groups was evaluated using Chi-square test and Fisher's exact test when appropriate. Student's t test was used for comparison of two means. Multiple logistic regression analysis was performed for risk factors of multicentricity. P < . 05 was considered to indicate statistical significance. Analyses were carried out with SPSS (version 13) software. Results : In all, 88 men and 42 women were included with a mean (range) age of 57 years. Vascular invasion, nuclear grade, and pathological and clinical stages of the primary tumors were the significant predictors of multicentricity in the statistical analyses. Conclusions : These data document that multifocality of RCCs is associated with presence of vascular invasion, high grade, and advanced staged tumors. Our results support the fact that NSS is an acceptable approach to RCC without these features, as oncological safety seems less evident in such cases and should be considered for absolute indications. Future trials should be performed with adequate funding and patient-focused outcomes.

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