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   Table of Contents - Current issue
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July-September 2021
Volume 13 | Issue 3
Page Nos. 199-328

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ORIGINAL ARTICLES  

Effect of preoperative finasteride on perioperative blood loss during transurethral resection of the prostate and on microvessel density in patients with benign prostatic hyperplasia: An open label randomized controlled trial Highly accessed article p. 199
Uma Kant Dutt, Sunil Kumar, Lalgudi Narayanan Dorairajan, Bhawana Ashok Badhe, Ramanitharan Manikandan, Suresh Singh
DOI:10.4103/UA.UA_35_20  
Objective: Transurethral resection of the prostate (TURP) is a common procedure for the treatment of benign prostatic hyperplasia (BPH). Previous studies on the effect of 5-alpha reductase inhibitors on perioperative blood loss in TURP and microvessel density (MVD) in the prostate are equivocal. We evaluated whether pretreatment with finasteride for 2 weeks before surgery can reduce perioperative blood loss in TURP and MVD in the prostate. Materials and Methods: Sixty-eight patients of BPH planned for TURP were randomized into two groups. The study group comprising 34 patients was treated with finasteride (5 mg/day) for 2 weeks and the placebo group comprising 34 patients received placebo for 2 weeks, before TURP. Blood loss was measured in terms of a reduction in the blood hemoglobin (Hb) and hematocrit (HCT) levels between preoperative values and 24 h after surgery. MVD was measured in the resected prostate tissue stained with anti-CD31 monoclonal antibody. Results: The reduction of Hb and HCT in the finasteride group was significantly lower than the reduction in the placebo group (P < 0.05). The artery (P = 0.005), vein (P = 0.05), and gland (P = 0.008) densities were significantly less in the finasteride group than in the placebo group. There was no significant correlation between blood loss and MVD. Conclusions: Our study suggests a clear advantage of the preoperative use of finasteride for 2 weeks by reducing the perioperative blood loss in TURP in patients with BPH. While there is a significant reduction in MVD in the prostate on treatment with finasteride, it is not clear that this is the mechanism of reduction in blood loss in TURP.
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Synergetic effect of hookah smoking on varicocele-associated male reproductive impairment in the Saudi community in Al Jouf region, Saudi Arabia p. 205
Mohammed Jayed Alenzi
DOI:10.4103/UA.UA_68_20  
Purpose: The aim of this study is to explore the clinical relationship between the varicocele-associated male infertility with hookah smoking practice in the Saudi community in the al Jouf region. Materials and Methods: A total of 192 patients were categorized into two groups; varicocele with (Varicocele-Associated Hooka (VH) group; n = 100) and without smoking (NHV group; n = 92). Laboratory investigations such as hormonal (follicle-stimulating hormone, and luteinizing hormone [LH]), semen analysis were performed. Ultrasonography-based varicocele screening was performed. Data were analyzed with SPSS version 21.0. P < 0.05 was considered statistically significant. Results: Increased prevalence of varicocele Grade 2 (57%) and Grade 3 (52.5%) in HV groups. In contrast, Grade 1 was increased in NHV group (55.6%). A significant (P = 0.05) decrease in testosterone levels in the HV group (2.83 ± 0.21) as compared to NHV group (2.33 ± 0.07) observed. Decreased levels of sperm count (21.96 ± 6.31) and sperm morphology (14.09 ± 0.45) were observed in HV groups as compared to NHV group (22.5 ± 5.49, 14.51 ± 5.02, respectively). HV groups showed the increased diameter of the testicular vein (3.52 ± 0.71) as compared to NHV group (3.42 ± 0.72). Chronic smoking revealed a statistically significant effect on testosterone (P = 0.015) and LH levels (P < 0.041) in the HV group. In addition, hookah smoking sessions per week affect sperm motility (P = 0.02) in the HV group. A significant correlation was observed in sperm count (r = 0.24, P < 0.016) and motility (r = 0.25, P = 0.010) in HV group. Conclusion: Chronic hookah smoking significantly affects the reproductive hormonal and semen parameters in varicocele patients as compared to people with varicocele without smoking. This implies that hookah has an adverse effect on male reproductive and infertility.
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Comparison of percutaneous nephrolithotomy under epidural anesthesia versus general anesthesia: A randomized prospective study p. 210
Manzoor Ahmad Dar, Sajad Ahmad Malik, Yaser Ahmed Dar, Prince Muzafer Wani, Mohammad Saleem Wani, Arif Hamid, Abdul Rouf Khawaja, Khalid Parvez Sofi
DOI:10.4103/UA.UA_82_20  
Introduction: PCNL has revolutionized the treatment of renal calculi putting almost an end to the era of open stone surgery. The procedure can safely be carried out under general anesthesia (GA) or regional anesthesia viz. spinal anesthesia (SA), epidural anesthesia (EA) or combined spinal and epidural anesthesia (CSE). Aims and Objectives: We evaluated the surgical outcome after PCNL in two groups of patients randomly divided to undergo procedure under GA or EA. Patients and Methods: Two hundred and thirty patients with American Society of Anesthesiologists (ASA) score <3 were randomly divided into two groups according to the type of anesthesia: i.e. GA (n=110) or EA (n=120). All patients underwent PCNL in prone position. Puncture was done using Bulls eye technique under fluoroscopic guidance and tract dilated using serial dilators up to 24Fr-28 Fr. Demographics, perioperative and postoperative parameters were noted and data analysed. Results: The two groups were comparable in terms of mean age, distribution of stone location, and stone burden. The stone free rate was 90.9% in GA group and 89.2% in EA group and the difference was statistically insignificant (P= 0.659). The requirement for auxiliary procedures was similar between the two groups. A significant difference in pain score was seen in favor of EA group during early post-operative period (P< 0.05). Conclusion: It seems that PCNL can be performed safely and effectively under regional epidural anesthesia with results comparable to general anesthesia with the added advantage of less immediate postoperative pain and analgesic requirement.
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Impact of COVID-19 pandemic on urology residency training p. 215
Fahad A Alyami, Mana A Almuhaideb, Meshari A Alzahrani, Yasser S Sabr, Raed M Almannie
DOI:10.4103/UA.UA_102_20  
Context: The COVID-19 pandemic has led a lot of countries worldwide to go on lockdown. Potential collateral damage is the impact of residency. Aims: The aim of this study is to assess the impact of COVID-19 pandemic on urology training aspects, study habits of residents, and their awareness and training regarding COVID-19. Settings and Design: A questionnaire aiming to assess the impact of COVID-19 pandemic on different urology training aspects. The questionnaire was sent to all urology residents under the Saudi Commission for Health Specialties (SCFHS) programs. Subjects and Methods: Urology residents under SCFHS programs, excluding 1st-year residents. The questionnaire included the following sections: demographic data, studying habits during the pandemic, involvement in training before the pandemic, involvement in training during the pandemic, and training related to COVID-19. Statistical Analysis Used: Using the SPSS software, frequencies of all data were calculated, and a Wilcoxon-signed rank test was done to assess the change in ordinal data. Results: A total of 77 residents completed the survey (38% response rate). Most residents (40.5%) reported that they “strongly agree” with the statement that they have more time for reading. There has been a decrease in on-call duties, outpatient visits, diagnostic procedures, endoscopic surgeries urology, minimally-invasive surgeries, and major open surgeries in comparison to before the pandemic, with a decrease in mean scores in all domains, especially in diagnostic procedures. Conclusions: There has been a decrease in residents' involvement in all training domains, and this has been similar to the results of other studies. E-learning sources, during these times, present themselves as a valuable source to compensate for what has been missed in training.
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Evaluation of ultrasonographic predictors of alpha-blocker mono-therapy failure in symptomatic benign prostatic enlargement p. 220
Mohamed Radwan, Ayman Rashed, Tarek Zaghloul, Abdelnaser Elgamasy, Salah Nagla, Ayman Hagrass
DOI:10.4103/UA.UA_87_20  
Objectives: Many sonographic parameters for predicting treatment failure for benign prostate enlargement have been described. Patients may take alpha-blockers for a long time at high cost before conversion to surgery. Purpose: Evaluation of the sonographic parameters that predict alpha 1 adrenoreceptor blocker monotherapy outcomes in symptomatic patients with benign prostate enlargement. Patients and Methods: Between June 2016 and July 2019, we prospectively enrolled 750 symptomatic patients with benign prostate enlargement. Trans-rectal ultrasonography was performed, and patients were given Tamsulosin (0.4 mg) oral tablets once daily for 6 months. Treatment outcomes were determined using quality of life, the International Prostatic Symptom Score, and maximum urine flow rate measures. The values of the measured baseline sonographic parameters on treatment outcomes were statistically analyzed. Results: Seven-hundred and fifty patients completed the study, and treatment was ineffective in 225 of them (30%). From the measured prostate and bladder sonographic parameters, intra-vesical prostate growth was only significant. Using a cutoff value of 8.2 mm, the area under the receiver operator characteristic curve for intra-vesical prostatic protrusion was 0.866. Using this cutoff value (with 95% confidence interval), both positive and negative predictive values were 73.3% and 98.18%, respectively. Conclusion: Based on sonographic parameters, only the intravesical prostate protrusion was valid for predicting alpha-blocker monotherapy failure in symptomatic benign prostate enlargement patients. This information helps determine a medical therapeutic plan and the need for surgical intervention.
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A comparative study of minimally invasive percutaneous nephrolithotomy and retrograde intrarenal surgery for solitary renal stone of 1–2 cm p. 226
Mayank Jain, CS Manohar, M Nagabhushan, R Keshavamurthy
DOI:10.4103/UA.UA_10_20  
Background: PCNL is the treatment of choice for renal stones. But wide array of complications due to larger tract size(>20 Fr) has lead to development of improved techniques like miniPCNL(<20 Fr) and RIRS(Retrograde intrarenal surgery). Aim and Objective:To perform a study comparing miniPCNL with RIRS for renal stones 1-2 cm with respect to stone free rate , complications and quality of life. Materials and Methods: A prospective, randomised study was carried out our tertiary care centre, recruiting 40 patients in each group from Dec 2016 to Oct 2018. Patients demographic characteristics, operative findings, surgical outcomes and quality of life( SF-36 questionnaire) were recorded with 3 months of follow-up. Results: RIRS has longer operative time (69.75 min > 51.58 min; p=0.003), lesser radiation exposure (p=0.012), shorter hospital stay (p =0.15), lesser blood loss and lesser post operative pain on POD1 and POD2 (p =0.005, p=0.001 respectively). RIRS group patients sufferred more post op complications (p=0.03 )of which urosepsis was most common. Stone free rate is significantly better(p =0.003) in miniPCNL group on POD1 , while SFR's at 1 month (miniPCNL-90% and RIRS -85%) and 3 month (miniPCNL- 92.5% and RIRS -87.5%) was better in miniPCNL group, but statistically insignificant.On subgroup analysis SFR in lower pole calculus was better in miniPCNL group at 1month and 3 month (p=0.008). Second intervention for stone clearance was required in 3 patients of miniPCNL and 5 patients of RIRS, out of which 4 had lower pole stone.No significant differnce was found in quality of life in both groups at 1 month. Conclusion: MiniPCNL is a better treatment modality for higher single step stone free rate, shorter operative time and fewer postop complication. RIRS has SFR slightly less than miniPCNL but has less radiation exposure and much less post operative pain. There is no significant difference in quality of life in both groups.
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A randomized study comparing conventional percutaneous nephrolithotomy versus check pyeloscopic percutaneous nephrolithotomy p. 232
Rohit Purwar, Vasudevan Thirugnanasambandam, Abdulrazack Mossadeq
DOI:10.4103/UA.UA_26_20  
Objective: The objective of this study is to compare the advantages of check-pyeloscopic percutaneous nephrolithotomy (CP-PCNL) over conventional PCNL (C-PCNL) in the management of renal calculi. Materials and Methods: All patients with renal calculi requiring PCNL who attended the department of urology in a tertiary care center from December 2016 to October 2018 were included in the study. The patients were randomized into two groups of 50 each. Each group underwent PCNL in a conventional or check pyeloscopic method, respectively. Results: A total number of complications were more in C-PCNL group comprising of two pelvic tears, 8 infundibular tears, 1 minor urothelial injury, 2 cases of bleeding lasting for more than 24 hours, while in CP-PCNL group, complications were less (comprising of 1 minor urothelial injury and 1 case of infundibular tear). Statistical analysis was used to compare both the groups, and the results were statistically significant (P = 0.027). Conclusion: Check pyeloscopy at the time of PCNL is a safe, effective, and economical technique. This study shows that the complications such as blood loss, urothelial injury, and postoperative pain are less when check pyeloscopy is done during PCNL.
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Efficacy of tranexamic acid in decreasing primary hemorrhage in transurethral resection of the prostate: A novel combination of intravenous and topical approach p. 238
Abhimanyu Gupta, Shivam Priyadarshi, Nachiket Vyas, Govind Sharma
DOI:10.4103/UA.UA_41_20  
Background: Transurethral resection of the prostate (TURP) is the gold standard for benign prostatic enlargement; however, hemorrhage still remains one of the major complications. Objective: The primary aim of this study was to evaluate the effect of tranexamic acid (TXA) in reducing intraoperative blood loss and need for blood transfusion. Secondary parameters compared were operating time, volume of irrigation fluid used, and reduction in hemoglobin concentration. Subjects and Methods: A total of 70 eligible patients undergoing TURP were randomized based on computer generated table into two groups. The study group (1) received IV TXA 500 mg after induction of anesthesia and 500 mg in each irrigation fluid bottle (dual mode) and the control group (2) received none. Results: The mean age (68.20 vs. 66.5 years), prostate size (57 vs. 51 g), and preoperative hemoglobin (13.3 vs. 13.5 g/dl) were similar between the groups. Intraoperative blood loss in the TXA group was found to be significantly reduced (174.60 ± 125.38 ml vs. 232.47 ± 116.8; P = 0.04). Blood transfusion was required in 2.8% of cases as compared to 14.2% in controls. Operating time, volume of irrigation fluid, and postoperative reduction of hemoglobin were not significant between the groups. No complications were observed in both groups. Conclusion: In this study, we observed that TXA, when used as a combination of Intravenous and topical route, effectively reduced intra-operative blood loss and the need for transfusion.
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Knowledge, attitudes, and perception patterns of contraception methods: Cross-sectional study among Saudi males p. 243
Moataz Sait, Abdullah Aljarbou, Raed Almannie, Saleh Binsaleh
DOI:10.4103/UA.UA_42_20  
Purpose: The aim of this study is to assess the knowledge, attitude, and perception pattern of contraception and family planning among males in Saudi Arabia. Methods: A cross-sectional study was conducted using a self-administered questionnaire. Study sample were Saudi males who presented to the urology clinics in one tertiary center. Beside demographic data, we evaluate the responders' knowledge about types of contraceptive methods, usage of one or more methods, reasons for using contraceptives, knowledge of contraception complications, awareness of religious opinion on contraception, the ideal number of children, and birth interval between them. Statistical analysis was performed using the Chi-square and Fisher's exact tests. A value of P < 0.05 was considered statistically significant. Results: Two hundred and forty-three subjects filled the questioner. The participants' mean age was 42.7 years (range, 19–81); 227 (93.4%) were married. The majority of the participants were aware of the concept of contraception (79%). However, only 54% of the cohort reported using at least one type of contraception. A high percentage of the participants wanted a limited number of children with longer birth intervals. Many factors are responsible for increasing awareness and practice of contraception, additionally; there is limited knowledge and practice regarding male contraception, particularly vasectomy. Withdrawal technique and oral contraceptive pills for females were the most commonly used contraceptive methods for Saudi family planning. The most common reason for using birth control methods was having a lot of children. More than two-thirds of males believed that birth control methods are not prohibited by Islamic law. Conclusions: Younger age, shorter duration of marriage, governmental employee, less number of children, higher education degree, and higher monthly income had higher impact on contraception awareness and utilization. Couples still prefer noninvasive methods for contraception. Despite the relatively low use of contraceptive methods, particularly the male methods, the majority of the participants know about contraception. Efforts to advocate and promote the effective use of reproductive and sexual health services among newly married couples are warranted.
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Effect of hormonal manipulation using clomiphene citrate prior to microdissection testicular sperm retrieval p. 254
Khalid Alrabeeah, Abdulmalik Addar, Ali Alothman, Saad Abu Melha, Abdullah Alkhayal
DOI:10.4103/UA.UA_129_20  
Introduction: Microdissection Testicular Sperm Extraction (micro-TESE) is a surgical method used for retrieving sperm from men with non-obstructive azoospermia. Clomiphene citrate (CC) is a selective estrogen receptor modulator (SERM) that stimulates luteinizing hormone (LH) and follicle-stimulating hormone (FSH) production. It is believed that treating patients with CC prior to micro-TESE increases the chance of sperm retrieval. Methods: This retrospective study was conducted in a tertiary care center in Riyadh, Saudi Arabia and included all patients who underwent Micro-TESE from August 2015 to November 2018. Data related to the pre-surgery hormonal levels, testicular volume, and associated genetic abnormalities were collected. chi-square and t-test were used to compare variables. A p-value of less than 0.05 was considered significant. Results: A total of 122 patients were included in this study, with 30.0% (n=37) treated with CC. The overall sperm retrieval rate was 44.3%. Micro-TESE results were not statistically affected by age, testosterone levels, Klinefelter syndrome, or taking CC. However, higher testicular volumes and lower LH and FSH levels had more positive micro-TESE results. Conclusion: In conclusion, Micro-TESE results were not affected by CC, age or testicular volume.
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Outcomes of flexible uretrorenoscopy for solitary renal stones up to 15 mm, hits and misses: A single-surgeon experience p. 258
Rahul Gupta, Arti Mahajan, Sunana Gupta, Suhail Masood
DOI:10.4103/UA.UA_51_20  
Abstract: Introduction: In this study, we retrospectively evaluated the outcomes of flexible uretrorenoscopy (fURS) for removal of solitary renal stones sized up to 15 mm. Material and Methods: We evaluated the data of 115 patients who underwent fURS at our unit between Jan 2018 and Dec 2019. All fURS were performed by a single surgeon using Flex-2 flexiscope. Ureteral Access sheath (UAS) of size 9/11 fr was used in all patients. Stones were fragmented using 20 watts laser. Few fragments were retrieved using Nitinol zero tip basket for assessment of the passability of remaining dust and sent for stone analysis. Data pertaining to demographic characteristics, stone size, stone site, operative time, intra and post operative complications were retrieved from the records. Results: Of the 115 patients who underwent fURS, 71 (61.7%) were male and 44 (38.2%) were female. Average age of patients was 32.9±8.9 years; the average body mass index was 22.9±3.9 kg/m2. Average size of the stone was 11.0±1.5 × 10.2±1.3 mm. The stone free rates at the end of 3 weeks and 3 months were 97% and 99%, respectively. Conclusion: fURS is an effective minimally-invasive procedure for removal of single stones up to 15 mm in size. We observed minimal morbidity rates and acceptable stone free rates in our series.
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Urge suppression and modified fluid consumption in the management of female overactive bladder symptoms p. 263
Manidip Pal, Ranita Roy Chowdhury, Soma Bandyopadhyay
DOI:10.4103/UA.UA_52_20  
Background: At the initial management of overactive bladder (OAB) syndrome urge suppression technique along with other behavioural modification could be a good option. Methods: Prospective experimental study conducted between 2015 and 2019. Women complaining of OAB were enrolled. Three-day bladder diary and patient global impression of severity (PGI-S) scale were evaluated at baseline. Then, the women were asked to perform the urge suppression technique whenever urgency occurred. She stopped moving, sat down and started squeezing the pelvic floor muscle quickly and tightly about ten times without full relaxation in between squeezes. After that, she did something to distract her mind. Once urgency disappeared, she proceeded to the toilet. If urgency reappeared, she stopped moving and repeated the same thing. Only on relax mood she entered toilet. Modified fluid consumption was - total daily requirement divided into three parts and two-third of that was taken from morning to lunch. The remaining one-third was divided again in three parts and two-third of that was taken before evening. Rest few amount was taken from the evening till waking up the next morning. After 3 months, 3-day bladder diary and patient global impression of improvement (PGI-I) scale assessed the improvement. Results: Ninety-one women ultimately completed the study. Frequency and nocturia were reduced. Seventy-six women had improvement of their urgency sensation (P < 0.001), whereas urgency urinary incontinence reduction was statistically not significant (P > 0.05). PGI-I scale showed that 51.6% felt that either they were very much better or much better. Conclusion: Urge suppression and modified fluid consumption is good adjunct in female OAB management.
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The yield of microscopic varicocelectomy in men with severe oligospermia p. 268
Abdulmalik M Addar, Ahmed Nazer, Abdulmalik Almardawi, Naif Al Hathal, Said Kattan
DOI:10.4103/UA.UA_53_20  
Introduction: Varicocele is detected in 35%–50% of men with primary infertility and up to 81% with secondary infertility. Various studies have shown that varicocele is related to testicular hypotrophy and impaired spermatogenesis. The effect of varicocelectomy in mild-to-moderate male factor infertility has been well reported. However, only a few studies addressed the impact of varicocelectomy in severe oligospermia. Methods: We included 45 patients with severe oligospermia (<5 million/mL) who underwent microsurgical varicocelectomy between May 2014 and November 2017. Results of semen analysis taken at 6 months after varicocelectomy were compared and patients were divided into responders and nonresponders. Chi-square was used to compare the preoperative and postoperative sperm count, motility, and volume. Results: After 6 months only one patient was found to be a responder with a pre- to post-operative motility of 45%–74% and a sperm concentration of 1 million/mL to 28.1 million/mL. There was a significant improvement in the mean sperm concentration after varicocelectomy which improved from 1.31 million/mL to 5.32 million/mL. However, a significant decrease in sperm motility was noted which decreased from 35.62% to 28.64% postoperatively. Postoperative semen volume increased from 2.56 mL to 3.19 mL, but this difference was not found to be statistically significant (P > 0.05). Four patients (8.9%) were found to have azoospermia after a 6-month follow-up. In these four patients who turned azoospermic had count <50,000 sperm/mL, two of them had a history of cryptospermia before varicocelectomy. Ejaculate sperm returned in two of these four patients in long-term follow-up (>6 months). Conclusion: The magnitude of improvement after microsurgical varicocelectomy for severely oligospermic patients is less profound than reported in mild male factor infertility.
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Survey of Saudi urology program directors: What do you look for in a candidate? p. 272
Fahad A Alyami, Mana A Almuhaideb, Meshari A Alzahrani, Abdulaziz M Althunayan, Raed M Almannie
DOI:10.4103/UA.UA_146_20  
Introduction: Prospective urology applicants in Saudi Arabia must go through a rigorous matching process. Defining which aspects of an applicant's portfolio or interview will get them matched is difficult. Our objective is to provide information on which aspects of an application are the most important. Subjects and Methods: In this cross-sectional study, an electronic survey was sent out to all urology program directors (PD). The survey included 27 items from an application that were rated by the respondent using a 5-point Likert scale. Results: Twenty-three urology PD completed the survey (79.3% response rate). Most of the PD subspecialized in endourology and minimally invasive surgery. The three most important aspects as perceived by all responding PD were as follows: performance during rotation at the respondent's centre, publications in urology, and the total number of electives in urology. The three least important factors were as follows: presentations in fields other than urology, recommendation letters from nonurologists, and quality reference letters from nonurologists. Conclusion: Performance during rotations has been shown in our and other studies to be one of the most important factors in an application. Surveying PD on what they value the most in an applicant, provides valuable information and more transparency regarding the match processes. We also recommend that our colleagues from different specialties conduct similar studies.
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Outcome of conservative and minimally invasive management in emphysematous pyelonephritis p. 277
Soumish Sengupta, Supriyo Basu
DOI:10.4103/UA.UA_85_20  
Context: Developing countries. Introduction: Emphysematous pyelonephritis (EPN) is a urologic emergency characterized by acute necrotizing infection with the presence of gas in the kidney, perinephric space, and/or urinary collecting system. Materials and Methods: It is a retrospective study of inpatients at the Department of Urology, RG Kar Medical College and Hospital, Kolkata, which includes twenty patients diagnosed as EPN between September of 2018 and May of 2020. Results: Patients were classified as per computed tomography (CT) severity grading proposed by Huang and Tseng. In our study, medical management with antibiotics was effective in 10% of patients. Twenty percent of patients were treated with medical management and internal ureteral stenting. Fifty percent of the patients were treated with medical management and percutaneous nephrostomy (PCN). Ten percent needed PCN drainage in addition to Double J (DJ) stenting. Ten percent needed percutaneous drainage of perinephric abscess along with PCN. Ten percent of patients were treated with open drainage in addition to DJ stenting and percutaneous drainage of perinephric collection as they failed to respond to minimally invasive intervention alone, with repeat ultrasonography showing persistent collection. There was no mortality in the group. Conclusion: EPN patients are mostly moribund with multiple comorbidities. It is vital to comprehend the management with a prompt CT imaging. Proactive hemodynamic stabilization, antimicrobial therapy, complementing it with DJ stenting and/or PCN in cases not responding to antibiotics alone, can treat most of the patients with this pathology.
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Predictors of success following extracorporeal shock-wave lithotripsy in a contemporary cohort p. 282
Mohit Bajaj, Russell Smith, Michael Rice, Kamran Zargar-Shoshtari
DOI:10.4103/UA.UA_155_19  
Objectives: The objectives of this study are to determine the predictors of success following extracorporeal shock-wave lithotripsy (ESWL) in a contemporary cohort at a high-volume stone center. Methods: We conducted a retrospective review all patients who underwent an elective ESWL within our institution over a 24-month period (January 2014 to December 2015). Data on patient demographics, stone variables, and inpatient treatment outcomes were evaluated. The presence of residual stone fragments larger than 4 mm on follow-up imaging was considered to be treatment failure. Using this threshold, clinically relevant variables between the treatment success and failure groups were identified. Multivariable logistic regression analyses (MVA) of clinically relevant variables were used to determine the independent factors predicting ESWL success. Results: Of 446 study eligible patients, 421 patients had complete follow-up data and were included in the analysis. Treatment was successful in 72.2% of patients in this study. Stone size, number of shocks delivered, and maximum treatment intensity were statistically different in the two groups. In a MVA where stone size, location, density, presence of ureteric stent, skin-stone distance (SSD), number of shocks, and maximum shock intensity were included, only stone size of <10 mm (odds ratio [OR] 3.4 [95% confidence interval [CI]: 1.98–5.84]) and SSD <15 cm (OR: 0.133, [95% CI: 0.027–0.65]) were the independent predictor of ESWL success. Conclusion: We have demonstrated “real world” outcomes with high-volume use of ESWL. In our experience that with diligent patient selection, ESWL remains an effective tool for the management of upper tract calculi.
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Effect of bladder cancer variant histology on survival outcome in patients treated with radical cystectomy: A single-centre experience p. 288
Selim Komina, Gordana Petrusevska, Vesna Janevska, Rubens Jovanovic, Pance Zdravkovski, Skender Saidi, Beti Ivanovska Zafirovska, Sonja Topuzovska
DOI:10.4103/UA.UA_95_20  
Context: Bladder cancer (BC) is the sixth most common malignant neoplasm in men. Recently, great effort has been devoted to the study of BC variant histology (VH). Yet, the results from these studies have shown conflicting data and remain unclear whether their presence alters recurrence and survival rates after radical cystectomy (RC). Aims: We undertook this study aiming to test the effect on VH on recurrence-free survival (RFS) and overall survival (OS) in single-center RC patients. Settings and Design: We have retrospectively analyzed medical records and pathology reports from 331 patients who underwent RC with or without pelvic lymphadenectomy at University Urology Clinic-Skopje, North Macedonia, in the period between 2010 and 2018. Subjects and Methods: Microscopic analysis of the specimens involved the evaluation of histological tumor type, tumor grade, pathological tumor node metastasis stage, presence of lymphovascular invasion, and resection margin status. Statistical Analysis Used: Univariable and multivariable Cox regression models were applied to test the effect of VH on RFS and OS. Results: We found 185 patients who matched our inclusion criteria. At multivariable analyses, lymphovascular invasion and positive resection margins were associated with shorter RFS. Similarly, patients diagnosed with lymphovascular invasion, positive resection margins, and a pelvic lymph node metastasis had poorer OS. VH was not found to be an independent predictor of both RFS and OS (P > 0.05). Conclusions: The present study did not reveal prognostic effect of VH on RFS and OS. In our series, histomorphologic parameters including lymphovascular invasion, resection margins, and pelvic lymph node metastasis were the most relevant predictors on survival outcome after RC.
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Cutoff level of prostate volume to predict the efficacy of α1-D/A adrenoceptor antagonist, naftopidil p. 296
Yasushi Tanuma, Yoshinori Tanaka, Tomoshi Okamoto
DOI:10.4103/UA.UA_93_20  
Introduction: In lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) patients, prostate volume (PV) at baseline affects the improvement of International Prostate Symptom Score voiding symptoms (IPSS-VS) by naftopidil (NAF), but not total IPSS (IPSS-TS). To predict the efficacy of NAF, the PV cutoff point was examined using IPSS-VS. Materials and Methods: Seventy-seven patients with LUTS/BPH were administrated with NAF 50 mg/day for 4 weeks. Age, PV, IPSS, IPSS quality-of-life (IPSS-QoL), and maximum flow rate (MFR) were evaluated at baseline, and IPSS, IPSS-QoL, and MFR were evaluated after the treatment (at 4 weeks). Responders and nonresponders were divided by IPSS-VS at 4 weeks, and the PV cutoff point was calculated. Results: At baseline, the mean age and PV were 70.7 ± 8.2 years (range, 54–88 years) and 43.3 ± 24.5 mL (range, 20.6–141.7 mL), respectively. After 4 weeks, area under the receiver operating characteristic curve was largest in the patients with <4 points of IPSS-VS. The best standard value to evaluate the efficacy IPSS-VS at 4 weeks was 4 points for the NAF treatment, and the best PV cutoff point was 37.3 mL (sensitivity 60.5%, specificity 71.9%). Conclusions: PV at baseline was one of the predictive factors which affected the efficacy of NAF for IPSS-VS, and LUTS/BPH patients who had PV more than 37.3 mL indicated poor improvement of IPSS-VS, even if IPSS-TS was improved.
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Subtotal vesical necrosis as a result of infected traumatic bladder hematoma: A rare case with a literature review of bladder necrosis due to hematoma p. 301
Rohan Valsangkar, Bhalchandra Kashypi, Jaydeep Date, Subodh Shivde
DOI:10.4103/UA.UA_101_20  
Subtotal bladder necrosis following bladder hematoma is rare. We report such a case following blunt abdominal injury. The urologic presentation was delayed hematuria which settled with conservative management but was followed by the development of urosepsis. Computed tomography scan showed full bladder due to long-standing liquified bladder hematoma. Suprapubic exploration revealed a bladder wall abscess which was drained (secondarily infected hematoma). Excision of the subtotal necrotic bladder and ileal conduit with left ureteroileal anastomosis was done later. The patient also had a simultaneous right renal and ureteric injury as an independent simultaneous event which required initial nephrostomy placement. It later healed with complete obliteration of the right renal pelvis which was managed by right nephrectomy later. A literature review of cases of vesical necrosis caused by hematomas (of different locations and etiology) is discussed.
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Pelvic organ prolapse in a woman with previous mitrofanoff operation: Management of a case p. 305
Gowri Dorairajan, Murali Subbaiah, Vandana Bojja, Dorairajan Narayanan Lalgudi
DOI:10.4103/UA.UA_114_20  
Mitrofanoff operation or vesico-appendicostmy is a continent conduit operation performed for intractable incontinence. The long-term complications reported in the literature are related to the stoma. Pelvic organ prolapse among women who have undergone this surgery is not reported earlier. A woman of 27 years of age presented with uterovaginal prolapse. She had sustained bladder neck transection following a road traffic accident at 16 years of age. The same was primarily repaired but incontinence had remained. Many standard operations for incontinence were performed. Finally, Mitrofanoff operation was carried out 9 years back because of persisting intractable incontinence. She got married and had two uneventful vaginal deliveries 5 and 2 years back. There was supravaginal elongation of the cervix with a rectocele. After counseling Fothergills operation with laparoscopic ligation was performed. The challenges and details of the management of the case are highlighted.
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Testicular fibroma: A case report and literature review p. 308
Amal M Algarni, Noor Nabi Junejo, Sultan S Alkhateeb, Turki Omar Al-Hussain
DOI:10.4103/UA.UA_119_20  
Sex cord-stromal tumors are the second most common testicular tumors after germ cell tumors. They account for about 2%–5% of adult testicular tumors. Most of these tumors are benign. The most common sex cord-stromal tumor is Leydig cell tumor. In contrast, testicular fibroma is a very rare type of sex cord-stromal tumors. Histologically, testicular fibromas resemble their ovarian counterparts; however, they are much less common than ovarian fibromas. To the best of our knowledge, <50 cases of testicular fibromas are reported in the English literature. Herein, we report a rare case of testicular fibroma with acellular collagen plaque in a 51-year-old male presenting as a painless testicular mass.
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Emphysematous cystitis: A case report and literature review of 113 cases p. 312
Satish Kumar Ranjan, Shiv Charan Navriya, Sunil Kumar, Ankur Mittal, Deepak Prakash Bhirud
DOI:10.4103/UA.UA_61_20  
Emphysematous cystitis (EC) is a rare complicated urinary tract infection characterized by gas formation within the wall of the urinary bladder. Although EC has multifactorial etiology, commonly seen in elderly, diabetic and female sex; most of the cases of EC present along with emphysematous pyelonephritis (EPN) and full-blown urosepsis. We present a case of EC with EPN presented with features of sepsis managed conservatively. Furthermore, we reviewed the literature of published cases reports of EC with or without EPN from 1999 to 2019 (20 Years). From eligible 113 case reports, data of clinical presentation, demographic profile, risk factors, diagnostic methods, treatment, and prognosis were analyzed.
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Robotic-assisted excision of a juxta renal retroperitoneal schwannoma p. 316
Abdulelah Al Gosaibi, Abdulaziz Al Mulhim, Meshaal Al Sadhan, Ali Alkharji, Emad Rajih, Abdullah M Alenizi
DOI:10.4103/UA.UA_99_20  
Retroperitoneal schwannoma is a rare benign tumor of the peripheral nerve Schwann sheath. We, herein, report the case of a 74-year-old woman who presented with vague abdominal pain. Computed tomography imaging revealed a retroperitoneal mass that is medial to the right kidney. The patient underwent robotic excision of the tumor with the pathology revealing schwannoma. We report this case due to the scarcity of this disease entity, especially at this location and to emphasize the indication and value of robotic technology in different pathological processes retroperitoneally.
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Renal cell carcinoma in a duplex kidney in pediatric p. 320
Naif Alqarni, Awatif Alanazi, Abdulmohsin Afaddagh, Samir Eldahshan, Mohammed Alshayie, Ahmad Alshammari
DOI:10.4103/UA.UA_126_20  
Renal cell carcinoma (RCC) in children is relatively uncommon, especially in the absence of syndromes or hereditary diseases. Duplex kidney – as a common congenital anomalies in children – is usually insignificant with no serious impact or known risk of tumor association. Herein, we report a 5-year-old girl who presented with gross hematuria and a right renal mass in duplex system identified on computed tomography. Radical nephrectomy was performed; the patient was diagnosed with Xp11 translocation RCC and no other modalities of treatments were needed over 3-month follow-up.
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Bladder endocervicosis: Recurrent presentations during pregnancy p. 323
Danielle Whiting, Ahmed Ali
DOI:10.4103/UA.UA_115_20  
Bladder endocervicosis describes the ectopic presence of endocervical tissue within the bladder. It is a rare condition with an unclear aetiology. We report the case of a 29-year-old woman who presented with bladder endocervicosis during her first pregnancy with recurrence during her second pregnancy. On both occasions, the patient was treated with transurethral resection and the lesion recurred. This is the first case in the literature of bladder endocervicosis presenting during pregnancy and suggests a hormonal stimulus is important in its development.
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Is radical cystectomy an overtreatment for T1 high-grade transitional cell carcinoma of the bladder? Lesson learnt from case series p. 326
John Brandon Arruda, Mohamad Waseem Salkini
DOI:10.4103/UA.UA_23_20  
The introduction of intravesical bacillus Calmette–Guérin (BCG) made a breakthrough in the treatment of high-grade nonmuscle-invasive bladder cancer. Indeed, the intravesical immunotherapy helped many patients in preserving their bladder for a period of time. However, many studies revealed that <50% of the patient will be able to maintain their bladder in 5 years of follow-up. The shortage of BCG adds to the odds of cancer progression and patient suffering. We present a series of three cases of disease progression despite the confirmed pathologic local staging of the bladder cancer to be nonmuscle disease. The message we would like to address from this review is that radical cystectomy is not an overtreatment of this potentially lethal disease.
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