A comparison of DAP and RENAL scoring systems in the achievement of trifecta in laparoscopic partial nephrectomy.

PURPOSE: The concept of 'trifecta' outcome postulated for radical prostatectomy has been adopted for partial nephrectomy, the gold standard for management of small renal masses. We sought to evaluate the role of nephrometry scores in predicting outcomes in terms of the trifecta. We compared two scoring systems for renal tumour complexity (RENAL and DAP) in the prediction of trifecta outcomes. MATERIALS AND METHODS: Sixty-nine patients who underwent laparoscopic PN (LPN) were evaluated in a single-centre retrospective study (2010-2017). RENAL and DAP scores were measured. Parameters relevant to the trifecta were tabulated. RESULTS: When comparing the two scoring systems in terms of warm ischaemia time (WIT), the DAP score could predict with statistically significant accuracy the completion of resection within 25 mins of WIT. Tumours were more evenly distributed according to anatomical characteristics with the DAP scoring system than with the RENAL scoring system. When comparing these systems in terms of complications, neither predicted complications based on complexity with significant accuracy. A low RENAL score predicted trifecta achievement in three-fourth (71.4%) of patients, while a medium RENAL score predicted trifecta achievement in half (54%) of patients. DAP score predicted trifecta achievement in all tumours with a low score, two-third (66%) in medium and less than half (42%) with a high score. Predictions based on DAP were accurate and significantly so (p = 0.024). CONCLUSIONS: DAP score predicted the outcomes of LPN in terms of trifecta significantly better than the RENAL score. In our experience, the DAP score was able to distribute tumour complexity among its groups more effectively than the RENAL score. There is early evidence that the DAP score may be more useful than the RENAL score for decision-making in nephron sparing surgery. This is especially pertinent for small renal masses at the upper limits of tumour complexity for which minimally invasive techniques can be safely applied.

Efficacy of 1 versus 3 days of intravenous amikacin as a prophylaxis for patients undergoing transurethral resection of the prostate: A prospective randomized trial.

INTRODUCTION: There are no uniform guidelines on the duration of antibiotic prophylaxis for transurethral resection of the prostate (TURP). The objective of this study was to evaluate the efficacy of 1 day versus 3 days of intravenous amikacin as prophylaxis, before TURP. MATERIALS AND METHODS: In this prospective randomized control trial, patients with sterile preoperative urine culture were randomized to receive either 1 day (Group A) or 3 days (Group B) of intravenous (IV) amikacin. All patients had their catheter removed on the 3rd day and a midstream urine culture was obtained on the 4th day. The follow-up was scheduled at 1 week and at 1 month. The rate of bacteriuria on the 4th postoperative day was analyzed as the primary outcome. The secondary outcomes included symptomatic urinary tract infection (UTI), its risk factors, and other complications at 1 month. RESULTS: Of the 338 patients randomized, 314 patients were evaluable until day 7 and 307 until 1 month. Bacteriuria rate at day 4 (Group A: 8.8% [95% confidence interval (CI): 4.2-13.2]; Group B: 4.4% [95% CI: 1.2%-7.7%], P = 0.124, Fisher's exact test) was similar in both the groups. At 1 month, the rate of symptomatic UTI was also similar in both the groups (3.5% [95% CI: 0.8-6.9] vs. 1.7% [95% CI: 0.2-4.2], P = 0.344, Fisher's exact test). Bacteriuria (colony-forming unit, >104/ml) at day 4 was a significant risk factor for developing symptomatic UTI (P = 0.006). Antibiotic resistance was higher in Group B (P = 0.002) (Group A: 7.1% [95% CI: 6.3-20] vs. Group B: [71%, CI: 38-104], P = 0.0021, Fisher's exact test). CONCLUSION: One day is possibly noninferior to 3 days of IV amikacin as prophylaxis in patients undergoing TURP with respect to bacteriuria and symptomatic UTI, with an added advantage of lower antibiotic resistance.

Diagnostic accuracy of urinary aquaporin-1 as a biomarker for renal cell carcinoma.

INTRODUCTION: Optimal patient selection plays a vital role in management of renal tumors with the introduction of nephron-sparing approaches and active surveillance. A reliable and accurate diagnostic biomarker will be a useful adjunct to decision-making. We studied the diagnostic accuracy of urinary aquaporin-1 (uAQP-1), an upcoming urinary biomarker, for renal cell carcinoma. MATERIALS AND METHODS: In this prospective biomarker study, urine samples were obtained preoperatively from 36 patients with an imaged renal mass suggestive of RCC and 24 healthy age-matched controls, chosen from among voluntary kidney donors. uAQP-1 concentrations were estimated with a sensitive and specific enzyme-linked immunosorbent assay (ELISA) and normalized by estimation of urinary creatinine. The Mann-Whitney U-test was used to compare differences between any two groups. A receiver operator characteristic (ROC) curve was plotted to analyze the diagnostic accuracy of uAQP-1 for RCC. RESULTS: The median uAQP-1 concentration among the cases and controls was 8.78 ng/mg creatinine (interquartile range [IQR]: 5.56-12.67) and 9.52 ng/mg creatinine (IQR: 5.55-12.45), respectively. There was no significant difference in uAQP-1 concentrations between the two groups. ROC analysis showed that, for a cutoff value of 8 ng/mg creatinine, the sensitivity and specificity of uAQP-1 as a diagnostic test were 47.2% and 66.7%, respectively, and area under the curve was 0.52 (95% confidence interval: 0.42-0.62). CONCLUSIONS: uAQP-1 concentrations did not discriminate between healthy individuals and patients with RCC. The results of this study suggest that uAQP-1 may not be a suitable diagnostic biomarker for RCC in the study population.

Satisfaction and genital perception after orchiectomy for prostate cancer: does the technique matter? A randomized trial.

OBJECTIVES: Bilateral extracapsular or total orchiectomy (BEO) for prostate cancer is presumed to have psychological consequences after the surgery due to perception of an empty scrotum. Bilateral subcapsular orchiectomy (BSO) was designed to preserve perception of palpable testes. We compared the patients' satisfaction and genital perception following BEO and BSO. MATERIALS AND METHODS: Prostate cancer patients eligible for androgen deprivation therapy who opted for orchiectomy were enrolled in prospective randomized study. Patients with bleeding disorder or uncorrected coagulopathy, poor performance score, and psychiatric problems were excluded. Outlook to life and own health in-general, overall satisfaction to the procedure and genital perception was evaluated using modified Fugl-Meyer questionnaire (FMQ) which was administered before and after 3 months of the surgery. Patients were randomized to BEO and BSO groups at the time of surgery using block randomization. Primary outcome was to compare the genital perception of testicular loss and patients' satisfaction to BSO and BEO. Secondary outcomes included testosterone and PSA control, operative time, and complications. RESULTS: Total 35 patients were enrolled in each group which was comparable. There was no difference in PSA control at 3 months. Mean operative time and blood loss were significantly lesser in BEO group. FMQ score at 3 months did not show significant difference. Majority of the patients in both groups were satisfied with procedure and the aesthetic value of scrotum after surgery. However, 84% in BSO group did not feel that testes were removed on self-examination, as compared to 28% in BEO group. Majority patients in both groups did not report physical or psychological discomfort from change in scrotal content. CONCLUSIONS: Results showed that patients' satisfaction and genital perception following BSO and BEO were similar. Feeling of remaining intrascrotal contents after BSO did not had added psychological advantage in terms of perception of genitalia.

Tamsulosin and placebo vs tamsulosin and tadalafil in male lower urinary tract symptoms: a double-blinded, randomised controlled trial.

OBJECTIVE: To compare the efficacy and safety of tamsulosin vs the combination of tamsulosin and tadalafil in male lower urinary tract symptoms (LUTS). PATIENTS AND METHODS: This was a double-blinded, parallel-arm randomised controlled trial. Men aged >45 years with moderate LUTS and a maximum urinary flow rate (Qmax ) of 5-15 mL/s were included. One arm received 0.4 mg tamsulosin only (Group-A), while the second received 5 mg tadalafil with tamsulosin (Group-B). The primary outcome was the International Prostate Symptom Score (IPSS). Secondary outcomes were IPSS quality of life (QoL) score, five-item version of the International Index of Erectile Function (IIEF-5) score, Qmax , and post-void residual urine (PVR). Block randomisation was used. Placebo was used for blinding and allocation concealment. Intention-to-treat analysis was used for outcome measures. RESULTS: Of the 183 men screened, 140 were randomised (71 in Group-A, 69 in Group-B); 116 (82.85%) (61 in Group-A, 55 in Group-B) completed the study. Baseline characteristics were comparable. The improvements in the IPSS, IPSS QoL score, IIEF score and Qmax were -1.69 (95% confidence interval [CI] -1.4 to -2.0), -0.70 (95% CI -0.60 to -0.80), 3.8 (95% CI 3.4-4.2) and 1.8 mL/s (95% CI 1.1-2.4) respectively, in favour of the combination group. The difference in PVR was not significant. There were no serious adverse events (AEs). The dropout rate due to AEs was 2.85%. Myalgia (five patients) was the commonest AE in the combination group. CONCLUSION: The combination of tamsulosin and tadalafil produced significantly better improvements in LUTS, QoL, erectile function and Qmax compared to monotherapy with tamsulosin, without an increase in AEs.

Chyluria with massive proteinuria: Do not reach for the biopsy gun!

We report on a patient presenting with persistent chyluria due to filariasis, whose clinical course was complicated by massive proteinuria and severe hypoalbuminemia. Treatment with dietary manipulation, antifilarials, and sclerotherapy resulted in successful reversal of the above abnormalities. It has been reported that chyluria is not associated with massive proteinuria, or that even in cases of massive proteinuria, hypoalbuminemia is not seen and implies a glomerular pathology. We argue that chyluria is always associated with proteinuria, which may be massive, and does not warrant a kidney biopsy unless proteinuria persists despite resolution of chyluria.

Susceptibility profile, resistance mechanisms & efficacy ratios of fosfomycin, nitrofurantoin & colistin for carbapenem-resistant Enterobacteriaceae causing urinary tract infections.

Background & objectives: The escalation in carbapenem resistance among Enterobacteriaceae has resulted in a lack of effective therapeutic alternatives. Older antimicrobials, fosfomycin, nitrofurantoin and colistin for urinary tract infections (UTIs) caused by carbapenem-resistant Enterobacteriaceae (CRE) may be effective treatment options. The objectives of this study were to evaluate the utility of fosfomycin, nitrofurantoin and colistin in treating UTI caused by CRE and molecular characterization of the plasmid-mediated carbapenem resistance mechanisms. Methods: Consecutive, non-duplicate isolates of CR Escherichia coli and Klebsiella spp. from urine cultures were included (n=150). Minimum inhibitory concentrations (MIC) were determined by E-test (fosfomycin and nitrofurantoin) and broth microdilution (colistin). Efficacy ratios were derived by dividing susceptibility breakpoints by observed MIC values of the drugs for the isolates. Isolates were screened for genes coding for carbapenemases using multiplex PCR. Fosfomycin, nitrofurantoin and colistin-resistant isolates were screened for plasmid-borne resistance genes fos A3, oqx AB and mcr-1, respectively using PCR. Results: Among E. coli, 98.9, 56 and 95 per cent isolates were susceptible to fosfomycin, nitrofurantoin and colistin, respectively, while 94 and 85 per cent of Klebsiella spp. were susceptible to fosfomycin and colistin, respectively. The efficacy ratios indicated fosfomycin as the drug of choice for UTI caused by CR E. coli and Klebsiella spp., followed by colistin. The blaNDM gene was most common, followed by blaOXA48-like. Plasmid-borne genes encoding resistance to fosfomycin, nitrofurantoin and colistin were absent. Interpretation & conclusions: With increasing resistance against the current treatment options, older drugs may emerge as effective options. Molecular screening of resistant isolates is essential to prevent the spread of plasmid-borne resistance against these drugs.

Attitude and perceived barriers towards the practice of evidence-based urology amongst urological trainees in India.

INTRODUCTION: Evidence-based medicine requires systematic access and appraisal of contemporary research findings, followed by their application in clinical practice. It assumes an even greater significance in the current era of aggressive, industry-driven marketing. METHODS: A questionnaire was designed combining the McColl questionnaire and Barrier scale with relevant modifications and was administered to the urology trainees attending a continuing urological education program. Statistical analysis was performed using SPSS version 25. RESULTS: The meeting was attended by 110 urological trainees from 55 urological training centers all over India. One hundred and three of them agreed to participate in the study. About 92% of the questionnaires were fully completed. Less than half of the participants (47%) had access to reliable urological literature at work. Only 11% of the respondents claimed to have been formally trained in evidence-based urology (EBU). The inability to understand statistical analysis was the most common (67.4%) perceived barrier to EBU. CONCLUSION: The urological trainees in India are positively inclined towards EBU. The lack of formal training in appraising the available literature and lack of protected time, and portals to access the literature at workplaces hinder them from improving their compliance to EBU.

The Impact of Narrow Band Imaging in the Detection and Resection of Bladder Tumor in Transitional Cell Carcinoma of the Bladder: A Prospective, Blinded, Sequential Intervention Randomized Controlled Trial.

OBJECTIVE: To determine the impact of Narrow Band Imaging (NBI) in detection and resection of tumors during transurethral resection of bladder cancer. MATERIALS AND METHODS: This was a single center randomized prospective interventional study with a sequential intervention design. Patients with bladder tumors were randomized into 2 arms where they were resected under white light (WL) first followed by NBI in arm A, or NBI followed by WL in arm B. The number of patients in whom additional lesions were detected by the second light source, in both arms, was analyzed. The feasibility of initial resection of tumor under NBI was also studied. RESULTS: A total of 110 patients were randomized. Of 54 patients in arm A (WL first) additional lesions were identified at the second look in 20 patients (37%). In contrast, of 56 patients in arm B (NBI first), additional lesions were identified in 5(9%) patients. This difference of 28% was statistically significant (P value <.001). In arm B (NBI first), there were 7 breaches in protocol, and all these patients had high risk (more than or equal to 3 in number or 3 cm in size) tumors (P value <.002). CONCLUSION: Narrowband imaging is superior to WL in the detection of tumors, thus allowing a more complete resection. However, initial resection under NBI is difficult due to poor visibility, especially for high-risk tumors.

Can kidneys be saved in patients with urinary tuberculosis? A study in the era of modern chemotherapy and surgical armamentarium.

OBJECTIVE: To assess renal unit survival and factors affecting renal salvageability in a cohort of patients receiving modern medical and surgical therapy for urinary tuberculosis. METHODS: This was a retrospective single-center study including all patients diagnosed and treated as urinary tuberculosis between 2005 and 2015 at Christian Medical College, Vellore, Tamil Nadu, India. The primary outcome was time to renal unit non-salvageability (estimated glomerular filtration rate of <15 mL/min). RESULTS: A total of 128 patients were included in the study. The mean age was 37.7 ± 11.3 years, 33% had microbiological and 73% had histopathological confirmation in addition to radiological diagnosis. The estimated median survival of the involved renal units (n = 187) on Kaplan-Meier estimate was 75 months (95% CI 39-99). On multivariate analysis, renal units with initial split function >15 mL/min had fivefold the survival estimate as compared with those ≤15 mL/min (P < 0.001); the presence of one, two and three infundibular strictures had a 2.2-, 2.9- and fivefold higher hazard of renal unit loss respectively, and lower ureteric strictures had fivefold longer estimated survival (P = 0.015) after treatment. Renal units in the reconstruction group had 5.44-fold (95% CI 2.71-10.88, P < 0.001) longer survival than the permanent diversion group, with a mean change in split function of +0.76 (±16.11) mL/min, versus -5.61 (±10.87) mL/min respectively. CONCLUSIONS: Loss of renal units is a function of time despite modern treatment. Baseline renal unit function, site of ureteric involvement and extent of infundibular involvement on imaging are helpful in predicting the duration of renal salvageability. When feasible, reconstruction is better at renal function preservation.

Renal transplantation into optimized abnormal lower urinary tract - Impact on graft outcomes, patient survival, and complications.

INTRODUCTION: Literature regarding the outcomes of renal transplant in patients with abnormal lower urinary tracts (LUTs) is conflicting. The study aimed to determine the graft outcomes and complications of renal transplantation in an optimized abnormal LUT as compared to those with a normal LUT. MATERIALS AND METHODS: In this single-center retrospective-matched cohort study, we identified 31 patients with an optimized abnormal LUT in our transplant database between 2006 and 2016 (Group A) and selected an equal number of matched controls (Group B). The primary outcome was graft survival, and secondary outcomes were overall survival and complications. RESULTS: The median age was 24 years (range: 12-45), and the median duration of follow-up was 36 months in both groups. On Kaplan-Meier analysis, the estimated mean graft survival was 106 months (confidence interval [CI]: 91-120) in Group A versus 128 months (CI:117-139) in Group B (P = 0.47, log-rank analysis). On subgroup analysis of Group A, augmented bladders had the poorest mean survival (81 months, CI: 56-106), P = 0.09). The mean estimated patient survival was comparable between Group A and B (109 months, CI: 96-122 versus 139 months, CI: 134-144), P = 0.13). Infective complications (27 episodes vs. 1) and re-admissions (77 vs. 30) were significantly higher in Group A (P = 0.04 and P < 0.01). Clean intermittent catheterization was a risk factor for infections (63% vs. 37%, P = 0.033, odds ratio: 5). CONCLUSIONS: The graft and overall survival was comparable at 3 years in both groups. Infective complications were higher in Group A.

Positive ureteric margins at radical cystectomy: Can it be predicted at initial transurethral resection of bladder tumour?

OBJECTIVE: To identify primary tumour-related factors at transurethral resection of bladder tumour (TURBT) that may predict positive distal ureteric margins (PUM) at the time of radical cystectomy (RC). PATIENTS AND METHODS: A retrospective, cohort study was conducted using our institution's data from June 2007 to June 2016. Patients who underwent TURBT followed by RC for non-metastatic urothelial carcinoma (UC) of the bladder were identified. In all, 211 patients underwent RC for UC during the study period. The patients were divided into two groups: Group-I (n = 17) with PUM and Group-II (n = 194) with negative ureteric margins. Univariate and multivariate analyses were performed to determine the predictors of PUM. RESULTS: On univariate analysis, multifocality, tumours involving the ureteric orifice, trigonal tumours, presence of carcinoma in situ (CIS), and lymphovascular invasion at TURBT, were significantly more common in Group-I. On multivariate analysis, tumour involvement in the ureteric orifice(s) and presence of associated CIS significantly predicted PUM. CONCLUSIONS: Primary tumour-related factors on initial TURBT that predicted PUM (at RC) were involvement of the ureteric orifice(s) and presence of associated CIS. These results may help to select patients who can be selectively offered intraoperative frozen section analysis.

Is there a role for second transurethral resection in pTa high-grade urothelial bladder cancer?

INTRODUCTION: Evidence for second transurethral resection of bladder tumour (TURBT) for pTa high-grade lesions is limited. This study aims to examine the role of a second TURBT in the pTa high-grade group and to generate recurrence and progression data for this group. MATERIAL AND METHODS: We retrospectively studied the clinical profiles and outcomes of all patients diagnosed with high-grade pTa lesions at first TURBT, between the years 2006-2015. Firstly, in patients who underwent a complete first TURBT, we calculated the proportion of patients with positive findings on second TURBT. Secondly, we assessed whether those who underwent a second TURBT had a longer recurrence-free survival compared to those who underwent a single TURBT. RESULTS: One hundred and twelve patients had a pTa high-grade urothelial bladder tumor (WHO 2004 classification) at first TURBT, out of whom 43 (38.3%) had a second TURBT. Indications for second TURBT were high-grade lesions (n = 36), absence of detrusor muscle (n = 2), and incomplete resection (n = 5). Out of the 36 patients who had a complete first TURBT and underwent a second look TURBT, 7 patients had positive findings (3 carcinoma in situ, 2 pTa low-grade lesions and 2 pTa high-grade lesions) and there was no upstaging. Of the 5 patients with an incomplete first TURBT, one upstaged to pT1 on second TURBT. Of the 81 patients who followed up with us, 25.9% had a recurrence and 8.6% progressed. The estimated median recurrence free survival was 60 months (95% CI 29.2-90.7) for the whole group and 76 months vs. 45 months for the second and single TURBT group respectively - a difference that was clinically, though not statistically, significant. Multiple (≥2) tumours had a lower recurrence free survival (HR of 4.60, CI 1.67-12.63, p = 0.003). CONCLUSIONS: Of the patients with pTa high-grade tumours who had a second TURBT after a complete first TURBT, 19.4% had a positive finding. Multiple tumours are four times as likely to recur as solitary tumours. The role of a second TURBT in this group needs to be studied in larger patient cohorts before a recommendation regarding its lack of clinical utility can be made conclusively.

The effect of phosphodiesterase-5 inhibitor, tadalafil, on in vitro potassium chloride-induced contractions of isolated human ureteral tissue.

INTRODUCTION: Drugs causing ureteral relaxation are used for medical expulsive therapy (MET) for stones. We investigated the in vitro ability of tadalafil to cause relaxation of potassium chloride (KCl)-induced contractions of isolated human ureteral tissue. MATERIALS AND METHODS: Eight grossly normal proximal ureteral tissues were collected from the radical and donor nephrectomy specimen. The standard organ bath protocol was followed. Ureteral contractions were induced with 80 mM KCl before and after exposure to tadalafil. RESULTS: The median amplitude and frequency of KCl-induced contractions and the median area under the contractility curve (AUCC) after exposure to 20 µM tadalafil showed significant reductions compared to that of before exposure to tadalafil (7.87 cm, 3.79/min, and 2.98 cm2, respectively, versus 9.37 cm, 4.48/min, and 4.50 cm2, respectively; P = 0,026, 0.008, and 0.008, respectively). After exposure to 40 µM tadalafil, the median amplitude and frequency of KCl-induced contractions and AUCC (4.50 cm, 2.56/min, and 0.92 cm2, respectively) showed significant reductions compared to that of before exposure to tadalafil (7.62 cm, 3.88/min, and 3.32 cm2, respectively; P = 0.008, 0.016, and 0.008, respectively). However, reductions in the parameters after exposure to 20 µM and 40 µM tadalafil were similar (P = 0.065, 0.195, and 0.130, respectively, for median amplitude, frequency, and AUCC). CONCLUSION: Tadalafil reduces KCl-induced contractions of isolated human ureteral tissue in vitro. No incremental relaxations in contractions occurred by increasing the dose of tadalafil from 20 µM to 40 µM.

Efficacy and role of Xpert® Mycobacterium tuberculosis/rifampicin assay in urinary tuberculosis.

INTRODUCTION: The aim was to study the accuracy of Xpert® (Cepheid Inc., Sunnyvale, CA, USA) Mycobacterium tuberculosis/rifampicin (MTB/RIF) assay as compared to a composite gold standard (urine culture, imaging, and biopsy) and to asses its utility as the initial test compared to smear microscopy to diagnose urinary tuberculosis. METHODS: This prospective study included adult patients suspected to have urinary tuberculosis from March 2014 to December 2017. Three urine samples were collected from each patient and were subjected to Xpert MTB/RIF assay, acid-fast bacillus (AFB) smear microscopy, and liquid media (BACTEC Mycobacteria Growth Indicator Tube [MGIT] 960) culture. Imaging and tissue biopsies were performed as clinically indicated. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated using the bootstrap method for 95% confidence intervals for the Xpert assay. RESULTS: Xpert MTB/RIF assay was found to be superior to the currently best available light-emitting diode fluorescent smear microscopy as the initial test for urinary tuberculosis (sensitivity of 69.09% vs. 32.72%). The Xpert MTB/RIF polymerase chain reaction test was found to have a moderate sensitivity (69.09%) and high specificity (100%) as compared to the composite reference standard. The sensitivity of liquid AFB culture MGIT 960 as compared to the reference standard was 90.32%. CONCLUSIONS: Xpert MTB/RIF assay on an early morning first void urine specimen can replace smear microscopy as the initial diagnostic test for urinary tuberculosis.

Urodynamic outcomes of tamsulosin in the treatment of primary bladder neck obstruction in men.

INTRODUCTION: Alpha blockers are widely used in the treatment of primary bladder neck obstruction; however, evidence for objective urodynamic efficacy is scarce. We studied the effect of the uroselective α1-blocker tamsulosin on urodynamic parameters in male patients with type I primary bladder neck obstruction. METHODS: A single center prospective observational study was carried out from July 2013 to February 2015. Male patients (18-50 years) with type 1 primary bladder neck obstruction were recruited. Selected patients were started on tablet tamsulosin 0.4 mg once daily for 3 months. International prostate symptom score (IPSS), uroflow and urodynamic studies were done pre- and post-treatment. Primary outcome was decreased in minimum detrusor pressure at maximum flow rate by 15%. Wilcoxon-matched pair signed-rank test was used. RESULTS: Of 39 patients recruited, 21 patients completed the follow-up as per protocol and were analyzed. Mean age was 41 years. 57% patients achieved the primary outcome (median detrusor pressure pre- and post-treatment were 71 and 56 cm of water, P < 0.001). Similarly, median values for bladder outlet obstruction index (BOOI) and IPSS decreased from 59 to 38 (P < 0.001) and 22 to 12 (P < 0.001), respectively. Median maximum flow rate increased from 8 to 10 ml (P = 0.05). Pretreatment BOOI of >60 was associated with poor outcomes. CONCLUSIONS: Tamsulosin 0.4 mg once a day is effective in reducing bladder outlet obstruction on pressure flow studies in patients with primary bladder neck obstruction type 1.

A prospective randomised double-blind placebo-controlled trial to assess the effect of diuretics on shockwave lithotripsy of calculi.

OBJECTIVE: To assess the effect of diuretics with shockwave lithotripsy (SWL) on the treatment of renal and upper ureteric calculi. PATIENTS AND METHODS: Adult patients with a solitary non-obstructive radio-opaque renal or upper ureteric calculus with normal renal function were included. They were prospectively randomised to receive either SWL with placebo or SWL with diuretics (40 mg parenteral furosemide) in a double-blind manner with a sample size of 48 patients in each arm. The primary outcomes were the SWL success and failure rates. The secondary outcomes were the number of shocks and sessions. RESULTS: Complete fragmentation was achieved in 89.6% of the patients in the furosemide arm as compared to 81.3% in the placebo arm. Clearance was achieved in 77.1% of the patients in the furosemide arm as compared to 70.8% in the placebo arm. The number of shocks and the number of sessions were higher in the placebo arm. These differences were not statistically significant. CONCLUSION: The use of diuretics along with SWL treatment of renal and upper ureteric calculi does not show a statistically significant improvement in fragmentation or clearance.

Does asymptomatic prostatic inflammation alter the outcome of transurethral resection of prostate?

INTRODUCTION: There is contradictory evidence in literature with respect to the association of asymptomatic prostatic inflammation on biopsy with complications of Transurethral Resection of Prostate. The aim of the present study was to evaluate the association of prostatitis in biopsy specimens of patients undergoing transurethral resection of prostate with bladder neck contracture (the primary end point) and other complications. MATERIAL AND METHODS: Patients who had undergone transurethral resection at a single centre between 2005 and 2010, with a minimum of 3 months follow-up were included. The study population was divided into two cohorts: those with inflammation on prostatic biopsy (Group A) and those without (Group B). These two groups were compared with respect to demographic data and pre-operative and intraoperative confounding factors. Immediate complications were documented using the modified Clavien-Dindo system and compared. Long term complications like bladder neck contracture, meatal stenosis, urethral stricture, and recurrent adenoma were also compared. RESULTS: Both groups were comparable except for Group A patients having a higher median resected weight (20 vs. 14 gms, p = 0.009). There was no significant difference between the groups with respect to the rate of bladder neck contracture and other long-term and short term complications on univariate and multivariate analysis. Larger resected weight of gland was associated with lower rate of bladder neck contracture on multivariate analysis (p = 0.019, Odds ratio: 0.937). CONCLUSIONS: Presence of histologically confirmed prostatic inflammation is not associated with bladder neck contracture or other complications following transurethral resection. Smaller resected prostatic weight was associated with higher incidence of bladder neck contracture.

Urine and serum fetuin-A levels in patients with urolithiasis.

INTRODUCTION: Fetuin-A is a glycoprotein secreted by liver and has been shown to inhibit extraosseous mineralization. Urolithiasis may be a manifestation in the urinary tract due to fetuin deficiency in urine. The objective of this study was to compare the 24-h urine and serum fetuin-A levels of patients with and without urolithiasis. METHODS: Serum and 24-h urine fetuin-A levels were measured in 41 patients with bilateral, multiple, or recurrent urinary tract calculi (Group A) and 41 matched controls with no calculi (Group B). Fetuin levels were measured by enzyme linked immunosorbent assay. Serum and urine fetuin-A levels in the two groups were compared. RESULTS: The median (range) 24-h urine fetuin-A value in Group A was 11.9 (1.12-221) mg/day and in Group B was 37.7 (1.28-125) mg/day. This difference was statistically significant (Mann-Whitney test, P = 0.0169). The median (range) serum fetuin-A in Group A was 0.67 (0.05-2.68) g/L and in Group B was 0.99 (0.01-5.5) g/L. The difference between serum values in the two arms was not statistically significant (Mann-Whitney test, P = 0.1817). However, the serum creatinine-adjusted mean log serum fetuin and urine fetuin were significantly different in the two arms (P = 0.003). The mean ± standard deviation (range) serum creatinine in Group A was 0.98 ± 0.25 (0.56-1.58) mg% and in Group B was 0.83 ± 0.16 (0.58-1.18) mg% (two sample t-test, P = 0.0031). CONCLUSIONS: Patients with urolithiasis have lower urine fetuin-A and creatinine-adjusted serum fetuin-A levels.