Penile prosthesis implantation is safe and effective in Peyronie's disease patients with and without erectile dysfunction.

Penile prosthesis (PP) is the mainstay of treatment in Peyronie's disease (PD) with co-existent refractory erectile dysfunction (ED). This study aimed to assess the clinical outcomes of patients who underwent PP as the first-line surgical treatment in PD without ED. A total of 636 patients underwent PP for PD from 2012 to 2022, but only 168 patients who underwent PP as first-line surgical management for PD with or without ED were included in the study. The mean (SD) age of 168 patients was 56.3 years (12.4). The mean curvature of the "PD with ED" group and the "PD without ED" group were 38.2 (5.6) degrees and 42.2 (5.9) degrees. The median (IQR) follow-up was 56.0 months (34.5- 61.4). Most (86.9%) patients underwent 3-piece inflatable PP. An important finding is that 33 patients (19.6%) without ED had undergone PP. Mechanical failure requiring revision surgery was less common in the 'without ED' group than in the ED group (6.8% vs. 10.2%, p 0.04). Most PD patients without ED (87.9%, 29/33) and with ED (88.9%, 120/135) were "satisfied" after PP implantation at six months, as defined by a score of ≥4 on a 5-point Likert scale. If surgery is offered in PD, PP may be considered a safe and effective first-line surgical treatment regardless of the ED, given the acceptable complications and high satisfaction rates. However, this new concept warrants further research.

Unconsummated marriage: a systematic review of etiological factors and clinical management.

BACKGROUND: Unconsummated marriage (UCM) is the inability of the heterosexual married couple to have penovaginal sexual intercourse. AIM: The study sought to systematically review current evidence regarding the etiological factors and clinical management of UCM. METHODS: A comprehensive bibliographic search on the MEDLINE, Scopus, Web of Science, and Cochrane Library databases was performed in June 2023. Studies were selected if they described married couples who never had sexual intercourse in case report or case series evaluating the related causes and/or management and reporting data with qualitative, quantitative, or mixed methods. The review was reported according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-analyses) statement and registered in PROSPERO with ID CRD42023433040. RESULTS: A total of 27 studies including 1638 males and 1587 females were selected. Eight (29.6%) articles were case reports involving a single couple and 19 (70.4%) studies were case series. Mean Murad score was 4.1 (range, 1-8) showing low-intermediate overall study quality. All articles had a level of evidence of 4. Most of studies were conducted in Egypt (n = 5 [18.4%]), Israel (n = 4 [14.9%]), and the United States (n = 4 [14.9%]). The mean age of males and females varied between 24.2 and 37.6 years and from 21 to 27.4 years, respectively. The reasons for the medical visit that led to the diagnosis of UCM were inability to consummate in 23 (85.2%) studies, inability to conceive in 1 (3.7%) article, and mixed in 3 (11.1%) articles. The mean duration of UCM varied from 7 days to 3.5 years. Eight studies involving both men and women showed that vaginismus (8.4%-81%) and erectile dysfunction (10.5%-61%) were the most common causes of UCM. Three articles reported that 16.6% to 26% of all UCM cases were due to both male and female factors. Sildenafil, tadalafil, intracavernosal injection, penile plication, female genital reconstructive surgery, vaginal dilators, lubricants, psychosexual therapy, and sex education were the various treatment modalities in 27 studies to achieve consummation rate of 66.6% to 100%. STRENGTHS & LIMITATIONS: A strength is that this is the first systematic review covering the entire spectrum of UCM. Limitations comprised the low quality of most of the included articles and the large percentage of UCM cases probably not published. CONCLUSION: Erectile dysfunction and vaginismus are the most reported causes of UCM; however, a strong psychological component certainly underlies a significant number of cases. A multidisciplinary approach based on strategic integration of sex education, medical therapy, psychosexual support, and surgical treatment would seem the most suitable option to manage couples with UCM.

Risk Factors for Revision After Artificial Urinary Sphincter Implantation in Male Patients With Stress Urinary Incontinence: A 10-Year Retrospective Study.

PURPOSE: To evaluate the preoperative and intraoperative risk factors for revision after artificial urinary sphincter (AUS) implantation in male patients with stress urinary incontinence (SUI). METHODS: A retrospective analysis from a prospectively maintained database was performed. Male patients, with moderate-tosevere SUI, undergoing AUS implantation were included. All patients underwent placement of AMS 800. Cause of revision, type of revision, and time to revision were recorded. Multivariable analyzes were performed using a logistic regression to investigate the risk factors. Competing risk analysis according to Fine-Gray model was used to study time to event data. RESULTS: A total of 70 patients were included. Revision surgery was performed in 22 of 70 patients (31.4%), after a median (interquartile range) time of 26.5 months (6.5-39.3 months). Overall, 19 of 22 repairs (86.4%) and 3 of 22 explants (13.6%) were recorded. Mechanical dysfunction, urethral erosion, urethral atrophy, and device infection were the causes of revision in 11 of 22 (50.0%), 6 of 22 (27.3%), 3 of 22 (13.6%), and 2 of 22 patients (9.1%). Vesicourethral anastomosis stenosis (P=0.02), urethral cuff size of 3.5 cm (P=0.029), and dual implantation (P=0.048) were independent predictors for revision. Vesicourethral anastomosis stenosis (P=0.01) and urethral cuff size of 3.5 cm (P=0.029) predicted a lower survival of the AUS. CONCLUSION: The vesicourethral anastomosis stenosis, urethral cuff size of 3.5 cm, and dual implantation are independent predictors for revision after AUS implantation. However, only the vesicourethral anastomosis stenosis and urethral cuff size of 3.5 cm predict a lower survival of AUS.

Penile Modeling in Peyronie's Disease: A Systematic Review of the Literature.

INTRODUCTION: Penile modeling to correct the penile curvature in Peyronie's disease (PD) may be achieved manually (intra-operatively or post-injection) or by using assisted devices (penile traction, vacuum device, or penile prosthesis). OBJECTIVES: To evaluate the efficacy, safety, and satisfaction associated with penile modeling in patients with PD. METHODS: A PROSPERO registered (CRD42021241729) systematic search in MEDLINE and Cochrane Library was done following PRISMA. PICO: Studies were deemed eligible if they assessed patients with PD (P) undergoing modeling procedures (I) with or without a comparative group(C) evaluating the efficacy, safety, or patient satisfaction (O). Retrospective and prospective primary studies were included. The primary outcome measure is the change in penile curvature after modeling. The secondary outcome measures are the change in stretched penile length, adverse events, and patient satisfaction after modeling. RESULTS: A total of 23 studies, involving 1,238 patients were included. Most studies (13, 56.5%) evaluated penile traction therapy. The studies were of low and intermediate quality (mean Newcastle-Ottawa Scale score of 5.7 and mean Jadad score of 3.3) with a mean level of evidence of 3.4. The mean penile curvature at baseline was between 31 and 80.8 degrees. Nine (39.1%) studies found a significant improvement (P < .05) of penile curvature after penile modeling, ranging between 11.7, and 37.2 degrees. An increase in mean stretched penile length was reported in 7 (30.4%) articles, varying between 0.4, and 1.8 cm. Serious complications such as penile prosthesis malfunctions (3.3-11.1%) and urethral injuries (2.9%) were only reported for intra-operative manual modeling. CONCLUSION: Although individual studies have noted improvement in penile curvature and stretched penile length, specific recommendations regarding penile modeling in PD cannot be provided due to limited evidence available. Further RCTs with adequate sample size, validated assessment tools, and longer follow-up are needed. Krishnappa P, Manfredi C, Sinha M et al. Penile Modeling in Peyronie's Disease: A Systematic Review of the Literature. Sex Med Rev 2022;10:427-443.

Surgical Outcomes and Patient Satisfaction With the Low-Cost, Semi-Rigid Shah Penile Prosthesis: A boon to the Developing Countries.

INTRODUCTION: In developing countries most patients with refractory erectile dysfunction cannot afford a penile prosthesis (PP) due to its cost and non-coverage by insurance companies. AIM: To assess the patient satisfaction outcomes with a novel, low-cost, semi-rigid PP. METHODS: 52 patients who had received the Shah semi-rigid PP between January 2013 and December 2018 were included in this bidirectional study. Patient demographics including age, etiology, body mass index, length of PP received and post-operative complications were recorded. Patient satisfaction with the PP was evaluated using the modified Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) Questionnaire. MAIN OUTCOME MEASURES: The primary outcome measures were overall satisfaction, total EDITS and mean EDITS score. The secondary outcome measures were residual penile tumescence, ease of concealment and post-operative complications. RESULTS: The mean age of the patients was 38.79 years (25-68). Overall satisfaction (EDITS Q-1) of 4 (0-4) was reported by 84.62% (44/52) of patients. There was no significant difference (P > .7) in the total EDITS and overall satisfaction based on various etiological factors. The mean EDITS scores (0-100) were 95.67 ± 10.76, 95.53 ± 8.46 and 91.72 ± 22.42 in 52 patients with BMI <25, 25-29.9 and >30 kg/m2 respectively. During sexual arousal after PP implantation, 26 (50%), 17 (32.7%) and 9 (17.3%) patients noted "good", "some" or "no" residual penile tumescence respectively. 47 (90.4%), 4 (7.7%) and 1 (1.9%) patients reported "good", "fair" and "poor" concealment respectively. In the prospective group, major and minor post-operative complications were seen in 10.7% (3/28) and 21.4% (6/28) of patients respectively. CONCLUSION: The semi-rigid Shah PP is a safe, effective and affordable option to treat patients with refractory ED. The ability to remove 1 or both sleeves in the Shah PP helps achieve a good fit with a small inventory. Krishnappa P, Tripathi A, Shah R. Surgical Outcomes and Patient Satisfaction With the Low-Cost, Semi-Rigid Shah Penile Prosthesis: A boon to the Developing Countries. Sex Med 2021;9:100399.

Home modeling after penile prosthesis implantation in the management of residual curvature in Peyronie's disease.

The aim of this study was to study the clinical effectiveness of a structured home modeling (HM) protocol in Peyronie's disease (PD) patients who have residual curvature up to 45° after inflatable penile prosthesis (PP) placement. A total of 92 patients with PD and coexistent refractory erectile dysfunction received inflatable PP. If residual curvature after manual modeling (MM) was more than 45°, incision-grafting was performed. If curvature was <45° after MM, patients were instructed to perform HM daily for 6 months, after 4 weeks from PP implantation. The mean preoperative penile curvature was 39.4 ± 5.7° (30-60). Sixteen (17.4%) patients required incision-grafting and the remaining 76(82.6%) patients followed HM protocol. The mean postoperative residual curvature after MM was 29.7 ± 3.2° (5-50). Sixty-five (85.5%) patients who underwent HM had 10° or less residual curvature after 3 months and 72 (94.7%) patients had 10° or less residual curvature after 6 months. Seventy (92.1%) patients responded as satisfied or very satisfied on the questionnaire with the outcome after 6 months. HM of the penis over Inflatable PP may straighten the penis without the need for an additional surgical maneuver in vast majority of the PD patients having residual curvature of <45°.

Vacuum physiotherapy after first stage buccal mucosa graft (BMG) urethroplasty in children with proximal hypospadias

ABSTRACT Introduction To assess the feasibility of vacuum physiotherapy meant to decrease graft contraction and recurrent penile curvature (PC), hence successful tubularization and a straight penis in patients underwent two-stage buccal mucosa graft (BMG) urethroplasty, in proximal hypospadias repair. Material and methods Between January 2014 and July 2018, 59 two-stage BMG urethroplasties performed at our referral center, were included in the study. The parents were counseled to use the vacuum device between the two stages. An internal, self-administered, semiquantitative, non-validated questionnaire was designed to record parent and patient adherence to the vacuum physiotherapy and parent satisfaction. Success rate of graft tubularization, curvature correction rates, and status of early (4 months) postoperative urinary stream were evaluated. Results Of 45/59 (76.3%) who returned the questionnaire, 77.8% followed the recommended physiotherapy protocol using the vacuum device. 93.3% of parents replied that the use of the vacuum was easy or moderately easy. None of the parents interrupted the physiotherapy because of perceived difficulty or intolerability. 100% of parents would have repeated the physiotherapy, if they had to. Overall, success rate of tubularization was 98.3% (58/59), complete curvature correction was achieved in 88.2% (52/59) of patients, and 79.7% (47/59) of patients showed a straight and powerful early post-operative urinary stream. Conclusions Physiotherapy with the vacuum device is safe, easy and practically feasible. Our vacuum physiotherapy protocol had high compliance rate. Vacuum physiotherapy should be considered for further assessment in patients undergoing two stage hypospadias repair using buccal mucosa.

Vacuum physiotherapy after first stage buccal mucosa graft (BMG) urethroplasty in children with proximal hypospadias.

INTRODUCTION: To assess the feasibility of vacuum physiotherapy meant to decrease graft contraction and recurrent penile curvature (PC), hence successful tubularization and a straight penis in patients underwent two-stage buccal mucosa graft (BMG) urethroplasty, in proximal hypospadias repair. MATERIAL AND METHODS: Between January 2014 and July 2018, 59 two-stage BMG urethroplasties performed at our referral center, were included in the study. The parents were counseled to use the vacuum device between the two stages. An internal, self-administered, semiquantitative, non-validated questionnaire was designed to record parent and patient adherence to the vacuum physiotherapy and parent satisfaction. Success rate of graft tubularization, curvature correction rates, and status of early (4 months) postoperative urinary stream were evaluated. RESULTS: Of 45/59 (76.3%) who returned the questionnaire, 77.8% followed the recommended physiotherapy protocol using the vacuum device. 93.3% of parents replied that the use of the vacuum was easy or moderately easy. None of the parents interrupted the physiotherapy because of perceived difficulty or intolerability. 100% of parents would have repeated the physiotherapy, if they had to. Overall, success rate of tubularization was 98.3% (58/59), complete curvature correction was achieved in 88.2% (52/59) of patients, and 79.7% (47/59) of patients showed a straight and powerful early post-operative urinary stream. CONCLUSIONS: Physiotherapy with the vacuum device is safe, easy and practically feasible. Our vacuum physiotherapy protocol had high compliance rate. Vacuum physiotherapy should be considered for further assessment in patients undergoing two stage hypospadias repair using buccal mucosa.

Cadaveric Penile Prosthesis Workshop training improves surgical confidence levels of urologists: South Asian Society for Sexual Medicine course survey.

OBJECTIVES: To analyze the impact of South Asia's first cadaveric hands-on workshop on urologists' training in inflatable penile prosthesis surgery. METHODS: A total of 72 urologists/andrologists participated in the 2019 South Asian Society for Sexual Medicine Pre-congress Penile Prosthesis hands-on workshop. The workshop included 4 h of lectures and 2 h of hands-on cadaveric laboratory experience using three-piece inflatable penile prosthesis. The Shapiro-Wilk test was used on self-rated procedural confidence levels, which proved the normality. A non-parametric McNemar test was used to examine the change in the number of correct answers. RESULTS: Of those who attended the cadaver laboratory, just 45 who answered the survey both before and after the workshop were included for analysis. Significant objective improvements were noted in procedural knowledge test scores (44.30 ± 0.027 vs 72.44 ± 0.024, P < 0.05) and median surgical confidence levels (4 vs 3 and 2, P < 0.001) of the urologists after the completion of the workshop. CONCLUSIONS: Cadaveric hands-on workshop training improves urologists' procedural knowledge and surgical confidence levels in carrying out three-piece inflatable penile prosthesis surgery. The feasibility of such workshops should be considered in increasing the surgical expertise of general urologists in prosthetic urology.

Prevalence, assessment and surgical correction of penile curvature in hypospadias patients treated at one European Referral Center: description of the technique and surgical outcomes.

PURPOSE: Penile curvature (PC) is a common component of hypospadias, but its presence is inconstantly assessed. We aim to report prevalence of PC in hypospadias patients, as well as to report our method to assess and correct PC, with the associated postoperative outcomes. METHODS: We scrutinized 303 pediatric hypospadias patients operated (2013-2018) at our referral center. PC was routinely assessed and eventually corrected with dorsal plications (DP) as one-stage procedure, or ventral tunica attenuations ± DP as two-stage repair. PC severity and surgical treatment of PC were compared between primary and failed hypospadias. Finally, PC severity, failed repair and PC treatment were tested as predictors of perioperative complications. RESULTS: PC (> 10°) was identified in 274/303 (90.4%) patients, 86.1% with distal, 91.8% with midshaft, and 100% with proximal hypospadias, respectively. PC was found in 51/64 (79.7%) of failed hypospadias. One-stage and two-stage procedures were adopted in 211/274 (77%) and 63/274 (23%) children, respectively. PC severity (p = 0.1) and PC treatment (p = 0.4) did not differ between primary and failed hypospadias. PC severity (all p > 0.2), failed repair (p = 0.8), and PC treatment (all p > 0.09) were not predictors of perioperative complications. 95.6% of patients achieved a straight penis. CONCLUSION: Less than 1/10 patients did not require PC correction. High rate of residual PC in failed hypospadias and similar severity between failed and primary suggest that PC was usually under-corrected. It is possible to correct PC completely and the resulting complication would not be associated with PC severity, failed repair or treatment adopted.

Surgical Management of Peyronie's Disease With Co-Existent Erectile Dysfunction.

INTRODUCTION: Surgical intervention in Peyronie's disease (PD) should ideally be delayed until the resolution of acute inflammatory phase. AIM: The objective of this review was to highlight the results of penile prosthesis to correct refractory erectile dysfunction (ED) in patients with PD, and the secondary procedures that may be required to correct the penile curvature. METHODS: A systematic search on PubMed online database using Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations was done using the MeSH terms "Peyronie's disease" and "erectile dysfunction." MAIN OUTCOME MEASURE: Success and satisfaction rates of various procedures. RESULTS: The search yielded 324 language-specific (English and Spanish language) articles and 58 articles were retained for final review. The following variables were assessed in different studies: number of patients, types of secondary procedure to correct the curvature, satisfaction rates, and follow-up period. CONCLUSION: The aim of the surgery in PD should be to achieve a functionally straight penis (<20 degree curvature) with good erection. Patients with refractory ED in PD are candidates for penile prosthesis. Secondary procedures, like manual modeling, plication, plaque incision, or excision grafting, may be required depending on the degree of penile curvature and penile length. In quest for the best graft, TachoSil graft seems to have gained popularity in Europe. Krishnappa P, Fernandez-Pascual E, Carballido J, et al. Surgical Management of Peyronie's Disease With Co-Existent Erectile Dysfunction. Sex Med 2019;7:361-370.

Malignant refractory priapism: An urologist's nightmare.

Malignant priapism is described as persistent, nonsexual erections caused by invasion or metastasis from a primary neoplasm. We present two cases of malignant priapism with different etiologies and the respective management strategies. A 75-year-old patient had undergone radical cystectomy for a high-grade bladder tumor 5 months ago and came with priapism. The patient persisted to have partial penile tumescence with low-grade pain even after intervention. Another 66-year-old patient came to emergency with persistent painful priapism who had been diagnosed to have Multiple Myeloma. He required a corporotomy and open drainage as a last resort which finally relieved him of pain but with loss of erection. The treatment needs to be individualized based on the clinical course of the patient.

Complications of robot assisted radical prostatectomy.

The urology community has adopted robot-assisted radical prostatectomy (RARP) as the most preferred surgical therapeutic approach in the management of localized prostate cancer. Safety and potential complications of RARP should be clearly known prior to attempting the surgery. The complications have been categorized as anesthesia & patient positioning related, vascular, non-vascular and delayed. European Associationof Urology guidelines recommend the use of Clavien-Dindo grading to report surgical complications.The median rate of over all complications of RARP is12.6%, with a range of 3.1-42%. Most of the complications are minor (Clavien-Dindo grades 1 and 2). With a dedicated approach, increasing experience, being aware of possible complications, and strict adherence to safety measures, most complications are preventable. RARP is a safe and reproducible technique.

ARTICULO SOLO EN INGLES.La comunidad urológica ha adoptado la prostatectomía radical asistida por robot (PRAR) como el abordaje terapéutico preferido en el tratamiento del cáncer de próstata localizado. La seguridad y las complicaciones potenciales de la PRAR deben ser claramente conocidas antes de intentar la cirugía. Las complicaciones se han clasificado como relacionadas con la anestesia y la colocación del paciente, vasculares, no vasculares y diferidas. Las guías clínicas de la Asociación Europea de Urología recomiendan utilizar la escala de Clavien-Dindo para comunicar las complicaciones. La tasa media global de complicaciones de la PRAR es del 12,6%, con un rango entre 3,1- 42%. La mayoría de complicaciones son menores (Clavien-Dindo grados 1-2). Con un abordaje dedicado, el aumento de la experiencia, conocer las posibles complicaciones y una estricta adherencia a las medidas de seguridad hacen que la mayoría de complicaciones sean prevenibles. La PRAR es una técnica segura y reproducible.

Sildenafil/Viagra in the treatment of premature ejaculation.

The arrival of Pfizer's blue pill Sildenafil in 1998 brought a great relief both to patient and physician signalling the start of a great era of medical therapy in sexual medicine. Since then the sexual medicine experts have been prescribing sildenafil in erectile dysfunction with acceptable minor adverse events. But the use of sildenafil in premature ejaculation (PE) is still debated. 2018 being the 20th anniversary of sildenafil, we have compiled interesting facts about the role of sildenafil in PE from various original articles, systematic reviews, meta-analyses, economic brochures and sexual medicine committee guidelines. The major issues in most of these studies were the heterogeneity in the definition of PE and estimating the exact ejaculatory latency time. This perspective article highlights the positive role of sildenafil in the management of PE (even without ED) with acceptable adverse events. Now that we have a standardised definition of PE from International Society of Sexual Medicine (ISSM) and a psychogenic component in PE definition, more randomised placebo-controlled studies are required to further establish its role.

Penile traction therapy with the new device 'Penimaster PRO' is effective and safe in the stable phase of Peyronie's disease: a controlled multicentre study.

OBJECTIVES: To evaluate the efficacy and safety of a new penile traction device (PTD), 'Penimaster PRO', in a group of patients with stable Peyronie's disease (PD) compared with a non-intervention group in a multicentre study. MATERIAL AND METHODS: A total of 93 patients with chronic stable PD (without erectile dysfunction, with no significant pain, and with a unidirectional curvature of at least 45° being stable for > 3 months) were recruited and followed for a 12-week period. Of these patients, 47 were randomly assigned to the Penimaster PRO group (PG) and 46 to the non-intervention group (NIG). Patients were asked to apply the PTD 3-8 h a day for 12 consecutive weeks, with specific instructions regarding the progressive increase of traction force applied to the penis over time. The primary outcome of the study was the change in the degree of curvature measured in the fully erect state after intracavernosal injection of alprostadil at baseline, 1, 2 and 3 months. Other variables, such as the type of curvature, stretched penile length (SPL), Peyronie's Disease Questionnaire (PDQ) scores, erectile function domain of the International Index of Erectile function (IIEF-EF) score and adverse events (AEs) were also assessed in each visit. RESULTS: Forty-one patients in the PG and 39 in the NIG completed the study. There was an overall reduction in curvature of 31.2° (P < 0.001) at 12 weeks compared to baseline in the PG, representing a 41.1% improvement from baseline, which significantly correlated with the number of daily hours the device was applied in a dose-dependent manner. Those patients using the device < 4 h/day experienced a reduction of 15°-25° (mean 19.7°, 28.8% improvement; P < 0.05), while patients using the device > 6 h/day experienced greater curvature reduction, ranging from 20° to 50° (mean of 38.4°, 51.4% improvement; P < 0.001). In contrast, no significant changes in curvature were observed in the NIG. Furthermore, SPL increased significantly in the PG compared to baseline and compared with the NIG, ranging from 0.5 to 3.0 cm (mean 1.8 cm; P < 0.05). The IIEF-EF score also improved in patients in the PG (by a mean of 5 points). Mild AEs occurred in 43% of patients, such as local discomfort and glans numbness. CONCLUSION: The use of the Penimaster PRO PTD, a non-invasive treatment, should be offered to patients with stable PD for 3 consecutive months before performing any corrective surgery, as this provided a significant reduction in the curvature, an increase in penile length and a significant improvement of the symptoms and bother induced by PD.

A Prospective Study to Evaluate the Efficacy of Botulinum Toxin-A in the Management of Dysfunctional Voiding in Women.

OBJECTIVES: To assess the outcomes of Botulinum Toxin-A (BoNT-A) to the external urethral sphincter (EUS) in dysfunctional voiding (DV) refractory to standard urotherapy and bowel management. METHODS: Our criteria to diagnose DV in women included neurologically normal individuals with lower urinary tract symptoms, dilated proximal urethra on voiding cystourethrogram, and high detrusor pressure (PdetQmax > 20 cm H2O) associated with increased electromyography activity during voiding in urodynamic study (UDS). A total of 16 female patients with a median age of 36 years (5-60 years) received BoNT-A from June 2014 to December 2015. Patients below and above 10 years of age received 100 units and 200 units of BoNT-A to EUS, respectively. Patients were followed up till 6 months. RESULTS: Mean AUA (American Urological Association) symptom score decreased significantly from 11.75 ± 6.14 to 5.06 ± 5.1 and 4.25 ± 3.4 at day 14 and day 45 after BoNT-A, respectively (P < .0001). There were no significant improvements in maximal flow (Qmax) on uroflowmetry (UFM) and detrusor pressure at maximal flow (PdetQmax) in UDS. Significant reduction in post-void residual (PVR) from 69.31 ± 77.3 to 17.50 ± 22.3 mL at day 14 (P = .007) was observed, although the reduction was not significant at day 45. Although minor adverse effects were reported, none were serious or life-threatening. CONCLUSIONS: Our study showed that BoNT-A plays a role in improvement of urinary symptoms and reduces PVR at D14 in DV, but showed no improvement in UFM and urodynamic parameters, albeit with limited numbers and limited follow-up.

Dihydroxyadenine stone with adenine phosphoribosyltransferase deficiency: A case report.

Adenine phosphoribosyltransferase (APRT) deficiency is a rare autosomal recessive error of purine metabolism resulting in the generation of 2,8-dihydroxyadenine (DHA), a highly insoluble metabolite of adenine, which can cause radiolucent urolithiasis. This is the second case of DHA stone being reported in India and the first case in India to document the mutation of the APRT gene on blood DNA analysis.

Supracostal percutaneous nephrolithotomy: A prospective comparative study.

INTRODUCTION: A widely prevalent fear of thoracic complications with the supracostal approach has led to its underutilization in percutaneous nephrolithotomy (PCNL). We frequently use the supracostal approach and compared the efficacy and thoracic complications of infracostal, supra 12(th), and supra 11(th) punctures. MATERIALS AND METHODS: This was a prospective study of patients who underwent PCNL between January 2005 and December 2012. The patients were divided into three groups based on the access: infracostal, supra 12(th) (between the 11(th) and 12(th) ribs) and supra 11(th) (between the 10(th) and 11(th) ribs). Clearance rates, fall in hemoglobin levels, transfusion rates, perioperative analgesic requirements, hospital stay and thoracic complications were compared. RESULTS: Seven hundred patients were included for analysis. There were 179 (25.5%) patients in the supra 11(th) group, 187 (26.7%) patients in the supra 12(th) group and 334 (47.8%) patients in the infracostal group. The overall clearance rate was 78% with no difference in the three groups. The postoperative analgesic requirements were significantly higher in the supracostal groups and showed a graded increase from infracostal to supra 12(th) to supra 11(th). During the study period, only 2 patients required angioembolization (0.3%) and none required open exploration. The number of patients requiring intercostal chest drain insertion was extremely low, at 1.6% and 2.2% in the supra 12(th) and supra 11(th) groups, respectively. CONCLUSIONS: Our results confirm the feasibility of the supracostal approach including punctures above the 11(th) rib, albeit at the cost of an increase in thoracic complications. Staying in the line of the calyx has helped us to minimize the most dreaded complication of bleeding requiring angioembolization.