Laparoscopic ablative and reconstructive surgeries in genitourinary tuberculosis.

BACKGROUND AND OBJECTIVES: Laparoscopy is the present standard of care for urologic diseases. Laparoscopy in renal tuberculosis (genitourinary tuberculosis) is difficult because of inflammation and fibrosis associated with the disease. We present the outcome of our experience of laparoscopy in genitourinary tuberculosis, both ablative and reconstructive. METHODS: The detailed data of patients with genitourinary tuberculosis who underwent laparoscopic surgeries between January 2011 and September 2012 were reviewed. Indications, type of surgery, duration, blood loss, intraoperative problems, postoperative outcomes, and follow-up details were noted. RESULTS: Overall, 7 laparoscopic procedures were performed: 5 nephrectomies, 1 ureteric reimplantation with psoas hitch, and 1 combined nephrectomy and laparoscopy-assisted Mainz II pouch reconstruction. The mean operative time was 192 minutes for nephrectomy, 210 minutes for ureteric reimplantation, and 480 minutes for nephrectomy with Mainz II pouch reconstruction. There were no conversions to open surgery. The mean amount of blood loss was 70 mL for the nephrectomies, 100 mL for ureteric reimplantation, and 200 mL for nephrectomy with Mainz II pouch reconstruction. In 5 of 6 patients who underwent nephrectomy, there was severe perinephric and peripelvic fibrosis posing difficulty in dissection. However, the renal vessels could be controlled individually. The mean postoperative hospital stay was 3 days for the nephrectomies, 5 days for the ureteric reimplantation, and 10 days for the nephrectomy with Mainz II pouch reconstruction. In all cases the recovery was uneventful. CONCLUSIONS: Laparoscopy, though technically more demanding, is a feasible and safe option for ablative and complex reconstructive procedures in genitourinary tuberculosis. It offers the benefits of minimally invasive surgery. The difficulty with this procedure is mostly because of peripelvic and perinephric fibrosis, whereas the lower ureter and bladder are relatively easier to dissect.

Black adrenal adenoma: distinction from PPNAD.

A 22-year-old woman with features suggestive of Cushing's syndrome was found to have right adrenal mass on imaging studies. She had paradoxical rise in basal cortisol on dexamethasone suppression testing. Black adenoma of the right adrenal cortex, a pigmented adenoma consisting of compact cells with numerous pigments suggestive of melanin and lipofuscin was laproscopically removed from this patient. This case illustrates that in the setting of unilateral adrenal mass with paradoxical cortisol response with dexamethasone suppression testing, pigmented adrenal adenomas should be also suspected in addition to primary pigmented nodular adrenocortical disease.The decision to go with either unilateral or bilateral adrenalectomy should be based on the attributes of contralateral adrenal gland.

Lymphadenectomy in bladder cancer: What should be the extent?

The extent of Lymh node dissection (LND) during radical cystectomy is a subject of increasing importance with several studies suggesting that an extended LND may improve staging accuracy and outcome. Significant numbers of patients have lymph node metastasis above the boundaries of standard LND. Extended LND yields higher number of lymph nodes which may result in better staging. Various retrospective studies have reported better oncological outcomes with extended LND compared to limited LND. No difference in the mortality and the incidence of lymphocele formation has been found between 'standard' and 'extended' LND. Till we have a well-designed randomized controlled trial to address these issues for level 1 evidence, it is not justified to deny our patients the advantages of 'extended' lymphadenectomy based on the current level of evidence.

Post-renal transplant surgical complications with newer immunosuppressive drugs: mycophenolate mofetil vs. m-TOR inhibitors.

PURPOSE: To compare the incidence of immediate surgical complications after renal transplantation between mycophenolate mofetil (MMF group)-based and mTOR inhibitors (mTOR group)-based immunosuppressive regimens. METHODS: The preoperative parameters in the recipients, rejection rates and surgical complications within 12 months in the recipients were analyzed in 80 patients who had live related renal transplantation. The immunosuppressive regimen was based on MMF (MMF, prednisolone, cyclosporine) in 40 patients and mTOR inhibitors (sirolimus/everolimus, prednisolone, cyclosporine) in 40 patients. RESULTS: The baseline characteristics were comparable between the two groups. Infective complications (urinary tract infections, pulmonary infections and superficial wound infection) occurred in 27.5% (11/40) and 12.5% (5/40) of patients from MMF and mTORI groups, respectively (P = 0.096). Patients in mTORI group had significantly more wound dehiscence (8/40 i.e., 20%) than in MMF group (1/40 i.e., 2.5%) (P = 0.014). There was no significant difference in the occurrence of clinically significant or symptomatic lymphoceles that needed intervention (3 vs. 2). The hospital stay was significantly prolonged in mTORI group mainly because of wound-related problems (35 vs. 24 days). CONCLUSION: In the post-renal transplant setting, use of mTORI results in significantly higher wound complications compared to that of MMF leading to prolonged hospital stay. There is no significant difference in infective complications or lymphocele incidence between these two immunosuppressive regimens.

Chronic kidney disease and small renal tumors: What urologists should know?

OBJECTIVE: To review the evidence in literature regarding the occurrence of Chronic Kidney Disease (CKD) after the treatment of small renal tumors with either radical nephrectomy (RN) or partial nephrectomy (PN). MATERIALS AND METHODS: Current literature reviewed using Mediline search regarding renal functional outcomes following surgical treatment of small renal tumours. RESULTS: Studies have clearly shown that RN leads to CKD more often than PN and RN remains an independent risk factor for patients developing new onset renal insufficiency. There is independent, graded association between a reduced estimated GFR and the risk of death, cardiovascular events, and hospitalization. PN achieves a better Health Related Quality Of Life due to better preservation of renal function. Radical nephrectomy is significantly associated with death from any cause compared with partial nephrectomy. CONCLUSION: Removal of entire kidney is definitely an over-treatment for small renal tumors and PN should be the standard of care for these small renal tumors even in the setting of a normal contralateral kidney.

Impact of age and gender on the clinicopathological characteristics of bladder cancer.

PURPOSE: To determine the impact of age and gender on the clinicopathological characteristics of histologically confirmed bladder cancer in India. MATERIALS AND METHODS: From January 2001 to June 2008, records of patients with bladder cancer were evaluated for age and gender at presentation, clinical symptoms, cystoscopic finding, history of smoking, and histopathological characteristics. A total of 561 patients were identified from the computer-based hospital information system and the case files of patients. RESULTS: A total of 97% of the patients presented with painless hematuria. The mean age was 60.2 +/- 4.4 years old (range: 18-90 years old) and the male to female ratio was 8.6:1. Transitional cell carcinoma (TCC) was the most common histological variety, which was present in 97.71% (470 of 481) of the patients. A total of 26% of the patients had muscle invasive disease at the time of presentation. However, 34.5% (166 of 481) of the patients did not show any evidence of detrusor muscle in their biopsy specimen. In patients with nonmuscle-invasive bladder carcinoma, 55% had p Ta while 45% had p T1. Overall, 44.7% (215 of 481) of the patients had low-grade disease. Among patients younger than 60 years old, low-grade (51.0% vs. 38.1%; P = 0.006) and low-stage (77.1% vs. 70.8%; P = 0.119) disease were more prevalent than in patients older than 60 years old. The incidence of smoking was much higher among males compared with females (74% vs. 22%). CONCLUSION: TCC is the predominant cancer, with significant male preponderance among Indian patients. Younger-aged patients have low-grade disease. Hematuria is the most common presentation and greater awareness is needed not to overlook bladder cancer.

Impact of delay in inguinal lymph node dissection in patients with carcinoma of penis.

AIM: To study the impact of delay in inguinal lymph node dissection (LND) in patients with squamous cell carcinoma of the penis, who have indications for LND at the time of presentation. MATERIALS AND METHODS: In total, 28 patients (mean age 52.1 +/- 12.8 years) with squamous cell carcinoma of the penis, treated from January 2000 to June 2008, were retrospectively studied with regard to clinical presentation, time of LND, and the outcome. The patients were divided into two groups based on the time for LND. Group 1 patients had LND at mean of 1.7 months (range 0-6 months) of treatment of the primary lesion, and group 2 had LND at a mean of 14 months (range 7-24 months) after treatment of the primary lesion. STATISTICAL ANALYSIS: The statistical analysis of survival was done using the Kaplan-Meier method and the Log Rank test, with p < 0.05 considered to be statistically significant. The Mann-Whitney test and Fisher's exact test were used for univariate comparison. RESULTS: Twenty-three of the 28 patients had inguinal LND. In group 1, of 13 patients, 12 were alive, with no recurrence of disease at a mean follow-up of 37 months (8-84) months. In group 2, only two patients were alive and disease-free, at a mean follow-up of 58 months (33-84 months). The five-year cancer-specific survival rates for early and delayed LND were 91 and 13%, respectively, (p = 0.007). CONCLUSIONS: When compliance with follow-up is suspect, patients with high grade or T stage (greater than T1) tumor are better treated by inguinal LND during the same hospital admission or within two months of primary treatment.

Routine ultrasound-guided aspiration cytology for evaluation of palpable thyroid nodules in an endemic area: is it justified?

PURPOSE: To prospectively evaluate the efficacy of routine ultrasound-guided fine-needle aspiration cytology (FNAC) of thyroid nodules in an endemic area and to analyze the factors influencing it. METHODS: Patients with thyroid nodules were randomly subjected to either conventional palpation-guided fine-needle aspiration cytology (PFNAC) or ultrasound-guided fine-needle aspiration cytology (USFNAC). The results of cytology were compared with the final histopathologic diagnosis in 112 patients who had undergone surgery. The performance of both methods was individually analyzed in solid nodules, cystic nodules, and solitary and multinodular goitres. RESULTS: Overall, USFNAC showed a significantly higher sensitivity (83.3% vs 54.6%, p < .001), positive predictive value (100% vs 85.7%, p < .001), and greater diagnostic accuracy (96.5% vs 89.1%, p = .052) compared with PFNAC. The sensitivity of USFNAC was significantly higher compared with that of PFNAC in cystic and complex nodules (75% vs 50%, p < .001) but not in solid nodules (77.8% vs 75%, p > .05). USFNAC was more sensitive and more accurate than PFNAC for detection of malignancy in multinodular goitres (66.7% vs 50%, p < .05; 95.6% vs 86.2%, p < .05, respectively). CONCLUSION: The superiority of "routine" USFNAC over PFNAC is mainly due to its better performance in cystic nodules and multinodular goitres. Hence, routine USFNAC can be recommended in areas where such lesions constitute the majority of thyroid nodules.

Acute urinary retention in benign prostatic hyperplasia: Risk factors and current management.

Acute urinary retention (AUR) is one of the most significant, uncomfortable and inconvenient event in the natural history of benign prostatic hyperplasia (BPH). The immediate treatment is bladder decompression using urethral or suprapubic catheterization. Several factors have been identified that are associated with or precipitate AUR. It is useful to classify AUR as BPH-related or not, than spontaneous or precipitated when the initial management is considered. Use of prophylactic 5 a-reductase inhibitors can prevent AUR in men with BPH having moderate to severe lower urinary tract symptoms and large prostate size. Alpha blockers can prevent AUR in symptomatic BPH patients and also facilitate catheter removal following episodes of spontaneous AUR. Anticholinergics can be safely combined with alpha blockers in symptomatic BPH patients without increasing the risk of AUR. Surgical treatment carries a higher rate of morbidity and mortality in men presenting with AUR compared to those presenting with symptoms alone. Urgent prostatic surgery after AUR is associated with greater morbidity and mortality than delayed prostatectomy. Alpha blockers mainly help to delay the surgery and may avoid surgery altogether in a subgroup of patients. TURP remains the "gold standard" if a trial without catheter fails. Alternative minimally invasive procedures can be considered in poor-risk patients, but its value is yet to be established.