Determining age-specific prostate-specific antigen for healthy Indian men: A retrospective study.

Introduction: Prostate cancer usually affects older men and accounts for considerable cancer-associated mortality in men globally. In India, there is a rise in prostate cancer, and the published literature to determine age-specific prostate-specific antigen (PSA) is limited by a small sample size. The objective of our study was to determine age-specific PSA for Indian men based on a very large cohort of apparently healthy men undergoing health screening. Methods: This was a retrospective study using the hospital-based database of men who had undergone PSA blood tests as a part of health screening at two tertiary referral centers in South India between January 1, 2011, and August 31, 2018. Anonymous data were extracted, and statistical analysis was performed. Results: During this period, 99,386 men underwent PSA blood tests. Non-Indian patients and patients with PSA levels either <0.2 or >20 were excluded from the study, leaving 86,728 patients who were further analyzed. Seventy percent of patients were below 60 years of age, and the mean PSA for the study cohort was 1.2 ng/mL (standard deviation 1.74), with a median PSA of 0.7 ng/mL (interquartile range 0.4-1.1). The 95th percentile serum PSA level was 1.40, 1.70, 3.10, 5.80, 8.82, and 11.31 ng/mL for age groups of ≤40, 41-50, 51-60, 61-70, 71-80, and >80 years, respectively. The mean, median, and 95th percentile PSA reportedly increased for each decade of life (P = 0.0005). Conclusions: Results of this study indicated a positive correlation between serum PSA level and age in Indian men. These values are lower than the age-specific PSA defined for Caucasian men. These findings provide a basis for establishing new age-specific reference ranges of PSA for Indian men which will help in clinical decision-making.

Efficacy of Degarelix in the Neoadjuvant Setting in Managing Locally Advanced Prostate Cancer.

Background Prostate cancer holds a substantial presence in the global cancer landscape, and a considerable proportion of diagnoses occur at late stages, particularly in India. Management of locally advanced prostate cancer necessitates a multimodal treatment strategy. A critical part of this strategy is neoadjuvant androgen deprivation therapy, typically administered via luteinizing hormone-releasing hormone (LHRH) analogs. This study explores the potential of an alternative approach: neoadjuvant therapy with degarelix, an LHRH antagonist, and its impact on perioperative and postoperative outcomes in patients undergoing radical prostatectomy for locally advanced or high-risk prostate cancer. Methodology We conducted a retrospective, non-randomized clinical study at Apollo Hospitals in Chennai, India. Patients diagnosed with locally advanced or high-risk prostate cancer who underwent radical prostatectomy were included. Participants were patients treated with neoadjuvant degarelix and subsequent radical prostatectomy between March 2020 and June 2022. We excluded patients receiving radical radiotherapy, those switching from LHRH agonists to antagonists, and those contraindicated for androgen deprivation therapy due to existing comorbidities. For comparison, we selected a group from the institutional database who received conventional treatment (i.e., without neoadjuvant therapy). Results The study compared two groups, each with 32 patients. The groups had no significant difference in total operative duration and console times. The postoperative pathological assessment showed significantly lower margin positivity rates and notable pathological downstaging in the group receiving neoadjuvant degarelix compared to the control group. The incidence of node positivity, prostate-specific antigen levels at three months postoperative, and number of pads used per day at one month did not differ significantly between the two groups. Conclusions Our study suggests that neoadjuvant degarelix could notably enhance patient outcomes in locally advanced prostate cancer management. The benefits include improved symptom control, significant reductions in margin positivity rates, and facilitated surgical procedures. Neoadjuvant degarelix therapy could potentially enhance the feasibility of the surgical intervention in locally advanced prostate cancer management, thus suggesting a promising pathway for improved patient care.

Influence of tumor size in the progression of venous tumor thrombus in renal cell carcinoma: A 7-year single-center experience.

Objective: The objective of the study is to describe the perioperative outcomes, disease-specific, and overall survival status in patients diagnosed with renal cell carcinoma with inferior vena cava (IVC) tumor thrombus. Patients and Methods: We did a retrospective analysis of all patients who underwent radical nephrectomy along with IVC thrombectomy from the year 2013 to 2020. Mayo's classification was used to stratify the level of IVC thrombus. Demographic, perioperative, histopathology data, complications, and survival status were analyzed. Results: Total number of patients included in the study was 39, (Male: Female = 84.6%: 15.4%). Median age of patients was 58 (interquartile range [IQR] 50-63) years. Median size of renal tumor (in cms) was 9.5 (IQR 7.5-12), 8 (IQR 7-11.5), 8.5 (IQR 7-11.75), and 11 (IQR 9.5-11) (P = 0.998) in level 1,2,3, and 4 tumors, respectively. Clear cell variant was seen in 32 patients (82%) with R0 resection in 17 patients. Twelve patients (30.7%) had systemic metastasis on presentation. The overall mean survival time was 66.4 months with 95% confidence interval (CI) (52.4-80.5 months). Mean recurrence-free survival is 76 months with (63-90) CI of 95%. Mean survival in patients who presented with metastasis is 47 months with 95% CI (52.4-80.5). Perioperative mortality rate was 5.12% in this study. Conclusion: The tumor size does not have an influence on the progression of tumor thrombus into IVC. Significant difference in survival was observed between different levels of thrombus with high mortality in level four tumors.

Herniation of the bladder through suprapubic catheter tract - An unusual complication.

Long-term complications of suprapubic catheters are not well documented in the literature. The common complications includes infection, stone formation, urine leakage and malignant changes. We report an unusual complication of bladder prolapse in a patient with long-term suprapubic catheterization. Due to the rarity of this complication, its management has not been well studied.

Robot assisted laparoscopic adrenalectomy: Should this be the new standard?

INTRODUCTION: Minimal invasive surgeries (MIS) for large size adrenal tumors are still debatable. The objective is to evaluate the contemporary peri- and post-operative outcomes of patients undergoing (open = OA, laparoscopic = LA, and robotic = RA) adrenalectomies in three institutions. MATERIALS AND METHODS: Retrospectively gathered peri- and post-operative data of 235 patients, underwent adrenalectomy at three Institutions over a 7-year period (2013-2020) were analyzed. All patients underwent thorough radiological and endocrine workup. RESULTS: Two hundred and thirty five patients who underwent adrenalectomy (OA (n = 29), LA (n = 146), and RA (n = 60)) were assessed. OA (n = 29) versus Minimally invasive surgery (n = 206) showed significant differences (median, p value) in larger tumour size, cm (9.4 vs 5, (p = 0.0001)), longer operative time, mins (240 vs 100, (p = 0.0001)), longer hospital stay, days (8 vs 3,(p = .0001)), Higher readmission rates (14% vs 1.9%), higher blood loss, ml (400 vs 100, (p = 0.0001)) requiring blood transfusion (14% vs 4.3%) (p = 0.03), higher intraoperative complication (21% vs 6%) (p = 0.0004), and post op complications (17% vs 5.3%) (p = 0.01). Amongst the MIS (RA vs LA), RA appeared be have better outcomes in terms of shorter operative time, less blood loss and less intra operative complications with a p value <0.05. These results were consistent for the assessment of patients who had ⩾6 cm tumor size. The postoperative complication rates were lowest with RA (3.3%) compared to OA (17%) and LA (6.1%). CONCLUSIONS: Contemporary practice of adrenalectomy shows that robotic adrenalectomy is safe and effective irrespective of the tumor size.

A Single Tertiary Center Experience in a South Asian Population: Does Tobacco Use Influence Bladder Cancer?

Introduction Tobacco use, especially cigarette smoking, is a well-documented risk factor for cancer; however, its specific effect on bladder cancer has not been clearly defined. This study aimed to determine the association between tobacco use and bladder cancer in a South Asian population. Materials and methods We conducted a retrospective review of the medical records of 64 patients diagnosed with bladder tumors from February 2018 to March 2020. Patients included in the study were surveyed via a questionnaire regarding tobacco use. All patients received transurethral resection of the bladder tumor, and we analyzed histopathological and clinical outcomes. Results Our study population's median age was 57 years, and the study included twice as many male patients as female patients. Most patients (n=45; 70%) reported not using tobacco products, and 19 patients (30%) reported tobacco use. Thirty-five of 45 nontobacco users (78%) had high-grade cancer, and 10 (22%) had low-grade cancer. Among the tobacco users, 10 (52%) had high-grade cancer, and nine (48%) had low-grade cancer. Conclusions According to our findings, a substantial cohort of bladder cancer patients is not tobacco users, and high-grade bladder cancer was more common to people who are not tobacco users. Other environmental factors play a key role in developing bladder cancer in our South Asian study population. Prevention efforts should focus on reducing bladder cancer risk factors.

Carcinosarcoma of the Prostate Masquerading as Benign Prostatic Enlargement: Lesson Learned.

Primary carcinosarcoma of the prostate is an extremely rare and aggressive malignancy. We report a patient who presented with obstructive symptoms and without a history of radiation, prior adenocarcinoma, or androgen deprivation therapy. Transurethral resection of the prostate was performed. Histopathology and immunohistochemistry revealed a confirmatory diagnosis of de novo carcinosarcoma of the prostate. The case is described for its rarity and masquerading nature.

Prevalence of Vitamin D Inadequacy in Urolithiasis Patients.

Introduction The role of vitamin D in kidney stone disease is unclear. Current evidence and existing studies are inconsistent and inconclusive. The objective of this study is to assess the prevalence of vitamin D (VD) inadequacy (VDI) and metabolic abnormalities in urolithiasis patients presenting to a tertiary care center. Materials and methods This is a prospective case-control study of 200 patients divided into two groups - Group 1: 100 urolithiasis patients (case group), and Group 2: 100 non-urolithiasis patients (control group) - which was conducted from January 2016 to January 2017. Demographic, clinical data, parathyroid level, serum 25-hydroxy VD [25(OH)D], and metabolic stone work-up were recorded and analyzed.  Results Patient demographics were comparable in both groups. The prevalence of vitamin D inadequacy in urolithiasis patients was 95% as compared to 57% in the control group. The mean value ± SD of serum vitamin D in urolithiasis patients (16.5 ± 8.6 ng/mL) was significantly lower than in non-urolithiasis patients (28.7 ± 8.3 ng/mL) (p = <0.0001). Thirty-seven percent of the patients were recurrent stone formers. Hyperparathyroidism was observed in 77% of the patients and 71% of them were secondary to VDI. Conclusion Urolithiasis patients were found to have an increased prevalence of deficient VD related to secondary hyperparathyroidism.

A Hemostatic Technique in Robot-Assisted Laparoscopic Partial Nephrectomy and Its Impact on Renal Function.

Purpose Robot-assisted partial nephrectomy (RAPN) has become popular in recent years for small renal masses. We describe a technique of suturing renal defects during RAPN that is reliable and quick, does not necessitate the need for hemostatic agents, and reduces perioperative complications. Materials and methods A total of 24 patients who underwent RAPN were included in the study period between 2013 and 2018 and data were analyzed. Perioperative and postoperative outcomes were measured and compared. Results The median tumor size was 4 cm. Median warm ischemia time was 41 minutes (IQR: 38-45 minutes) and estimated blood loss was 150 mL (IQR: 120-200 mL). There were no major intraoperative complications or conversions to open surgery. No urine leaks or postoperative bleedings were observed. Conclusion Our technique is safe and effective. It negates the use of hemostatic agents, decreases perioperative complications, and negates that determination of long-term renal function is not associated with prolonged warm ischemia time alone. Hence, we propose that our technique is safe in partial nephrectomy when the pelvic calyceal system and renal vessels are opened in multiple locations.

A Prospective Study on the Efficacy of Cognitive Targeted Transrectal Ultrasound Prostate Biopsy in Diagnosing Clinically Significant Prostate Cancer.

PURPOSE: We present our study, done to identify the diagnostic yield of cognitive targeted biopsy using mpMRI data, to diagnose clinically significant prostate cancers, in a cohort of biopsy and treatment naive men. MATERIALS AND METHODS: This is a prospective, single institutional study, done from September 2018 to March 2020 in 75 biopsy naive men. The patients with 3, 4 and 5 PIRADS scores underwent mpMRI cognitive target biopsy (mpMRI CTB) followed by standard biopsy (SB) in the same setting by two different urologists. Diagnostic yield of biopsy cores, complications, and stage migration of Gleason's grades was analyzed. RESULTS: Out of 75 patients, 34.6% had abnormal digital rectal examination (DRE), and the median serum PSA was 10.6 (4.5-20) ng/mL. Total MRI suspicious lesions were 163. Out of 1263 SB cores, 371 cores were positive for cancer (29.35%), and out of 326 mpMRI CTB cores, 120 were positive for cancer (36.8%) (P<0.0001). Histopathological examination (HPE) revealed 88%, 92%, and 100% clinically significant cancers in PIRADS 3, 4 and 5 lesions. SB and mpMRI CTB in combination have better cancer detection yield than either of the modality when used alone (P-<0.0001). Clavien-Dindo grade 1 and grade 4a complication were seen in 47 (62.6%) and three (4%) patients. CONCLUSION: In biopsy-naive men with suspected prostate cancer and equivocal DRE, the addition of pre-biopsy mpMRI detects greater numbers of people with clinically significant prostate cancer when compared with SB alone. Combining SB with mpMRI CTB has a superior diagnosing ability when compared with either of the biopsy modalities when used alone.

The Chennai port closure method: A novel simple technique for laparoscopic port closure.

PURPOSE: Large-size ports used for laparoscopic and robotic procedures will require appropriate closure to reduce the probability of trocar site complications including hematoma and hernia. Closure of these ports is done by various methods like the open method extending skin incisions, S-retractor, Carter Thomason method, and so on. Chennai port closure (CHC) method, a novel technique that had been in practice in our unit for more than 2 years, ensures direct visualization of the suture placement, and hence, the abdominal wall fascia and peritoneum are secured. MATERIALS AND METHOD: We herein describe an easy technique for fascial closure in port size (≥ 10 cm) after minimally invasive surgery, including both laparoscopic and robotic procedures, using a cobbler needle in 151 patients in the study period between February 2017 and March 2020 for various urological procedures. This technique was done before the introduction of the trocar sheath and ensures direct visualization of the abdominal fascial closure. RESULTS: There were no major intraoperative events, additional operating time, and need for any costly instruments. No bowel injuries or trocar site hernias were documented during a mean follow-up of 28 months. Presently, this technique is used by many surgeons in our hospital without much difficulty. CONCLUSION: The Chennai port site closure technique is an effective, simple, easy-to-apply, and safe procedure.

Bladder Neck Resection Combined with Ten Point Intralesional Mitomycin C Injection in Management of Refractory Bladder Neck Contracture in Post TURP Status: A Single-Center, 2-Year Experience.

PURPOSE: Bladder neck contracture is an annoying problem for patients as well as urologists. Recurrence still remains a common problem associated with significant morbidity. This study evaluated the efficacy and side effects of mitomycin C (MMC) which has anti-fibroblast as well as anti-collagen properties in the deterrence of bladder neck contracture (BNC) recurrence after transurethral bladder neck resection (TUBNR). MATERIALS AND METHODS: Ten patients between March 2017 and April 2018 with extremely persistent BNCs who underwent multiple failed endoscopic procedures (≥3 times) were evaluated by using International Prostate Symptom Score (IPPS), uroflowmetry, quality of life (QOL) and post void residual urine (PVR) preoperatively. All patients underwent transurethral bladder neck resection (TUBNR) followed by ten-point intraoperative MMC injection, not exceeding a total dose of 2 mg (0.2 mg/mL), which was given circumferentially at the resected site, using Williams cystoscopic needle. Patients were reviewed at 3 months, 6 months, 1 year and 2 years postoperatively. RESULTS: The procedure was done on a day care basis. The recurrence period prior to our treatment was 3.2 ± 1.3 months. The follow-up was for 24 months. Overall 80% (8 of 10) of patients demonstrated resolution of BNCs as well as sufficient flow rate which was evaluated by uroflowmetry, PVR, IPPS and QoL postoperatively. One patient had detrusor underactivity. Relapse was seen in two patients. None of the patients experienced any significant adverse effects related to MMC. CONCLUSION: Intraoperative ten-site injection of MMC after TUBNR can be regarded as a safe and efficient technique with no serious adverse event.

Acquired post cesarean uretero-uterine fistula - a rare entity.

In this contemporary era,ureteric injuries are not uncommon. They are inadvertent and overwhelming complication following pelvic surgeries.We describe a case of Uretero-uterine fistula (UUF) in a 36 year old woman, who underwent repeat lower cesarean section two months earlier, admitted with complaints of paradoxical incontinence of urine and copious watery vaginal discharge. After extensive clinical and radiological evaluations, she underwent robotic bilateral ovary preserving hysterectomy with ureteroneocystostomy (Boari flap and psoas hitch with Double J stenting).

Robot Assisted Laparoscopic Adrenalectomy: Does Size Matter?

OBJECTIVE:  Open adrenalectomy (OA) is considered to be the standard care for large adrenal tumors. Minimally invasive surgery (MIS) using laparoscopic technique is considered for many patients in the modern era. Robot assisted laparoscopic adrenalectomy (RALA) can be an extremely useful tool which will negate the disadvantage of laparoscopic method. The aim of the present study is to determine whether adrenal tumor size and laterality have an impact on patients undergoing RALA with respect to perioperative and postoperative outcomes.  Methods: During the study period, 38 patients who underwent RALA in a tertiary care center were considered for retrospectively analysis. The study populations were subdivided into distinctive groups based on the tumor size (<5 cm and ≥5 cm, <8 cm and ≥8 cm), and side (right and left side). For all the subgroups, perioperative and postoperative outcomes were analyzed. Perioperative and postoperative outcomes were assessed between patient groups, group a) <5 cm and ≥5 cm tumor, group b) <8 cm and ≥8 cm, and group c) laterality (right vs left). RESULTS:  None of the patients showed any differences. In the current study, the conversion rate, readmission, and mortality were not observed. No major complications were noted. CONCLUSION:  RALA appears to be an extremely viable alternative to MIS using laparoscopic technique. The operative time, console time, blood loss, complication rates, and stay were extremely minimal irrespective of the size or laterality of the adrenal tumor.

Robotic Management of Pelvic Lipomatosis-Experience with Difficulties Encountered and the Techniques to Successful Outcomes.

BACKGROUND: Pelvic lipomatosis (PL) is a rare condition characterized by diffuse pelvic overgrowth of nonmalignant but infiltrative adipose tissue in perivesical and perirectal space. OBJECTIVE: To share our robotic experience and difficulties encountered and suggested techniques to overcome them successfully. It is the first series from India. DESIGN SETTING AND PARTICIPANTS: A prospective observational study was conducted. All consecutive patients diagnosed with PL between 2016 and 2019 underwent robotic-assisted wide bladder fat extirpation and bilateral ureteral reimplantation (extravesical refluxing type) with double J stenting and were evaluated prospectively. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Demographics, serum creatinine level, radiographic features, postoperative complications, and patient-reported outcomes were evaluated. Continuous variables are presented as median and range, as the sample size is very small. RESULTS AND LIMITATIONS: We encountered a total of five patients with PL. The median console time was 126 (range 120-130) min, with a median estimated blood loss of 120 (range 100-150) ml. Postoperative complications were Clavien-Dindo grade I in three cases, and the median hospital stay was 2 d. Distal ureteric margins showed subepithelial edema with submucosal fibrosis, and bladder fat biopsies were reported as adipose tissue with hemorrhage. At initial 3-mo and annual follow-ups, all patients had normal serum creatinine and there was no evidence of disease recurrence. Limitations of our study are the very small sample size (a low incidence of PL) and short follow-up time period (the question of how long the surgical effect will be sustained due to abnormal proliferation of fat cells remains unanswered). CONCLUSIONS: Robotic management of wide bladder fat extirpation and bilateral ureteral reimplantation with double J stenting has a good success rate and good outcome in PL. PATIENT SUMMARY: Pelvic lipomatosis is a very rare condition. Robotic management in treating the condition has good outcome for the patient. Here, we have discussed the difficulties encountered in treating the condition and the techniques used to overcome them.