Expert Opinion on the Diagnosis and Management of Male Hypogonadism in India.

Male hypogonadism (MH) is a clinical and biochemical syndrome caused by inadequate synthesis of testosterone. Untreated MH can result in long-term effects, including metabolic, musculoskeletal, mood-related, and reproductive dysfunction. Among Indian men above 40 years of age, the prevalence of MH is 20%-29%. Among men with type 2 diabetes mellitus, 20.7% are found to have hypogonadism. However, due to suboptimal patient-physician communication, MH remains heavily underdiagnosed. For patients with confirmed hypogonadism (either primary or secondary testicular failure), testosterone replacement therapy (TRT) is recommended. Although various formulations exist, optimal TRT remains a considerable challenge as patients often need individually tailored therapeutic strategies. Other challenges include the absence of standardized guidelines on MH for the Indian population, inadequate physician education on MH diagnosis and referral to endocrinologists, and a lack of patient awareness of the long-term effects of MH in relation to comorbidities. Five nationwide advisory board meetings were convened to garner expert opinions on diagnosis, investigations, and available treatment options for MH, as well as the need for a person-centered approach. Experts' opinions have been formulated into a consensus document with the aim of improving the screening, diagnosis, and therapy of men living with hypogonadism.

Ambulatory Minimally Invasive Endoscopic Combined Intrarenal Surgery in Management of Large Impacted Proximal Ureteral Calculi: A Feasibility Study at a Tertiary Referral Center.

Aim: To conduct a comparative, nonrandomized study to assess the feasibility of mini-Endoscopic Combined Intrarenal Surgery (ECIRS) using supine Mini-percutaneous nephrolithotomy (PCNL) access (16F) in Galdakao-Modified Supine Valdivia position for managing proximal large-volume impacted ureteral calculi as ambulatory day-care surgery vis-a-vis standalone ureteroscopy (URS) with push-back PCNL, if needed. The primary aim was to study the outcomes and stone-free rates (SFRs). Secondary aim was to compare the intraoperative and short-term postoperative complications. Materials and Methods: Data of 60 patients undergoing ECIRS (Group 1) from January 2016 to December 2019 were collected prospectively in a nonrandomized fashion from a single center after Ethics Committee approval. A matched-paired analysis was performed with retrospectively collated data of 60 patients undergoing standard URS/pushback PCNL (Group 2) using analysis of variance, Fisher's exact test, and Chi-square test. p < 0.05 was considered statistically significant. Outcomes and Results: Group 1 patients had a significantly shorter procedure time vs Group 2 (42.1 ± 11.2 minutes vs 52.1 ± 13.7 minutes; p < 0.001). Group 1 (59/60) patients had an overall single stage SFR of 98.3%, which was significantly higher than single-stage SFR of 83% in Group 2 (50/60) (p < 0.002). Group 2 patients had a higher incidence of fever (10 vs 4, p = 0.01). However, there were no cases of sepsis in either group. Rest of the complications were comparable for both, as the need for ancillary procedures was significantly higher in Group 2 (10% vs 1.7%, p < 0.001). Patients were discharged on the same day in both groups. Conclusions: The findings of our study suggest that, in large and impacted proximal ureteric stones, combined minimally invasive endoscopic approach offers the best option to render the patient stone free by a single intervention. With better intra- and postoperative outcomes and safety profile, Mini-ECIRS may be considered as an ambulatory procedure in this setting.

Ultrasound-guided supine mini-percutaneous nephrolithotomy in ectopic pelvic kidney.

Management of urolithiasis in an ectopic pelvic kidney is challenging and laparoscopic pyelolithotomy and laparoscopy-guided percutaneous nephrolithotomy (PCNL) are commonly favored options. We report a case of ultrasound-guided supine mini-PCNL in ectopic pelvic kidney in an adolescent female. Complete stone clearance was achieved with an uneventful postoperative period. Ultrasound-guided supine mini-PCNL is safe and effective treatment option for the management of calculus in the ectopic pelvic kidney. The risk of injury to surrounding structures associated with ultrasound modality of access can be avoided with proper case selection and careful technique.

Mini-percutaneous cystolithotripsy (mPCCL) versus transurethral cystolithotripsy (TUC) in pre-school children: Prospective comparative non-randomized outcomes over 8 years.

INTRODUCTION: Bladder stones in children can often be challenging to manage. We present our experience of minimally invasive percutaneous cystolithotripsy using 'mini-perc' instruments in the treatment of the bladder stones in pre-school children. The study also compares the outcomes of mini-percutaneous cystolithotripsy (mPCCL) and transurethral cystolithotripsy (TUC). OBJECTIVE: We hypothesized that mPCCL is a new minimally invasive technique with comparable outcomes to TUC. STUDY DESIGN: After parental consent and institutional review board approval, consecutive pre-school children with bladder stones were included from January 2011-December 2018. We shifted from the TUC to mPCCL in 2014, with mPCCL introduced as a new technique. Outcomes including stone free rate (SFR) and complication rates were compared for patients aged between 1 and 5 years of age who underwent mPCCL or TUC. RESULTS: A total of 31 patients (16 patients in Group 1 (mPCCL) and 15 patients in Group 2 (TUC) underwent the procedure. The mean age, stone size and operative times were 2.4 ± 0.96 years and 3.8 ± 0.77 years; 1.86 ± 0.65 cm and 1.34 ± 0.52 cm; and 33.5 ± 8.42 min and 38.2 ± 6.76 min for groups 1 and 2 respectively. While there were no intra or post-operative complications in group 1, in group 2 one patient required conversion to mPCCL due to difficulty in fragment removal per urethra and one with residual fragment needed repeat cystoscopy and fragment removal (Clavien IIIb). All patients in both groups were discharged the following day after catheter removal and remained stone free at 1- and 6-month follow-up. DISCUSSION: Our study shows good outcomes in managing bladder stones with the use of both TUC and mPCCL. We shifted from the former to mPCCL in 2014 during which there was an overlap of both these techniques, while mPCCL was being introduced. Subsequently, all stones have been managed with mPCCL without the need to revert back to TUC. In Group 1, we performed mPCCL, where the puncture was performed under ultrasound-guidance and fragment retrieval was accomplished with the vacuum-cleaner effect through the operating sheath. Complete stone clearance was achieved in all cases with no complications or need for secondary procedures. Limitations of our study include small sample size, single-centre experience, and lack of randomization. Further prospective randomized multicenter studies may be required to validate our results. CONCLUSION: The technique of percutaneous suprapubic cystolithotripsy using mini-nephroscope is an alternate to transurethral cystolithotripsy. While both these techniques are suitable for smaller bladder stones, PCCL may be considered as the preferred management option of especially large bladder calculus in preschool children.

Superperc: A new technique in minimally-invasive percutaneous nephrolithotomy.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) has undergone significant changes in recent years in the quest for improving efficacy and reducing morbidity. Newer minimally-invasive modalities of PCNL such as mini-PCNL, ultra-mini PCNL, and micro-PCNL have evolved with advancement in optics and technology. However, with these newer advancements, migration of small fragments produced with laser lithotripsy remains a concern, which may result in incomplete stone clearance. We describe a new technique of PCNL termed "Superperc", that utilizes suction to remove all the fragments and maintain one-way flow. METHODS: This was a prospective observational study involving 52 consecutive patients who underwent PCNL with the Superperc technique from April 2014 to June 2015. Surgery was performed using a pediatric ureteroscope used as a nephroscope and a specially designed sheath with a suction attachment. The Superperc uses a 10/12 F tract size, specially designed Superperc sheath (Shah Sheath) with suction mechanism and a pediatric ureteroscope (4.5/6 Fr, Richard Wolf) as nephroscope. RESULTS: The mean age of the group was 41.8 years (range 6-84) with 33 males and 19 females. Mean stone size was 19.11 mm (range 10-37 mm) and mean operative time was 40.9 min (range 26-92 min). Twenty-seven renal units had upper calyceal puncture, whereas 12 had middle, 8 lower calyceal and 5 had two punctures. DJ stent was placed in 20 patients, whereas 32 patients were totally tubeless. Only three patients required a nephrostomy tube. The mean hemoglobin drop was 0.32 g with no blood transfusion. Postoperatively, three patients had a mild fever and one had transient hematuria. The stone clearance rate in our study was 96.15% and the mean hospital stay was 31.5 h (range 22-76 h). CONCLUSION: Superperc is a new technique of minimally-invasive PCNL and can be successfully done with minimal modification in armamentarium, with the potential advantage of good stone clearance.

Use of a Novel Flexible Mini-nephroscope in Minimally Invasive Percutaneous Nephrolithotomy.

OBJECTIVE: To assess the feasibility and safety of a novel flexible mini-nephroscope in minimally invasive percutaneous nephrolithotomy (PCNL). Presumably, limiting the size and number of tracts during PCNL has the potential of decreasing the morbidity of the procedure. We present our experience with this new technique. MATERIALS AND METHODS: A retrospective analysis of patients with multiple kidney stones treated with mini-PCNL combined with a novel flexible mini-nephroscope was performed. Minimally invasive PCNL was done with rigid 12 F MIP-M nephroscope, followed by flexible mini-nephroscopy for smaller stones in other inaccessible calyces. Record was made of the operating time, stone-free rates, postoperative pain, morbidity, hospital stay, time to recovery, complication rates, and ancillary procedures. Matched-pair analysis was done with cases operated by flexible ureteroscopy performed with Flex X-2 or Flex X-c scope. RESULTS: Twenty-five patients in the study group were matched with 25 cases from the flexible ureteroscopy group. Both groups were comparable in terms of age, laterality, and mean composite stone burden. The mean operating time was 40.1 ± 10.6 minutes in the mini-PCNL group and 51.2 ± 8.8 minutes in the flexible ureteroscopy group. Mean hospital stay was similar in both groups. The primary stone clearance rate of 92% (23 of 25) in the mini-PCNL group was better than the clearance rate of 80% (20 of 25) in the flexible ureteroscopy group. Eight percent in the mini-PCNL group required ancillary procedures as compared with 20% of cases in the flexible ureteroscopy group. Postoperative pain and analgesia requirement in these patients was minimal. There were no significant complications. CONCLUSION: Flexible mini-nephroscope is an effective adjuvant to minimally invasive PCNL in achieving high clearance rate with minimum morbidity.

Ultra-mini-percutaneous nephrolithotomy: A minimally-invasive option for percutaneous stone removal.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) has witnessed rapid advancements, the latest being ultra-mini-percutaneous nephrolithotomy (UMP), which makes the use of 11-13F sheaths as compared to 24-30F sizes used in conventional PCNL. This miniaturization aims to reduce morbidity and improve patient outcomes. We evaluated the safety and efficacy of UMP and report our ourtcomes. PATIENTS AND METHODS: A total of 120 patients underwent UMP from July 2012 to March 2014. These patients had a single unilateral renal stone measuring between 8 and 20 mm. All patients underwent UMP using a 3F nephroscope, 7.5F inner sheath, and 11F or 13F outer metallic cannula, which served as the Amplatz sheath. Stone fragmentation and clearance were achieved with holmium laser. No nephrostomy or stent was used routinely. RESULTS: Complete stone fragmentation was achieved in 114 out of 120 patients (95%) using UMP; whereas the remaining 6 were converted into mini-PCNL using a 12.5F nephroscope and 15F Amplatz sheath. The mean operative time was 39.7 ± 15.4 min, and the mean postoperative hospital stay was 22.3 ± 2.2 h. Postoperatively, 6 (5%) patients had residual fragments measuring ≤4 mm. At the 2 weeks follow-up, the stone-free status was >99% (119/120). There were no significant postoperative complications. CONCLUSION: This study shows UMP to be an effective and safe procedure for managing stones up to 20 mm. This procedure offers an attractive alternative to shock wave lithotripsy and retrograde intrarenal surgery for managing small stones.

Can Subepididymal Orchiectomy Re-emerge as the Treatment of Choice in Patients with Advanced Prostatic Carcinoma?

To study the effectiveness of bilateral subepididymal orchiectomy compared to bilateral simple and subcapsular orchiectomy in terms of androgen ablation, control of disease progression and esthetic superiority. 114 patients of advanced prostatic carcinoma (T3, T4, M1) were randomized to 3 groups- Group A: bilateral simple orchiectomy (38 patients), Group B: bilateral subcapsular orchiectomy (38 patients), & Group C: bilateral subepididymal orchiectomy (38 patients). Serum PSA and serum testosterone values were checked pre-operatively and at 3 months follow-up. Patients' esthetic satisfaction was scored on a quality of life scale of 1-5. In Groups A, B and C, at 3 months the post-operative mean serum testosterone values were 34.7, 38.1 and 36.7 ng/dl (p = 0.0524); and mean serum PSA values were 4.2, 3.9 and 3.4 ng/ml (p = 0.09) respectively, the differences not being statistically significant. On esthetic satisfaction scale the average scores were 1.8, 2.7 and 4.0 respectively, the difference being highly significant (p < 0.0001). Subepididymal orchiectomy maintains esthetic appearance of scrotum and provides superior patient satisfaction as compared to standard total and subcapsular orchiectomy, while achieving equal efficacy. Bilateral sub-epididymal orchiectomy may thus be considered procedure of choice to achieve androgen ablation in advanced prostatic carcinoma.

Tubeless percutaneous nephrolithotomy.

INTRODUCTION AND OBJECTIVE: Placement of a percutaneous nephrostomy tube for drainage has been an integral part of the standard percutaneous nephrolithotomy (PCNL) procedure. However, in recent years, the procedure has been modified to what has been called 'tubeless' PCNL, in which nephrostomy tube is replaced with internal drainage provided by a double-J stent or a ureteral catheter. The objective of this article is to review the evidence-based literature on 'nephrostomy-free' or 'tubeless' PCNL to compare the safety, effectiveness, feasibility, and advantages of tubeless PCNL over standard PCNL. MATERIALS AND METHODS: We performed a MEDLINE database search to retrieve all published articles relating to 'tubeless' PCNL. Cross-references from retrieved articles as well as articles from urology journals not indexed in MEDLINE, were also retrieved. RESULTS: The majority of the studies have shown 'tubeless' PCNL to be a safe and economical procedure, with reduced postoperative pain and morbidity and shorter hospital stay. tubeless PCNL has been found to be safe and effective even in patients with multiple stones, complex staghorn stones, concurrent ureteropelvic junction obstruction, and various degrees of hydronephrosis. The technique has been successful in obese patients, children, and in patients with recurrent stones after open surgery. CONCLUSION: Tubeless PCNL can be used with a favorable outcome in selected patients (stone burden <3 cm, single tract access, no significant residual stones, no significant perforation, minimal bleeding, and no requirement for a secondary procedure), with the potential advantages of decreased postoperative pain, analgesia requirement, and hospital stay. However, for extended indications, like supine PCNL, multiple, complex and staghorn stones, and concurrent PUJ obstruction, the evidence is insufficient and should come from prospective randomized trials.