Clinicopathological study of adrenal pheochromocytoma and extra-adrenal paragangliomas with reference to GAPP and PASS scoring systems.

BACKGROUND: The presence of distant metastasis is known to drastically reduce survival of adrenal pheochromocytoma (PH) and extra-adrenal paraganglioma (PGL). Therefore, predicting malignant potential has an immense impact on prognosis. Pheochtomocytoma of adrenal gland scaled score (PASS) and the grading of adrenal pheochromocytoma and paraganglioma (GAPP) score are two histological algorithms used to predict metastatic potential, but neither has been regarded as 'gold-standard'. Both these scoring systems are yet to be validated. Here, we tried to validate the association of GAPP/PASS scores with disease outcome and strength of association between individual GAPP/PASS parameters with prognosis. MATERIALS AND METHODS: This was a prospective study comprising 22 pheochromocytomas and eight paragangliomas. GAPP score was calculated in paraganglioma cases, and both GAPP/PASS scores were calculated for pheochromocytomas. Disease outcome was then tallied with risk stratification of the GAPP/PASS scoring system. Succinate dehydrogenase B (SDHB) immunohistochemistry was done in 15 cases to see its impact on prognosis. RESULTS: The common PASS parameters associated with malignancy were 'high cellularity', 'tumor cell spindling' and 'extension into adipose tissue'. PASS score showed high sensitivity and negative predictive value but low specificity and positive predictive value. Similarly, GAPP score also showed high sensitivity and negative predictive value but low specificity and positive predictive value. CONCLUSION: In our study, GAPP/PASS scores successfully segregated tumor with low malignant potential from tumor with higher risk of metastasis, although specificity of GAPP was more than PASS. We also found that addition of objective parameters like SDHB immunohistochemistry may further increase the specificity of the existing scoring system.

Supine versus prone percutaneous nephrolithotomy in management of patient with complex renal stone diseases.

OBJECTIVES: Compare the surgical outcomes, safety, stone free rate, hospital stay, and complication of prone and supine PCNL in case of complex renal stone. MATERIALS AND METHODS: This is an observational study conducted in our institute, it consist of 120 patients over the period of 2 years from July 2021 to June 2023, all the patients were divided into two groups: 60 patients underwent modified supine percutaneous nephrolithotomy (PCNL) and remaining 60 patients underwent standard prone PCNL. The measured data included operative time, number of punctures, blood loss, stone-free rate, length of hospital stays, and rate of complications. RESULTS: The two groups were comparable in mean age, male to female ratio, number of punctures, number of tract, size of tract, residual calculi in follow up period, blood transfusion, re-do surgery, chest complication, hospital stay, and postoperative fever and pain. The mean operating time was 1.59 h in supine PCNL and 2.49 h in prone PCNL. The p value was significant (p = 0.001). CONCLUSIONS: By this study we observed that the supine PCNL is associated with statistically significant reduced operating time as compared to conventional prone PCNL with advantages of not putting the patient in prone position. The postoperative complications such as pain and fever were not significant when compared in both groups. We conclude our study and found that, the supine PCNL is an equally effective in treating complex renal stone as compared to prone PCNL.

Short time (10 min) Catheter Traction Following TURP: IS it helpful with less morbidity?

INTRODUCTION: Transurethral Resection of Prostate (TURP) is the most common treatment for Benign Prostatic Hyperplasia (BPH). Blood loss during and after transurethral resection of the prostate (TURP) is a potential cause of morbidity and clot retention. Usual practise is to apply traction in every case of TURP to reduce early postoperative hematuria and clot retention. There are very few studies in the literature and they have mainly concentrated on the effect of traction on reducing blood loss but there is scanty data regarding the morbidity associated with the use of traction. Various authors have described their method of traction application. So, in this study, we will compare the result of short term (10 min) traction with standard (4-6 h) traction. MATERIALS AND METHODS: It is a prospective comparative study with 50 participants, conducted at the department of Urology of a tertiary care hospital in eastern India after taking ethical clearance and consent from the patient. The patients attending urology O.P.D. with LUTS and diagnosed as BPH and planned for elective TURP and who had prolonged traction after TURP were excluded. Study period was one and the half year. RESULTS: Post operatively 25 patients were managed with catheter traction while 25 patients were managed with short term traction of 10 min. Pain which is assessed by visual analog scale (VAS) at 2 and 4 h post operatively is statistically significant with p value of <0.05 and cut off of 65 g prostate volume is drawn below which the successful outcome of short term traction is feasible without any complications. CONCLUSION: If hemostatsis is done properly then short term traction is preferable, safe and had fewer complications for prostate volume <65 g in comparison to standard traction TURP comparing the overall factors. Although, VAS score at 2 and 4 h post operatively shows patient experienced less pain even in prostate volume >65 g.

Low-intensity extracorporeal shockwave therapy for Peyronie's disease: An Indian experience.

Introduction: Efficacy of low-intensity extracorporeal shockwave therapy (LiESWT) in Peyronie's disease (PD) has not been studied in an Indian population. Here, we studied the effect of LiESWT in Indian PD patients. Methods: This prospective study was conducted on 25 patients who completed weekly sessions of LiESWT for 6 weeks with a follow-up of 6 months. Patients were evaluated using International Index of Erectile Function (IIEF)-5 questionnaire for erectile dysfunction and visual analog scale for pain. Baseline and follow-up examinations included measurement of plaque size and curvature. The primary outcome was to assess remission of pain and reduction of plaque size along with improvement of penile curvature and erectile function as the secondary outcome. Results: Primary goal of pain reduction and ≥50% reduction of plaque size was achieved in 64% and 20% of patients, respectively. Improvement in vaginal penetration during sexual intercourse and IIEF-5 score increase of ≥3 was achieved 20% and 36% cases, respectively. The mean reduction of penile curvature was more with plaque calcification (PC), but the difference was not statistically significant (P = 0.26). The difference in mean visual analog scale reduction was more in noncalcified plaque (P = 0.002). The mean reduction of plaque size in patients with PC was significant (P = 0.03). Conclusions: Shockwave therapy is a probable alternative treatment option. A significant improvement was observed in pain and plaque size in patients treated by LiESWT. The presence of PC may affect the outcome of LiESWT in PD.

A comparative study of alpha-1a blockers (tamsulosin) versus estrogens in the treatment of lower urinary tract symptoms in perimenopausal females.

OBJECTIVE: Lower urinary tract symptoms (LUTS) in perimenopausal females are very common. It can be treated with alpha-blockers or application of topical oestrogen. The purpose of this study is to compare the efficacy of alpha-blockers versus topical estrogen in the treatment of LUTS in perimenopausal females. MATERIALS AND METHODS: All perimenopausal females between the age group of 45 and 60 years who present with the symptom of voiding LUTS were divided into two groups. Acute urinary retention patients were excluded from the study. The first group was given alpha-blocker (tamsulosin) and other group was given topical estrogen application (0.5%-1%) in the periurethral region. Patients were followed up clinically by voiding components of the International Prostate Symptom Score and objectively by uroflowmetry and postvoid residual (PVR) urine estimation (ultrasonography). RESULTS: Alpha-blocker group had 40 females and topical estrogen group had 40 females. During the 6-week period, 8 patients of the first group and 6 patients of the estrogen group discontinued the treatment. In the first group, pretreatment mean Qmax (maximum flow rate) of patients was 7.2 ml/s and posttreatment Qmax was 18.4. In the second group, the values were 7.4 ml/s and 10.2, respectively. This difference was statistically significant (P < 0.0001). In the first group, pretreatment PVR urine was significant, which became insignificant after the treatment, whereas in the second group, PVR was significant posttreatment also. CONCLUSION: Alpha-1a blockers should be used as the first-line medical management in perimenopausal females with symptoms of LUTS, as they have a clear advantage over topical estrogens.

Ex vivo testing of air-cooled CW/modulated 30 W thulium fiber laser for lithotripsy.

A diode-pumped, air-cooled, all-fiber, quasi-continuous-wave thulium laser at an operating wavelength of 1.94 µm has been designed to study the performance of the laser parameter on the rate of fragmentation and its dependence on stone composition, fragmented particle size, as well as the retropulsion effect. The optimized laser cavity with an active fiber core/cladding diameter of 10/130 µm under a counter-propagating pump provides a stable laser power of 30 W at a slope efficiency of 50% and wall plug efficiency of 17%. The rate of fragmentation along with the retropulsion effect has been studied with human calcium oxalate monohydrate (COM) urinary stones (N=36) of different composition by using the designed laser and 200-µm-core low OH silica delivery fiber. The thulium fiber laser setting of 2.7 J pulse energy at the pulse rate of 10 Hz, pulse width of 90 ms, and peak power of 30 W is successful in breaking human COM stones in a controlled manner at a fragmentation rate of 0.8±0.4 mg/s, with almost uniform fragments of particle size less than 1.6 mm. During the stone fragmentation, the stone displacement (retropulsion effect) is less than 15 mm, even for the fragmented stone mass of 15±5 mg.

Penile strangulation by different objects and its removal by the modified string method: Management of four cases with review of literature.

Penile strangulation is a challenging clinical situation and usually requires prompt treatment. Penile strangulation by a nonmetallic or thin metallic ring is easily overcome by severing/cutting the object; however, a heavy and long metal ring causing penile strangulation is not only difficult to sever but also it may worsen the scenario if removal is tried with inappropriate method. Here, we report four cases of penile strangulation by different objects which were successfully removed by aspiration and string method. We found that instead of using heavy cutting instruments and other surgical methods, string and aspiration technique is much better.

Rare cases of ectopic ureter: Analysis from a single centre with review of the literature.

OBJECTIVE: Purpose of our study was to aggregate and analyse rare cases of Ectopic Ureter (EU), their association with other anomalies, clinical features, diagnosis and management. MATERIAL AND METHODS: A total of nine patients with rare presentation of EU were evaluated. Combination of endoscopic and imaging modalities was used as required to define the anatomy and devise the best surgical approach in these cases. RESULTS: Among six females and three males with EU, four cases had bilateral EU, four unilateral EU and one case had EU of a solitary kidney. Urinary incontinence was encountered in five cases including one male patient whilst other cases presented with varied clinical features and associated anomalies. Two patients had anorectal malformations, and two had uterine anomalies in the form of bicornuate uterus. Other patients had multiple rare associations such as triplication of ureter, bilateral absence of seminal vesicles with infertility, multicystic dysplastic kidney, ureter draining in uterus, renal failure, absence of bladder trigone, and hypospadias etc. Ureteric reimplantation was performed in four cases, two required ureteroureterostomy, another two had undergone upper pole nephrectomy and in one case renal transplant had been carried out owing to chronic renal failure. CONCLUSION: EU is among group of those congenital entities which remain shrouded until adulthood, when symptoms become distressing. Fortunately, prognosis is favourable after surgical correction, in spite of its rarity. Complexity arises when other associated anomalies are identified.

Influence of Microheterogeneous Environments of Sodium Dodecyl Sulfate on the Kinetics of Oxidation of l-Serine by Chloro and Chlorohydroxo Complexes of Gold(III).

The oxidation of l-serine by chloro and chlorohydroxo complexes of gold(III) was spectrophotometrically investigated in acidic buffer media in the absence and presence of the anionic surfactant sodium dodecyl sulfate (SDS). The oxidation rate decreases with increase in either [H+] or [Cl-]. Gold(III) complex species react with the zwitterionic form of serine to yield acetaldehyde (principal reaction product) through oxidative decarboxylation and subsequent deamination processes. A reaction pathway involving one electron transfer from serine to Au(III) followed by homolytic cleavage of α-C-C bond with the concomitant formation of iminic cation intermediate has been proposed where Au(III) is initially reduced to Au(II). The surfactant in the submicellar region exhibits a catalytic effect on the reaction rate at [SDS] ≤ 4 mM; however, in the postmicellar region an inhibitory effect was prominent at [SDS] ≥ 4 mM. The catalytic effect below the critical micelle concentration (cmc) may be attributable to the electrostatic attraction between serine and SDS that, in turn, enhances the nucleophilicity of the carboxylate ion of the amino acid. The inhibition effect beyond cmc has been explained by considering the distribution of the reactant species between the aqueous and the micellar pseudophases that restricts the close association of the reactant species. The thermodynamic parameters Δ H0 and Δ S0 associated with the binding between serine and SDS micelle were calculated to be -14.4 ± 2 kJ mol-1 and -6.3 ± 0.5 J K-1 mol-1, respectively. Water structure rearrangement and micelle-substrate binding play instrumental roles during the transfer of the reactant species from aqueous to micellar pseudophase.

Study of salivary gland lesions with fine needle aspiration cytology and histopothology along with immunohistochemistry.

Salivary gland swelling is a common and important problem. Acute and chronic sialadenitis, different benign and malignant neoplasms are the common causes which present with salivary gland swelling. Imaging technique is not so helpful in pre-operative diagnosis; microscopical examination is required for diagnosis. Pre-operative core needle biopsy is hazardous and may damage facial nerve, lead to fistula formation or associated with tumour seeding. Fine needle aspiration cytology (FNAC) is however virtually risk-free. The study was done to assess the utility of FNAC and its accuracy and pitfalls with respect to histopathology and advantages of immunohistochemistry. The study was done with 40 cases of salivary gland swelling. After clinical examination, FNAC and histopathological examination along with immunohistochemistry was done and the results were correlated. Out of 40 cases, 25 involved the parotid gland, most common age group affected was 20 - 40 years and male: female ratio was 5: 3. Out of 40 cases 37 cases were cytologically and histopathologically correlated and rest 3 cases were different. Among these 3 cases, 2 were adenoid cystic carcinoma which was cytologically diagnosed as benign neoplasm (monomorphic adenoma). One case of Warthin's tumour was cytologically diagnosed as pleomorphic adenoma. The sensitivity of this study was found to be 71.43%, specificity 100% and accuracy was 93.10%. This study corroborates well with other studies including immunohistochemical findings. p53 expression was found to be related with nature of the neoplasm. FNAC is an important tool for early diagnosis of salivary gland lesions.

Enormous disfiguring thyroid swelling.

A 35 year old woman presented to us with a huge thyroid swelling (17 × 11 × 14 cm) in front of her neck which she had for the last 10 years. She was not toxic or dyspnoeic. It was multinodular with areas of firmness and cystic feeling. She had some degree of tracheal compression but no intra thoracic extension as confirmed by a CT scan of the neck. Endotracheal intubaton was done and she was operated on using a long transverse incision with division of the strap muscles for better exposure. She did not need a tracheostomy and the post operative period was uneventful. The histopathological revealed a goitre.

Roundworm in a chest drain.

A 19 year old man who suffered a stab injury in the epigastric region and had a chest drain was referred to our accident and emergency department. A chest x-ray showed left sided opacities with fundic gas in the region of the left hemithorax.A roundworm was seen in the chest tube. An exploratory laparotomy revealed a diaphragmatic tear with a laceration of the anterior wall of the stomach from which multiple roundworms were coming out and had entered the pleural cavity and then the chest drain. The tears were repaired and abdomen closed. The patient is doing well.