The aim of this study is to compare urodynamic and continence parameters among patients undergoing orthotropic neo-bladder substitution with sigmoid or ileal segments. Variations in the Urodynamic parameter between the continent and incontinent patients were also evaluated.
Patients and Methods:
From January 2008 to March 2012, 44 patients underwent ileal neobladder (IN) reconstruction and 36 patients underwent sigmoid neobladder (SN) reconstruction. Evaluation of Urodynamic and Continence parameters was performed at 12 months after surgery.
The average capacity of IN and SN was 510 ml and 532 ml respectively. The voiding pressure, mean peak flow rates and post void residual urine (PVRU) for IN and SN were 27.5 cm H2O versus 37 cm H2O, 15ml/s versus 17ml/s and 36 ml versus 25 ml respectively. Daytime continence for IN and SN was 93% (41/44) and 89% (32/36), and night-time continence was 91% (40/44) and 78% (28/36) respectively. The compliance, maximum cystometric capacity and PVRU in the daytime continent (versus incontinent) were 61 (versus 41), 471 (versus 651) and 22 (versus 124) and in the night-time continent (versus incontinent) were 57 (versus 43), 437 (versus 654) and 18 (versus 105) respectively.
A neobladder constructed from detubularized ileum or sigmoid achieves urodynamically proven adequate capacity and compliance with 89-93% daytime and 78-91% night time continence. Continent men when compared with incontinent (both daytime and night time) were more likely to have comparatively higher compliance, lower maximum cystometric capacity and lower PVRU. Urodynamic study could predict which incontinent men would improve with pelvic floor exercises and clean intermittent catheterization (CIC).
Ileal neobladder; nonrandomized; prospective; sigmoid neobladder; urodynamic
Background and Objectives:
To compare laparoscopic transperitoneal versus retroperitoneoscopic pyeloplasty for primary ureteropelvic junction obstruction in a prospective randomized manner and assess overall results with long-term follow-up.
In this prospective study, from 2008 to 2012, 112 cases of primary ureteropelvic junction obstruction were randomized in a 1:1 ratio into 2 groups. Group I included patients who underwent transperitoneal laparoscopic pyeloplasty, and group II consisted of patients who underwent retroperitoneoscopic laparoscopic pyeloplasty. Demographic and clinical characteristics and postoperative and operative data were collected and analyzed. The statistical analysis was performed with the Fisher exact test, χ2 test, and Mann-Whitney U test for independent groups, and P < .05 was considered statistically significant.
The total operative time and intracorporeal suturing time were significantly higher in group II than in group I (P < .001). The visual analog scale score for pain on postoperative day 1 and the requirement for tramadol were significantly higher in group I than in group II (P = .004). The hospital stay and the rate of temporary ileus were significantly greater (P < .036 and P < .02, respectively) in group I than in group II. The success rate of transperitoneal laparoscopic pyeloplasty versus retroperitoneoscopic laparoscopic pyeloplasty was 96.4% versus 96.6% with a mean follow-up period of 30.75 ± 4.85 months versus 30.99 ± 5.59 months (P < .88).
Transperitoneal laparoscopic pyeloplasty is associated with significantly greater postoperative pain, a higher tramadol dose, a higher rate of ileus, and a longer hospital stay in comparison with retroperitoneoscopic laparoscopic pyeloplasty. Although the operative time for retroperitoneoscopic laparoscopic pyeloplasty is significantly longer, the success rate remains the same for both procedures.
Randomized; Transperitoneal; Retroperitoneal; Pyeloplasty; Primary ureteropelvic junction obstruction
Histocompatibility is the basis by which multicellular organisms of the same species distinguish self from non-self. Relatively little is known about the mechanisms underlying histocompatibility reactions in lower organisms. Botryllus schlosseri is a colonial urochordate, a sister group of vertebrates, that exhibits a genetically determined natural transplantation reaction, whereby self-recognition between colonies leads to formation of parabionts with a common vasculature, whereas rejection occurs between incompatible colonies. Using genetically defined lines, whole-transcriptome sequencing, and genomics, we identified a single gene that encodes self/non-self and determines “graft” outcomes in this organism. This gene is significantly upregulated in colonies poised to undergo fusion or rejection, is highly expressed in the vasculature, and is functionally linked to histocompatibility outcomes. These findings establish a platform for advancing the science of allorecognition.
Filarial chyluria is a common problem in filarial endemic countries. Its management begins with medical therapy but some patients progress to require surgery. The present study aimed to determine factors affecting response to medical management in patients of filarial chyluria.
Materials and Methods:
This prospective study conducted between August 2008 and November 2012, included conservatively managed patients of chyluria. Demographic profile, clinical presentation, treatment history and urinary triglycerides (TGs) and cholesterol levels at baseline were compared between the responders and non-responders. Apart from the clinical grade of chyluria, hematuria was evaluated as an independent risk factor.
Out of the 222 patients (mean age, 37.99 ± 13.29 years, 129 males), 31 patients failed to respond while 35 had a recurrence after initial response; the overall success rate being 70.3% at a mean follow-up of 25 months. No difference was observed in demographics, clinical presentation, presence of hematuria, disease duration and mean urinary TGs loss between responders and non-responders. On multivariate analysis, patients with treatment failure were found to have a higher-grade disease (14.3% Grade-I, 36.6% Grades-II and 60% Grade-III), higher number of pretreatment courses (1.59 ± 1.08 vs. 1.02 ± 0.79) and heavier cholesterol (26.54 ± 23.46 vs. 8.81 ± 8.55 mg/dl) loss at baseline compared with responders (P < 0.05).
Conservative management has a success rate in excess of 70%, not affected by the disease chronicity, previous episodes and recurrent nature. However, higher-grade disease, extensive pre-treatment with drugs and higher urinary cholesterol loss at baseline are the predictors of poor response. Hematuria is not an independent poor risk factor for conservative management.
Cholesterol; chyluria; filariasis; triglycerides
Prospective randomized study on transperitoneal laparoscopic ureterolithotomy (TPLU) versus open ureterolithotomy (OU) for treatment of large impacted ureteric stones (≥ 1.5 cm) and assessment of overall results.
Material & Methods
In a prospective study between 2010 to 2012, 30 patients underwent TPLU and 30 OU based on 1:1 randomization. The operation was indicated primarily in 44 cases or after failed shock-wave lithotripsy/ureteroscopy in 16 cases. Two groups were compared for operative time, success rate, visual pain score, analgesic requirement, hospital stay, and postoperative complications. Statistical analysis was performed with SPSS® version 16.0 using Fisher exact or Mann-Whitney U tests with p < 0.05 considered statistically significant.
The difference in visual pain score (6.2 in TPLU group vs 3.1 in OU group on day 1; 4.8 vs. 2.4 on day 2) and tramadol requirements (184.32 mg in TPLU group vs. 150.87 mg in OU group on day 1; 97.34 mg vs. 65.56 mg on day 2) were statistically significant and more in OU. Hospital stay and convalescence were significantly lower in the TPLU. However, stone removal in one attempt was similar in both the groups.
Although successful stone removal rates are equal in both groups, TPLU is associated significantly with less postoperative pain, less analgesic requirement, shorter hospital stay and short convalescence in comparison to OU.
Laparoscopy; Ureterolithotomy; Ureteral calculus
To present our experience of treating supratrigonal vesicovaginal fistulae by laparoscopic technique and their long-term follow-up.
Material and Methods
Between January 2008 and June 2012, 28 cases of supratrigonal fistulas were repaired by laparoscopic transperitoneal transvesical technique with interposition flap. The obstetric fistula was present in 18 and gynecologic fistula in 10 patients. Single supratrigonal fistula was present in 26 patients and in 2 patients there were 2 fistulae lying side to side. The vaginal opening was closed as single layer interrupted suture and cystotomy closed as single layer continuous suture by 3-0 polygalactin. The omentum was used as interposition flap in all except 2 cases in whom postero-superior vesical fold of peritoneum was used. The open conversion was required in 2 cases. The urethral catheter was removed in 4 weeks following a micturating cystogram.
The mean fistula size was 1.2 cm (range 0.8-2.5 cm). Open conversion was performed in 2 cases of whom one had excess carbon-dioxide retention and cardiac arrhythmia and in another case the needle of 3-0 polygalactin was avulsed and lost in peritoneal cavity which was recovered following laparotomy. All patients were continent following the catheter removal. The median follow-up is 24 months. None developed any complication related to laparoscopic repair till last follow-up.
Laparoscopic repair of supratrigonal vesicovaginal fistulae is an effective and safe minimally invasive treatment with excellent result.
Transperitoneal approach; Laparoscopic surgery; Vesicovaginal fistulae
Nephrolithiasis has been reported in 20-28% of patients, of whom 50% are symptomatic for stone disease and 20% require definite urologic intervention. The management of nephrolithiasis includes oral alkali dissolution therapy, extracorporeal shock wave lithotripsy and surgical treatment. In such patients, percutaneous nephrolithotomy (PNL) as a method of stone treatment has been reported in few cases with limited experience. The aim of this study is to present our experience of PNL in autosomal dominant polycystic kidney disease (ADPKD) and assessing the outcome results.
Material and Methods
From 2002 to 2011, 22 patients (26 renal units) suffering from ADPKD with stone were managed by PNL. Demographic characteristics, operative parameters and postoperative complications were recorded and analysed.
The overall success rate of PNL was 82.1% and PNL with extracorporeal shock wave lithotripsy for clinically significant residual fragments was 92.85% respectively. The hematuria required blood transfusion (n = 9), postoperative fever due to cyst infection (n = 4) and paralytic ileus (n = 3) were recorded.
The PNL in ADPKD PNL is safe and effective but have more postoperative complications such as bleeding requiring transfusions, fever due to cyst infection and paralytic ileus.
Percutaneous nephrolithotomy; Nephrolithiasis; Autosomal dominant polycystic kidney disease
A 22-year-old young woman presented with dysuria and lower urinary tract symptoms that had persisted for 6 months. She was diagnosed with a tumor near the bladder neck. Transurethral resection was done under anaesthesia. The histopathological examination with immunohistochemical staining showed the tumor to be a low-grade leiomyosarcoma. Adjuvant chemoradiation was given, and the patient has been doing well for 12 months of follow-up. Nonurothelial tumors of the bladder are rare and consensus is lacking regarding their definitive treatment. Furthermore, little is known about the natural history and prognosis of this type of bladder sarcoma. We present a minimally invasive treatment for this relatively rare tumor in which bladder preservation was achieved with no evidence of local or distant recurrences during the follow-up to date.
Hematuria; Leiomyosarcoma; Urinary bladder neoplasms
An 18-year-old man born with aphallia had undergone phallic reconstruction in childhood followed by total urethral reconstruction with a buccal mucosal graft and groin-based pedicle (Singapore) flap urethroplasty at 13 years of age. The patient presented with obstructive voiding symptoms lasting 6 months followed by acute urinary retention. The results of a voiding cystourethrogram showed a filling defect in the distal urethra that had been reconstructed by use of the skin flap. On urethroscopy, a 3 cm×2 cm sized tricholithobezoar was seen in the distal urethra. Pneumatic lithotripsy followed by bulbar urethrolithotomy was performed in the same operation to extract the bezoar. The remaining hairs were mechanically epilated. The patient has been doing well for 6 months of follow-up.
Bezoars; Epilation; Stone
Patent ductus arteriosus (PDA), in which there is a persistent communication between the descending thoracic aorta and the pulmonary artery that results from failure of normal physiologic closure of the fetal ductus, is one of the more common congenital heart defects in preterm neonates. The closure of PDA can be done with either Indomethacin or Brufen which are cyclooxygenase 1, 2 inhibitor; however these drugs are associated with side effects. We report an interesting findings of ductal closure in 10 preterm neonates (gestational age 27-33 wks) presenting with significant large PDA who had failed or had absolute contraindication with Brufen. These preterm neonates were treated with oral paracetamol in the dose of 15 mg/kg 8 hourly. The PDA closure was achieved within 48 h and there was no complication.
Ductus; paracetamol; brufen; preterm
Introduction and Objectives:
To prospectively document the perioperative complications of percutaneous nephrolithotomy (PCNL) using the modified Clavien grading system. Evaluation of complications and clearance rates according to stone complexity using the validated Guy's Stone Score (GSS) was also done.
Materials and Methods:
A total of 221 renal units underwent 278 PCNL procedures at a urology resident training center between September 2010 and September 2011 and data were recorded prospectively in our registry. Patients with co-morbidities like diabetes, renal failure, hypertension and cardiopulmonary diseases were excluded. Stone complexity was classified according to the GSS while peri-operative complications were recorded using the modified Clavien grading system.
Two hundred and forty-five complications were encountered in 278 PCNL procedures involving 116 renal units (41.72%). Complications of Grades 1, 2, 3a, 3b, 4a, 4b and 5 were seen in 52 (18.7%), 122 (43.8%), 42 (15.1%), 18 (6.4%), 6 (2.1%), 4 (1.4%) and 1 (0.3%) renal units respectively. There were 68, 98, 50 and 5 renal units in GSS I, II, III and IV groups, respectively. All grades of complications were more common in GSS III and IV (P<0.05). For GSS I, II, III and IV 100%, 74%, 56% and 0% of renal units, respectively, were stone-free after one session and 0%, 24%, 44% and 60% respectively needed two sessions to be stone-free.
Although the complication rates were higher most were of low grade and self-limiting. Complications were significantly more common with higher GSS and the GSS effectively predicted stone-free rates.
Complication; Guy's Stone Score; modified Clavien grading system; percutaneous nephrolithotomy
OVO-like proteins (OVOL) are members of the zinc finger protein family and serve as transcription factors to regulate gene expression in various differentiation processes. Recent studies have shown that OVOL genes are involved in epithelial development and differentiation in a wide variety of organisms; yet there is a lack of comprehensive studies that describe OVOL proteins from an evolutionary perspective. Using comparative genomic analysis, we traced three different OVOL genes (OVOL1-3) in vertebrates. One gene, OVOL3, was duplicated during a whole-genome-duplication event in fish, but only the copy (OVOL3b) was retained. From early-branching metazoa to humans, we found that a core domain, comprising a tetrad of C2H2 zinc fingers, is conserved. By domain comparison of the OVOL proteins, we found that they evolved in different metazoan lineages by attaching intrinsically-disordered (ID) segments of N/C-terminal extensions of 100 to 1000 amino acids to this conserved core. These ID regions originated independently across different animal lineages giving rise to different types of OVOL genes over the course of metazoan evolution. We illustrated the molecular evolution of metazoan OVOL genes over a period of 700 million years (MY). This study both extends our current understanding of the structure/function relationship of metazoan OVOL genes, and assembles a good platform for further characterization of OVOL genes from diverged organisms.
Insertions of spliceosomal introns are very rare events during evolution of vertebrates and the mechanisms governing creation of novel intron(s) remain obscure. Largely, gene structures of melanocortin (MC) receptors are characterized by intron-less architecture. However, recently a few exceptions have been reported in some fishes. This warrants a systematic survey of MC receptors for understanding intron insertion events during vertebrate evolution.
We have compiled an extended list of MC receptors from different vertebrate genomes with variations in fishes. Notably, the closely linked MC2Rs and MC5Rs from a group of ray-finned fishes have three and one intron insertion(s), respectively, with conserved positions and intron phase. In both genes, one novel insertion was in the highly conserved DRY motif at the end of helix TM3. Further, the proto-splice site MAG↑R is maintained at intron insertion sites in these two genes. However, the orthologs of these receptors from zebrafish and tetrapods are intron-less, suggesting these introns are simultaneously created in selected fishes. Surprisingly, these novel introns are traceable only in four fish genomes. We found that these fish genomes are severely compacted after the separation from zebrafish. Furthermore, we also report novel intron insertions in P2Y receptors and in CHRM3. Finally, we report ultrasmall introns in MC2R genes from selected fishes.
The current repository of MC receptors illustrates that fishes have no MC3R ortholog. MC2R, MC5R, P2Y receptors and CHRM3 have novel intron insertions only in ray-finned fishes that underwent genome compaction. These receptors share one intron at an identical position suggestive of being inserted contemporaneously. In addition to repetitive elements, genome compaction is now believed to be a new hallmark that promotes intron insertions, as it requires rapid DNA breakage and subsequent repair processes to gain back normal functionality.
Alternative splicing and posttranslational modifications (PTMs) are major sources of protein diversity in eukaryotic proteomes. The SR protein SF2/ASF is an oncoprotein that functions in pre-mRNA splicing, with additional roles in other posttranscriptional and translational events. Functional studies of SR protein PTMs have focused exclusively on the reversible phosphorylation of Ser residues in the C-terminal RS domain. We confirmed that human SF2/ASF is methylated at residues R93, R97, and R109, which were identified in a global proteomic analysis of Arg methylation, and further investigated whether these methylated residues regulate the properties of SF2/ASF. We show that the three arginines additively control the subcellular localization of SF2/ASF and that both the positive charge and the methylation state are important. Mutations that block methylation and remove the positive charge result in the cytoplasmic accumulation of SF2/ASF. The consequent decrease in nuclear SF2/ASF levels prevents it from modulating the alternative splicing of target genes, results in higher translation stimulation, and abrogates the enhancement of nonsense-mediated mRNA decay. This study addresses the mechanisms by which Arg methylation and the associated positive charge regulate the activities of SF2/ASF and emphasizes the significance of localization control for an oncoprotein with multiple functions in different cellular compartments.
SF2/ASF is a prototypical SR protein, with important roles in splicing and other aspects of mRNA metabolism. SFRS1 (SF2/ASF) is a potent proto-oncogene with abnormal expression in many tumors. We found that SF2/ASF negatively autoregulates its expression to maintain homeostatic levels. We characterized six SF2/ASF alternatively spliced mRNA isoforms: the major isoform encodes full-length protein, whereas the others are either retained in the nucleus or degraded by NMD. Unproductive splicing accounts for only part of the autoregulation, which occurs primarily at the translational level. The effect is specific to SF2/ASF and requires RRM2. The ultraconserved 3′UTR is necessary and sufficient for downregulation. SF2/ASF overexpression shifts the distribution of target mRNA towards mono-ribosomes, and translational repression is partly independent of Dicer and a 5′ cap. Thus, multiple post-transcriptional and translational mechanisms are involved in fine-tuning the expression of SF2/ASF.
We report a unique case of primary hepatocellular carcinoma in an ectopic liver rest in the left renal hilum masquerading as a left adrenal tumor. Adrenal tumors have been reported within adrenal rests inside the liver but hepatocellular carcinoma in ectopic liver rests in the adrenal area is an extremely rare entity. To the best of our knowledge, this is the first case report from the Indian subcontinent to describe this event in the English literature.
Our patient, a sixty-year-old, non-diabetic, non-hypertensive male, presented with a history of left flank pain for the past six months. He was a chronic smoker and also consumed excessive amounts of alcohol. He had chronic obstructive pulmonary disease and was hepatitis B surface antigen positive. A contrast enhanced computer tomography scan of the abdomen showed an 8×8×8 cm, well-defined, heterogeneously enhancing mass with central necrosis, in the left suprarenal region. The provisional diagnosis of an adrenal tumor was made and open transperitoneal excision of the tumor along with two enlarged lymph nodes was done. Immunohistochemistry staining of the specimen revealed it to be a primary hepato cellular carcinoma. The patient died within six months of surgery owing to extensive metastases. We concluded that chronic hepatitis B infection and chronic and excessive alcohol consumption and/or chronic smoking may have been the predisposing factors for the occurrence of primary hepatocellular carcin oma in the liver rest in our patient. The prognosis appears to be poor despite surgical management.
carcinoma; hepatocellular; liver neoplasms
Ureterocystoplasty is a novel operation well suited for patients having small capacity urinary bladder with unilateral poorly functioning kidney and megaureter. The megaureter is detubularized and used for urinary bladder augmentation. The ureter lining has advantage of being non-secretory and free from the metabolic complications of enterocystoplasty. This operation is mainly done in children. This is one of the very few from the Asian subcontinent which describes the short term results of ureterocystoplasty in an adult patient. We report a case wherein ureterocystoplasty was performed in an 18-year male presented with a small capacity neurogenic bladder with a grossly dilated and tortuous left ureter and a non-functioning left kidney. Left ureter was detubularized and used for augmentation after left nephrectomy. Blood supply to the left ureter was preserved during the dissection. After the operation, the bladder capacity increased adequately and he is doing well at a followup of 1 year. Ureterocystoplasty works well in the adult patients also and the bladder capacity increases adequately following this procedure.
Urinary bladder; Augmentation; Ureter
Fistula following circumcision and at times accompanied by disfigurement of the glans penis is a common problem in our country, where a large number of circumcision is performed by untrained professionals. These complications may have profound negative psychological impact on the growing child. Herein, we report the successful closure of such fistula using buccal mucosa, which occurred following circumcision (for phimosis) in a 15 year old boy. This resulted in the disfigurement of the glans penis with a distal urethral fistula. The fistula was managed by dorsal onlay buccal mucosa graft urethroplasty (BMGU). The patient has excellent cosmesis at 6 months followup with a good urinary stream. This technique can give better results than those, where skin grafts or local flaps are used for fistula closure. BMGU is a versatile technique with good long term results. The cosmesis and functional results are satisfactory and help in improving the self esteem and sexual function in the years to come.
Techniques; Buccal mucosa; Circumcision; Fistula; Phimosis
A rare case of Acute lymphoblastic leukemia with hemophillia in a 12 year old boy is presented in the article. Patient was known case of hemophillia (factor VIII deficiency). He was diagnosed as a case of ALL based on bone marrow examination and immunophenotypic study. Patient was treated as per Children Cancer group guidelines. The main aim of reporting this rare association lies in developing treatment strategies in preventing life threatening bleeding due to this rare association which though may be accidental but need further research.
Chronic prostatitis / chronic pelvic pain syndrome (NIH-type II and type III prostatitis) are common cause of chronic pelvic pain. The exact etiology of these entities are unknown. They are associated with varying degree of voiding and sexual dysfunction. Consensus regarding treatment of these pain syndromes is lacking. Review of literature suggest a therapeutic role of alpha adrenergic receptor blockers in the management of NIH-type II and type III prostatitis. A trial of alpha-blocker is reasonably inexpensive and appropriate for most patients suffering from NIH-type III prostatitis and NIH-type II prostatitis. A general consensus is that if a patient agrees to a trial of alpha-blocker therapy which subsequently shows a good response then it should be continued for at least 6 months for a proper therapeutic effect. This review analyses the role of alpha-blockers in this disease/syndrome; discusses the possible mechanism of action through which these drugs provide relief and also highlights some of the important trials which have paved way for this particular treatment option in this intriguing disease /syndrome.
Prostate; Pain; Adrenergic alpha antagonists; Chronic prostatitis with chronic pelvic pain syndrome
The purpose of this prospective study was to evaluate the donor site morbidity in patients who have undergone oral mucosa graft urethroplasty for stricture of the urethra. The impact of smoking and oral consumption of tobacco and/or paan masala on the donor site was also assessed. This study is probably the first of its kind where the affect of smoking, paan masala and tobacco chewing on the donor site morbidity has been documented.
Forty-eight patients suffering from stricture of the urethra underwent oral mucosa graft urethroplasty between July 2005 and December 2007. The patients were divided into two groups (users or non-users) based on tobacco consumption and oral hygiene. The donor site was evaluated at frequent intervals for pain, swelling, numbness, bleeding, salivation and tightness of mouth.
Donor site morbidity was more in users with poor oral hygiene. Pain scores were higher amongst the users and the morbidity persisted longer in the users compared to non-users with good oral hygiene.
Patients who consume tobacco and have poor oral hygiene should be warned regarding poorer outcomes after oral mucosa graft urethroplasty.