A sentinel lymph node (SLN) is the first lymph node to drain a solid tumor and likely the first place metastasis will travel. SLN biopsy has been well established as a staging tool for melanoma and breast cancer to guide lymph node dissection (LND); its utility in bladder cancer is debated. We performed a systematic search of PubMed for both human and animal studies that looked at SLN detection in cases of urothelial carcinoma of the bladder. We identified a total of nine studies that assessed a variety of imaging techniques to identify SLNs in patients with urothelial carcinoma of the bladder. Eight studies investigated human patients while one looked at animal (dog) models. Seven studies representing 156 patients noted the negative predictive value of the SLN to predict a metastasis free state was 92% (92/100). The SLN biopsy was less accurate in metastatic patients with a positive predictive value of only 77% (43/56) with a false negative range of in individual studies of 0-19%. Clinically, positive nodes routinely do not take up the pharmaceutical agent for SLN. Therefore, SLN biopsy is a promising concept with a 92% negative predictive value; however, the false negative rates are high which may be improved by standardizing populations and indications. Novel technologies are improving the detection of SLN and may provide the surgeon with an improved ability to detect micrometastasis, guide surgery, and reduce patient morbidity.
Bladder cancer; radiology; sentinel lymph node; technology
Ultrasound is an imaging technology that has evolved swiftly and has come a long way since its beginnings. It is a commonly used initial diagnostic imaging modality as it is rapid, effective, portable, relatively inexpensive, and causes no harm to human health. In the last few decades, there have been significant technological improvements in the equipment as well as the development of contrast agents that allowed ultrasound to be even more widely adopted for urologic imaging. Ultrasound is an excellent guidance tool for an array of urologic interventional procedures and also has therapeutic application in the form of high-intensity focused ultrasound (HIFU) for tumor ablation. This article focuses on the recent advances in ultrasound technology and its emerging clinical applications in urology.
Advances; cancer; kidney; prostate; ultrasonography; urology
Urolithiasis is a common disease with increasing prevalence worldwide and a lifetime-estimated recurrence risk of over 50%. Imaging plays a critical role in the initial diagnosis, follow-up and urological management of urinary tract stone disease. Unenhanced helical computed tomography (CT) is highly sensitive (>95%) and specific (>96%) in the diagnosis of urolithiasis and is the imaging investigation of choice for the initial assessment of patients with suspected urolithiasis. The emergence of multi-detector CT (MDCT) and technological innovations in CT such as dual-energy CT (DECT) has widened the scope of MDCT in the stone disease management from initial diagnosis to encompass treatment planning and monitoring of treatment success. DECT has been shown to enhance pre-treatment characterization of stone composition in comparison with conventional MDCT and is being increasingly used. Although CT-related radiation dose exposure remains a valid concern, the use of low-dose MDCT protocols and integration of newer iterative reconstruction algorithms into routine CT practice has resulted in a substantial decrease in ionizing radiation exposure. In this review article, our intent is to discuss the role of MDCT in the diagnosis and post-treatment evaluation of urolithiasis and review the impact of emerging CT technologies such as dual energy in clinical practice.
Advances; computed tomography; urolithiasis
Multiparametric-magnetic resonance imaging (mp-MRI) has shown promising results in diagnosis, localization, risk stratification and staging of clinically significant prostate cancer. It has also opened up opportunities for focal treatment of prostate cancer. Combinations of T2-weighted imaging, diffusion imaging, perfusion (dynamic contrast-enhanced imaging) and spectroscopic imaging have been used in mp-MRI assessment of prostate cancer, but T2 morphologic assessment and functional assessment by diffusion imaging remains the mainstay for prostate cancer diagnosis on mp-MRI. Because assessment on mp-MRI can be subjective, use of the newly developed standardized reporting Prostate Imaging and Reporting Archiving Data System scoring system and education of specialist radiologists are essential for accurate interpretation. This review focuses on the present status of mp-MRI in prostate cancer and its evolving role in the management of prostate cancer.
Diffusion imaging; functional imaging; MRI-guided biopsy; multiparametric-MRI; prostate cancer
Advances in imaging technology, especially in the last two decades, have led to a paradigm shift in the field of image-guided interventions in urology. While the traditional biopsy and drainage techniques are firmly established, image-based stone management and endovascular management of hematuria have evolved further. Ablative techniques for renal and prostate cancer and prostate artery embolization for benign prostatic hypertrophy have evolved into viable alternative treatments. Many urologic diseases that were earlier treated surgically are now effectively managed using minimally invasive image-guided techniques, often on a day care basis using only local anesthesia or conscious sedation. This article presents an overview of the technique and status of various image-guided urological procedures, including recent emerging techniques.
Angiography; fluoroscopy; imaging; ultrasonography; urology
Recent advances in multiparametric magnetic resonance imaging (mp-MRI) have led to a paradigm shift in the diagnosis and management of prostate cancer (PCa). Its sensitivity in detecting clinically significant cancer and the ability to localize the tumor within the prostate gland has opened up discussion on targeted diagnosis and therapy in PCa. Use of mp-MRI in conjunction with prostate-specific antigen followed by targeted biopsy allows for a better diagnostic pathway than transrectal ultrasound (TRUS) biopsy and improves the diagnosis of PCa. Improved detection of PCa by mp-MRI has also opened up opportunities for focal therapy within the organ while reducing the incidence of side-effects associated with the radical treatment methods for PCa. This review discusses the evidence and techniques for in-bore MRI-guided prostate biopsy and provides an update on the status of MRI-guided targeted focal therapy in PCa.
Focal therapy in prostate cancer; multiparametric magnetic resonance imaging; MRI-guided prostate biopsy; prostate cancer
Pelvic lymphadenectomy during radical prostatectomy (RP) improves staging and may provide a therapeutic benefit. However, there is no clear consensus on the selection criteria for subjecting patients to this additional procedure. With a growing adoption of robot assisted radical prostatectomy (RARP) in India, it has become imperative to study the incidence and predictive factors for lymph node involvement in our patients.
Materials and Methods:
From February 2010 to February 2014, 452 RARP procedures were performed at our institution. A total of 100 consecutive patients from July 2011 to August 2012 were additionally subjected to a robotic extended pelvic lymphadenectomy (EPLND). Lymph node positivity rates and lymph node density were analyzed on the basis of preoperative prostate specific antigen (PSA), Gleason score, clinical stage, D’Amico risk category and magnetic resonance imaging (MRI) findings. Multivariate analysis was performed to ascertain factors associated with lymph node positivity in our cohort.
The mean age of the patients was 65.5 (47–77) years and the body mass index was 26.3 (16.3–38.7) kg/m2. The mean console time for EPLND was 45 (32–68) min. A median of 17 (two to 40) lymph nodes were retrieved. Seventeen patients (17%) had positive lymph nodes (median of 1, range 1–6). Median lymph node density in these patients was 10%. When stratified by PSA, Gleason score, clinical stage, D’Amico risk category and features of locally advanced disease on MRI, a trend towards increasing incidence of lymph node positivity was observed, with an increase in adverse factors. However, on multivariate analysis, clinical stage > T2a was the only significant factor impacting lymph node positivity in our cohort.
A significant proportion of men undergoing RARP in India have positive lymph nodes on EPLND. While other variables may also have a potential impact, a higher clinical stage predisposes to an increased incidence of lymph node metastases.
Extended pelvic lymphadenectomy; pelvic lymphadenectomy; prostate cancer; radical prostatectomy; robot assisted radical prostatectomy
The learning curve for robotic partial nephrectomy was investigated for an experienced laparoscopic surgeon and factors associated with warm ischemia time (WIT) were assessed.
Materials and Methods:
Between 2007 and 2014, one surgeon completed 171 procedures. Operative time, blood loss, complications and ischemia time were examined to determine the learning curve. The learning curve was defined as the number of procedures needed to reach the targeted goal for WIT, which most recently was 20 min. Statistical analyses including multivariable regression analysis and matching were performed.
Comparing the first 30 to the last 30 patients, mean ischemia time (23.0–15.2 min, P < 0.01) decreased while tumor size (2.4–3.4 cm, P = 0.02) and nephrometry score (5.9–7.0, P = 0.02) increased. Body mass index (P = 0.87), age (P = 0.38), complication rate (P = 0.16), operating time (P = 0.78) and estimated blood loss (P = 0.98) did not change. Decreases in ischemia time corresponded with revised goals in 2011 and early vascular unclamping with the omission of cortical renorrhaphy in selected patients. A multivariable analysis found nephrometry score, tumor diameter, cortical renorrhaphy and year of surgery to be significant predictors of WIT.
Adoption of robotic assistance for a surgeon experienced with laparoscopic surgery was associated with low complication rates even during the initial cases of robot-assisted partial nephrectomy. Ischemia time decreased while no significant changes in blood loss, operating time or complications were seen. The largest decrease in ischemia time was associated with adopting evidence-based goals and new techniques, and was not felt to be related to a learning curve.
Renal cell carcinoma; partial nephrectomy; robotics
Many healthy elderly Indian men seek surgical treatment for localized prostate cancer. Quite often, radical surgery is not offered to the patients over 70 years of age due to the perception of increased side-effects and complications. We have previously reported our results of robotic radical prostatectomy in a study comprising 150 Indian patients, where almost a quarter of patients were elderly. This subgroup analysis was therefore focused on evaluating perioperative and continence outcomes in elderly men (≥70 years) with localized prostate cancer.
Materials and Methods:
Between April 2010 and August 2013, 153 men had robot-assisted radical prostatectomy performed by two surgeons. Of the 150 men analyzed, 39 (26%) were aged ≥70 years. All patients underwent robotic prostatectomy using a 4 arm da Vinci surgical system. Pre-operative, intraoperative and post-operative parameters were studied. Check cystogram was performed in all patients prior to catheter removal. Complications were categorized using the Clavien-Dindo classification system. Continence was defined as use of “no pad” or security liner only. All data were recorded prospectively and analyzed using SPSS version 20.
There were no significant intraoperative or perioperative complications in this group. Median blood loss during surgery was 150 mL. None of the patient required blood transfusion. There were two minor complications (5.1%) within the first 30 days of surgery: Minimal anastomotic site leak (one patient) requiring replacement and prolongation of Foley's drainage by 1 week and ileus (one patient). No patient had any cardiopulmonary or vascular complications in the post-operative period. The median duration of hospital stay was 3 days. The median duration of catheterization was 7 days. No patient had problem of bladder neck stenosis in the follow-up period. At 1 month, 3 months, 6 months and 1 year of follow-up, 66.7% (n = 26), 74.3% (n = 29), 87.9% (n = 34) and 94.8% (n = 37), respectively, were continent.
Robotic surgery is safe and feasible in a select group of elderly patients. It has acceptable and minimal perioperative complications along with good continence outcome.
Continence; elderly men; prostate cancer; robotic prostatectomy; robotic surgery
Socio-economic rehabilitation is an important outcome parameter in successful renal transplant recipients, particularly in developing countries with low income patients who often depend on extraneous sources to fund their surgery costs. We studied the socioeconomic rehabilitation and changes in socioeconomic status (SES) of successful renal allograft recipients among Indian patients and its correlation with their source of funding for the surgery.
Materials and Method:
A cross-sectional, questionnaire-based study was conducted on 183 patients between January 2010 to January 2013. Patients with follow up of at least 1 year after successful renal transplant were included. During interview, two questionnaires were administered, one related to the SES including source of funding before transplantation and another one relating to the same at time of interview. Changes in SES were categorized as improvement, stable and deterioration if post-transplant SES score increased >5%, increased or decreased by <5% and decreased >5% of pre-transplant value, respectively.
In this cohort, 97 (52.7%), 67 (36.4%) and 19 (10.3%) patients were non-funded (self-funded), one-time funded and continuous funded, respectively. Fifty-six (30.4%) recipients had improvement in SES, whereas 89 (48.4%) and 38 (20.7%) recipients had deterioration and stable SES. Improvement in SES was seen in 68% patients with continuous funding support whereas, in only 36% and 12% patients with non-funded and onetime funding support (P = 0.001) respectively. Significant correlation was found (R = 0.715) between baseline socioeconomic strata and changes in SES after transplant. 70% of the patients with upper and upper middle class status had improving SES. Patients with middle class, lower middle and lower class had deterioration of SES after transplant in 47.4%, 79.6% and 66.7% patients, respectively.
Most of the recipients from middle and lower social strata, which included more than 65% of our patient's population, had deteriorating SES even after a successful transplant. One-time funding source for transplant had significant negative impact on SES and rehabilitation.
Funding sources; renal transplantation; social participations; socioeconomic rehabilitationreconstruction
Arteriovenous fistula (AVF) is the gold standard vascular access for hemodialysis (HD). A thrill or murmur immediately after creation of AVF is considered a predictive sign of success. However, this does not ensure final maturation for successful HD. Our objective was to determine different clinical and duplex parameters within AVF to predict maturation and subsequent successful HD.
Materials and Methods:
A prospective observational study was conducted on 187 patients who had AVF formation from July 2012 to May 2013. Following surgery, all patients had Doppler ultrasound (DU) on Days 0 and 7. Doppler parameters noted in the outflow vein were: Thrill, broadening of spectral waveform with increased peak systolic velocity (PSV) and spiral laminar flow (SLF). Patients with at least one positive parameter at Day 0 were followed-up serially and underwent repeat Doppler imaging on Day 7. Patients with the absence of all three parameters on Day 0 were excluded from the study. Endpoint was maturation of AVF, i.e. successful HD. Statistical analysis was performed with binary logistic regression, to find out the strongest and earliest predictor for maturation of AVF using SPSS version 20.
SLF and broadening of spectral waveform with increased PSV were found to have a significant association with maturation (P = 0.0001). Presence of SLF on Day 0 most strongly predicted maturation. Presence of thrill or murmur could not predict the maturation.
SLF pattern in AVF is the most important and the earliest predictor of maturation.
Doppler; fistula; flow patterns; hemodialysis; predictor; spiral laminar
We compare the outcomes of three different diuretic protocols for renograms in children with hydronephrosis.
Materials and Methods:
Between August 2011 and July 2013, 148 diuretic renograms were performed to evaluate unilateral grade 3–4 hydronephrosis (reflux, posterior urethral valves, post-pyeloplasty status excluded). Patients were allotted into three groups based on the timing of diuretic administration: Diuretic given 15 min before (F-15), at the same time as (F + 0) and 20 min after (F + 20) radionuclide administration. Dynamic images and renogram curves were inspected to identify in each group (1) number of equivocal curves and (2) number of interrupted studies due to patient movement/discomfort/voiding. Statistical significance was determined by the Fisher exact test.
There was no significant difference in age/sex distribution between groups F-15 (n = 35), F + 0 (n = 38) and F + 20 (n = 75). The number of equivocal curves was significantly less in F + 0 (2/38) and F-15 (3/35) compared with F + 20 (20/75). The number of interrupted studies was significantly less in F + 0 (2/38) compared with F-15 (9/35) and F + 20 (18/75).
The F + 0 and F-15 protocols are superior to the F + 20 protocol in reducing the number of equivocal curves, while the F + 0 protocol is superior to the other two in reducing interruptions due to patient movement or voiding. F + 0 is the diuretic protocol of choice for renogram in children.
Diuretic protocol; hydronephrosis; nuclear renogram
A 19-year-old male patient underwent right percutaneous nephrolithotomy (PNL) for right renal 1.5 × 1.5 cm lower pole stone. The procedure was completed uneventfully with complete stone clearance. The patient developed peritonitis and shock 48 h after the procedure. Exploratory laparotomy revealed a large amount of bile in the abdomen along with three small perforations in the gall bladder (GB) and one perforation in the caudate lobe of the liver. Retrograde cholecystectomy was performed but the patient did not recover and expired post-operatively. This case exemplifies the high mortality of GB perforation after PNL and the lack of early clinical signs.
Biliary peritonitis; gall bladder perforation; percutaneous nephrolithotomy
Percutaneous nephrolithotomy (PCNL) is a standard procedure for large renal calculi but has potential for complications. Rarely, biliary tract injury can occur during PCNL that can lead to biliary peritonitis with sepsis. Such cases are usually managed by emergent cholecystectomy. We present a case of biliary peritonitis resulting from gall bladder injury during PCNL, managed minimally invasively with an abdominal drain and endoscopic retrograde cholangiography with common bile duct stenting.
Biliary injury; common bile duct stenting; minimal invasive; percutaneous nephrolithotomy
Radical cystectomy is the standard treatment for muscle invasive bladder cancer. Lymphocele is a common sequalae of pelvic lymphadenectomy. We report an unusual presentation of pelvic lymphocele developing after radical cystectomy reconstructed with an ileal conduit where the patient developed obstruction of the ileal conduit loop due to external pressure of the lymphocele. Catheter drainage of the conduit relieved the symptoms and a computerized tomography scan showed a large lymphocele causing acute angulation and resultant obstruction of the ileal conduit. The patient was treated with percutaneous drainage of the lymphocele and remains symptom-free on follow-up at 1 year.
Ileal conduit; pelvic lymphadenectomy; percutaneous drainage
Artery–ureteral fistula (AUF) is a rare condition but there is an increase in the number of reported cases. It is frequently difficult to treat. A 63-year-old male who had undergone a Dacron Y-graft placement for an infrarenal aortic aneurysm 3 years earlier, presented with hematuria. Contrast-enhanced computed tomography revealed a fistula located between the right common iliac artery and the right ureter at graft anastomosis. Endovascular treatment using a covered stent was performed successfully.
Artery–ureteral fistula; covered stent; endovascular treatment; ureteral obstruction
Bacillus Calmette-Guerin (BCG) is considered the most effective adjunctive treatment available to treat superficial bladder carcinoma. Although BCG is well tolerated by most patients, it may be associated with adverse effects. One of these is BCG granulomas in the kidney. We herein report a case of a 52-year-old patient who, during a surveillance contrast-enhanced computed tomography (CT) scan, was found to have multiple hypodense lesions in the left kidney. Ultrasound-guided biopsy proved it to be BCG granulomas. After 3 months of anti-tubercular treatment, a repeat CT showed complete resolution of the lesions.
Bladder carcinoma; intravesical Bacillus Calmette-Guerin treatment; BCG complications; granulomatous disease
Spontaneous extrusion of the testis from the scrotum is a very rare cause of acute scrotum in neonates. It has been described as scrotoschisis in few case reports. The exact etiology of this condition is not known. Replacing the testes and repair of scrotum is needed and associated with good prognosis. We report two cases that presented in a short interval to us with a review of the literature.
Neonate; testicular extrusion; scrotum
A bilateral S-shaped kidney is a rare anomaly in which both the kidneys are in their normal position, in contrast to the commonly reported S-shaped fusion anomaly, in which the contralateral kidney crosses the midline to fuse with opposite kidney leaving the ipsilateral renal fossa empty. Here we present the diagnosis and management of a case of bilateral S-shaped renal anomaly with associated left pelviureteric junction obstruction and nonfunctioning kidney and right renal stones. Left kidney was managed by open nephrectomy and right kidney by PNL.
Bilateral; renal anomaly; shaped
Nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) offers comparable oncologic results, but a lower risk of chronic kidney disease, when compared with radical nephrectomy. However, there are limited data in the literature examining the safety of NSS in the setting of metastatic RCC. To evaluate the feasibility of NSS and impact on cancer-specific survival (CSS) in patients with metastatic disease, we performed a systematic review of the literature. There is ample evidence that NSS is feasible in metastatic RCC, with comparable results in terms of CSS compared with radical cytoreductive nephrectomy.
Metastatic; partial nephrectomy; renal cell carcinoma
Physicians frequently encounter questions by parents regarding the normal size of a child's penis. We evaluated normal variations of penile dimensions, correlation of penile length with height, weight, and body mass index (BMI) of boys and analyzed the differences in penile dimensions from those reported from other countries.
Materials and Methods:
A cross-sectional study was conducted at our institution during October 2012-December 2012. A total of 250 subjects (birth to 10 years) were evaluated and divided into 10 groups with 1-year interval taking 25 children in each. Penile dimensions measured twice by a single observer with Vernier calipers included the length of flaccid penis fully stretched and diameters at mid-shaft and corona. Diameters were multiplied by pi (π = 3.14) to calculate circumferences. Mean, standard deviation, and range were calculated. Height, weight, and BMI were noted and statistically correlated with the penile length using the Pearson correlation coefficient. Data were compared with similar studies reported on other populations in the past and individually evaluated with every study using Student's t-test.
The mean values for the penile length, mid-shaft circumference, and coronal circumference were 3.34, 3.05, 3.29 cm during infancy, 4.28, 3.86, 4.11 cm during 4-5 years, and 5.25, 4.78, 5.05 cm during 9-10 years, respectively. The penile length increased with advancing age in successive age groups, but it did not have a direct correlation with either height, weight, or BMI. Penile dimensions in North Indian children were found to be statistically smaller in comparison with most studies from other countries.
We provide the normal range and variations of penile dimensions in North Indian children.
Anthropometry; circumference; penis; length