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   Table of Contents - Current issue
July-September 2021
Volume 32 | Issue 3
Page Nos. 93-139

Online since Tuesday, September 28, 2021

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Editorial p. 93
Yao-Chi Chuang
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Videourodynamic precision diagnosis and treatment of lower urinary tract symptoms in women Highly accessed article p. 94
Hann-Chorng Kuo
Lower urinary tract symptoms (LUTSs) in women are common in urological practice but are usually uninformative for diagnosing the underlying lower urinary tract dysfunction. To obtain a precise diagnosis and devise a precise treatment strategy, a videourodynamic study (VUDS) is an essential tool for investigating the bladder and bladder outlet dysfunction, especially when LUTS cannot be relieved after initial medical treatment. An accurate VUDS diagnosis can guide effective treatment and prevent unnecessary or incorrect surgical intervention. This article reviews updated applications of VUDS in the diagnosis and treatment of LUTS in women.
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“True gold fears no fire” – High-quality videourodynamic studies make possible precision diagnosis of lower urinary tract symptoms in women p. 102
Eric Chieh-Lung Chou
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Outcomes of starting low-dose pazopanib in patients with metastatic renal cell carcinoma who do not meet eligibility criteria for clinical trials p. 104
Jun Akatsuka, Go Kimura, Kotaro Obayashi, Kotaro Tsutsumi, Masato Yanagi, Yuki Endo, Hayato Takeda, Tatsuro Hayashi, Yuka Toyama, Yasutomo Suzuki, Tsutomu Hamasaki, Yoichiro Yamamoto, Yukihiro Kondo
Purpose: Eligibility for clinical trials is very strict and only patients who satisfy various criteria can enter trials. The individual use of pazopanib has not been adequately investigated. An optimal administration regimen for pazopanib in “real-world” patients with metastatic renal cell carcinoma (mRCC) is required. Our purpose was to determine the tolerability and efficacy of first-line pazopanib with a low starting dose in patients with mRCC who were ineligible for clinical trials. Materials and Methods: This study included patients with mRCC who underwent treatment with first-line pazopanib and were previously excluded from clinical trials because they did not meet the inclusion criteria. A 400 mg pazopanib starting dose is used routinely in patients with mRCC; if tolerated, dose escalation up to 800 mg may occur. Results: We identified 18 patients with mRCC who received first-line pazopanib and were previously determined ineligible for clinical trials. Pazopanib dose was escalated in 12 patients (66.6%), to 600 mg/day in 8 patients (44.4%) and to 800 mg/day in 4 patients (22.2%), and was not escalated in 6 patients (33.3%). In 3 patients (16.7%), pazopanib was discontinued owing to intolerability. The most common frequent adverse event was elevated alanine aminotransferase levels in 6 patients (33.3%), followed by a decreased platelet count in 5 patients (27.8%) and anorexia in 5 patients (27.8%). Partial response was seen in 5 patients (27.8%) and stable disease in 10 patients (55.6%); median progression-free survival was 11.9 months (95% confidence interval: 6.3–28.7 months). Conclusion: Our data indicated that a low starting dose of 400 mg pazopanib did not negatively affect treatment tolerability and efficacy in patients with mRCC ineligible for clinical trials. We found that lower starting doses may lead to better results. Additional studies are needed in a larger cohort and longer follow-up to attain authentic outcomes.
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Feasibility and safety of retrograde radical cystectomy under combined spinal and epidural anesthesia in high-risk and elderly patients. A single surgeon experience p. 111
Abdul Rouf Khawaja, Yasir Dar, Malik Suhail, Khalid Sofi, Prince Muzaffar, Sajad Parra, Sajad Malik, Arif Bhat, Mohd Wani
Purpose: The purpose of the study is to study feasibility and safety of retrograde radical cystectomy (RC) under regional anesthesia (RA) in high-risk and elderly patients of muscle invasive bladder carcinoma. Materials and Methods: This study was an observational study, conducted in the department of urology, SKIMS, Kashmir, India, from 2012 to 2020. All patients underwent retrograde RC under RA. Results: Thirty-seven patients were operated with median follow-up period of 32 months and included 30 male and 7 female patients with median age of 74.5 years (70–83 years). The American Society of Anesthesiologists score was II in 20 patients, III in 15 patients, and IV in 2 patients. All the patients included in study had significant comorbidities. All patients were anemic and required preoperative blood transfusions for optimization. Total blood loss ranged from 200 to 900 ml (mean: 400 ml). Bilateral internal iliac artery was ligated preemptively in all patients. Total transfusion required ranged from one to six units (mean: 2 units). Number of lymph nodes removed ranged from 15 to 35 (mean: 20). Total peritoneal exposure time ranged from 0 to 70 min (mean: 50 min). None of the patient needed intensive care postoperatively. Gastrointestinal tract (GIT) recovery time ranged from 1 to 4 days (mean of 1.5 days). Total hospital stay ranged from 7 to 15 days (mean: 9 days). On follow-up, one patient had stent (feeding tube) fracture, and the residual fragment was managed by antegrade approach. One patient had ureteroileal anastomotic stricture which was managed by refashioning of the anastomosis (Bricker to Wallace). One patient had stomal stenosis with features of recurrent urinary tract infections and underwent refashioning of stoma with stabilization of renal function. Conclusion: To circumvent the need of postoperative ventilation, intensive care unit admission, and prolonged hospital stay, we advocate retrograde extraperitoneal RC under combined RA (CRA) as preferred approach of surgical intervention in high-risk and elderly patients with little abdominal organ disturbance and early bowel recovery.
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Everted Saphenous Vein Graft (eSVG) urethroplasty in long-segment anterior urethral strictures: Medium-term follow-up results p. 117
Swatantra Nagendra Rao, Nikhil Khattar, Arif Akhtar, Anuj Varshney, Hemant Goel
Purpose: An everted saphenous vein graft (eSVG) has been used for urethroplasty in men with long segment anterior urethral stricture and chronic tobacco exposed oral mucosa with good initial results. The present study aimed to assess the medium-term outcomes of eSVG urethroplasty (eSVGU) in such patients. Materials and Methods: Prospectively maintained database of 32 patients with chronic tobacco exposed oral mucosa, who underwent an eSVGU for long segment anterior urethral stricture (≥9 cm), was reviewed. Outcomes were assessed with International Prostate Symptom Score (IPSS), uroflowmetry with postvoid residual urine at 1, 3, and 6 months, and thereafter 6 monthly symptomatic assessments. Retrograde urethrogram was done at 3 months and repeated only if there was a recurrence. Successful urethroplasty was defined as satisfactory voiding (maximum flow rate [Qmax] >15 ml/sec) and no need for any auxiliary procedures in follow-up. Patients who lost to follow-up before 3 years were excluded from the final analysis. Data from the patients were recorded on a spreadsheet and expressed as mean and standard deviation wherever feasible. Results: Mean stricture length was 13.75 cm. Two patients were lost to follow-up after 12 months and were excluded from the final analysis. At a mean follow-up of 58 months, 19 patients (63.33%) were voiding successfully with mean IPSS 8.15 and Qmax 23.54 ml/s respectively, while 11 patients (36.67%) required auxiliary procedures and were considered failed. Conclusion: Medium-term results suggest that an eSVG can be considered as a good alternative graft for urethroplasty in patients with long anterior urethral strictures.
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Effect of short-term preoperative dutasteride and finasteride on bleeding after transurethral resection of the prostate: A prospective randomized study p. 125
Nitesh Kumar, Sunil K Palve, Karthik Marripeddi, Sanath Thantla
Purpose: Transurethral resection of the prostate (TURP) is the standard surgical treatment for patients with benign prostatic hyperplasia (BPH). Among the many complications of TURP, the most prevalent and serious complication is hemorrhage. The aim of the study was to compare the effect of short-term (2–4 weeks) pretreatment of BPH with dutasteride and finasteride on bleeding after TURP. Methods: A prospective randomized double-blinded study was conducted in Osmania General Hospital, a tertiary care center for a period of 2 years. Two hundred and forty patients who were planned for TURP were included and randomized into four groups; D2: 2 weeks of dutasteride, F2: 2 weeks of finasteride, P2: 2 weeks of placebo, and D4: 4 weeks of dutasteride. The primary outcome was to evaluate the volume of blood loss. Results: The baseline variables were comparable among the groups. Statistically significant differences were seen in total volume of blood loss (183.4 vs. 172.7 vs. 288.5 vs. 173.2 ml, P = 0.01), blood loss per minute of operating time (3.80 vs. 3.65 vs. 5.71 vs. 3.61 ml/min, P = 0.02), and blood loss per gram of resected prostatic tissue (7.61 vs. 7.43 vs. 11.57 vs. 7.21 ml/g, P = 0.008). Blood transfusion requirement was significantly more in the placebo group (11.8%) compared to other groups (P = 0.02). Conclusion: Short-term preoperative dutasteride and finasteride for 2 weeks are equally effective, and they significantly reduce the perioperative blood loss during TURP. Four weeks of dutasteride has no significant advantage when compared to its 2-week course.
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An observational study on the efficacy of mirabegron in medical expulsive therapy of the lower ureteric calculus p. 132
Souvik Chatterjee, Vishal Jalan, Dilip Kumar Pal
Purpose: Medical expulsive therapy (MET) is used in lower ureteric calculus to reduce symptoms, to facilitate passage, and to decrease the requirement of endourological surgical interventions. Alpha-blockers, spasmolytics, and calcium channel blockers have been shown to be effective in clinical trials. Beta-3 receptor stimulation in the ureter has been shown to decrease the intraluminal pressure. Thus, Mirabegron, beta 3 receptor agonist, can be thought as alternative MET agent. Materials and Methods: We have done prospective observational study to see the efficacy of mirabegron for MET of lower ureteric calculus ≤10 mm in size. Patients were divided into two groups: Group A (n = 50) received diclofenac 50 mg twice daily for 5 days then on demand for 4 weeks and Group B (n = 50) received diclofenac 50 mg twice daily for 5 days than on demand and mirabegron 50 mg daily for 4 weeks. Patients were followed up weekly with clinical examination, ultrasound screening of kidney, ureter, and bladder (KUB) and noncontrast computed tomography scan KUB after the 28th day of therapy. Results: We found that the passage of stone is significantly higher in mirabegron group (Group A: 68% and Group B: 92%; P < 0.05), and this effect is also statistically significant for stones <7 mm size (Group A: 73.91%, Group B: 96.96%, P = 0.01026). Duration of stone expulsion in Group A: 20.29 ± 5.512 days and Group B: 10.65 ± 4.294 days (P = 0.00001) and the relief of storage symptoms are earlier in mirabegron group (Group A: 16.28 ± 5.65 days and Group B: 6.2 ± 2.58 days, P = 0.00001). Conclusion: Our study reveals that Mirabegron is effective for the treatment of lower ureteric stones ≤10 mm size, especially for stone of size <7 mm and it improves the storage symptoms in these patients.
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Retroperitoneal dedifferentiated liposarcoma with a compressed invasion-free kidney: A rare case report p. 137
Shang-Rong Zhong, Thomas Y Hsueh, Jung-Mao Chou
A 68-year-old female patient presented an evident drop in weight within half a year. A heterogeneous huge tumor was found in the left retroperitoneal space through a nonenhanced abdominal computed tomography. The tumor contributed mass effect on adjacent organs and structures, with equivocal left kidney outline. Enhanced kidney magnetic resonance imaging illustrated its hyper-vascular content and clear border. Radical excision was performed through an open approach. The mass was 25 cm in length and weighed about 5 kg. Grossly, it was accompanied by a compressed but invasion-free kidney. The diagnosis of dedifferentiated liposarcoma was made, and a focally involved margin was identified. The average annual incidence of retroperitoneal sarcomas is 2.7 cases/million. Retroperitoneal soft-tissue sarcoma seldom induces symptoms until the tumor makes a mass effect on adjacent organs. The tumor of this patient stands out as the compressed, yet invasion-free left kidney. Surgical resection is regarded as the only potential curative therapy. Due to the large size at presentation and wide extent of the tumor, it often results in limited resectability or positive margin. Important prognostic factors of retroperitoneal sarcoma involve surgical margin, tumor grade, differentiation, and histologic subtype. Dedifferentiated liposarcoma has a worse prognosis and a positive gross margin implies a higher chance of local recurrence as well as a higher mortality rate.
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