Expert survey on management of prostate cancer in India: Real-world insights into practice patterns

To gain insights on the diverse practice patterns and treatment pathways for prostate cancer (PC) in India, the Urological Cancer Foundation convened the first Indian survey to discuss all aspects of PC, with the objective of guiding clinicians on optimizing management in PC. A modified Delphi method was used, wherein a multidisciplinary panel of oncologists treating PC across India developed a questionnaire related to screening, diagnosis and management of early, locally advanced and metastatic PC and participated in a web-based survey (WBS) (n = 62). An expert committee meeting (CM) (n = 48, subset from WBS) reviewed the ambiguous questions for better comprehension and reanalyzed the evidence to establish a revote for specific questions. The threshold for strong agreement and agreement was ≥90% and ≥75% agreement, respectively. Sixty-two questions were answered in the WBS; in the CM 31 questions were revoted and 4 questions were added. The panelists selected answers based on their best opinion and closest to their practice strategy, not considering financial constraints and access challenges. Of the 66 questions, strong agreement was reached for 17 questions and agreement was achieved for 22 questions. There were heterogeneous responses for 27 questions indicative of variegated management approaches. This is one of the first Indian survey, documenting the diverse clinical practice patterns in the management of PC in India. It aims to provide guidance in the face of technological advances, resource constraints and sparse high-level evidence.

Percutaneous nephrolithotomy for 1-2 cm lower-pole renal calculi

Objectives:

The most appropriate management of patients with lower-pole calyceal (LC) stones remains controversial. In this review we discuss the role of percutaneous nephrolithotomy (PCNL) in the management of LC stones 1–2 cm in maximum dimension.

Materials and Methods:

A detailed literature review was performed to summarize the recent technical developments and controversies in PCNL. The results of PCNL for 1-2 cm LC calculi were reviewed.

Results:

PCNL is increasingly employed as a primary modality in the treatment of LC calculi. It has a high success rate and acceptably low percentage of major complications in experienced hands. Supine position is found to be as safe and effective as prone position. Urologist-acquired access is associated with fewer access-related complications and better stone-free rates. Ultrasound is increasingly employed as an imaging modality for obtaining access. There have been increasing reports of tubeless PCNL in the literature. Most patients undergoing tubeless PCNL do not need hemostatic agents as an adjuvant for hemostasis. Non-contrast computed tomography does not yield statistically valuable increase in the diagnosis of significant residual stones compared with that of plain X-ray and linear tomography. Comprehensive metabolic evaluation and aggressive medical management can control new stone recurrences and growth of residual fragments following PCNL.

Conclusions:

PCNL is a highly effective procedure with consistently high stone-free rates when compared with extracorporeal shockwave lithotripsy or retrograde intrarenal surgery. The results also do not depend on anatomic factors and stone size. It is associated with low morbidity in experienced hands.

Laparoscopic nephrectomy for giant staghorn calculus with non-functioning kidneys: is associated unsuspected urothelial carcinoma responsible for conversion? Report of 2 cases

BACKGROUND

Neglected renal stones remain a major cause of morbidity in developing countries. They not only result in functional impairment of affected kidney, but also act as an important predisposing factor for development of urothelial neoplasms. It is not uncommon to miss an associated urothelial tumor in a patient of nephrolithiasis preoperatively.

CASE PRESENTATION

In last 3 years, we came across two patients with giant staghorn calculus and poorly functioning kidneys who underwent laparoscopic nephrectomy. In view of significant perirenal adhesions & loss of normal tissue planes both these patients were electively converted to open surgery. The pathological examination of specimen revealed an unsuspected urothelial carcinoma in both these patients. The summary of our cases and review of literature is presented.

CONCLUSION

It is important to keep a differential diagnosis of associated urothelial malignancy in mind in patient presenting with long standing renal calculi. The exact role of a computerized tomography and cytology in preoperative workup for detection of possible associated malignancy in such condition is yet to be defined. Similarly if laparoscopic dissection appears difficult during nephrectomy for a renal calculus with non-functional kidney, keeping a possibility of associated urothelial malignancy in mind it is advisable to dissect in a plane outside gerotas fascia as for radical nephrectomy.

Male Gender Assignment in Aphallia: A Case Report and Review of the Literature

Aphallia is known to be a very rare congenital malformation, with an occurrence of 1 in every 30 million births; only 75 cases have been reported in the literature till recently (Hendren WH. J Urol 1997; 157: 1469-1474). Gender reassingnment is recommended for the affected newborns in infancy (Elder JS. In: Walsh PC, Retik AB, eds. Campbell's Urology. Philadelphia: Saunders: 12343-12344). We herewith report a patient of aphallia who presented at the age of 16 years and was treated with phallus reconstruction and urethral reconstruction.

Laparoscopic Nephroureterectomy for Tuberculous Nonfunctioning Kidneys Compared with Laparoscopic Nephroureterectomy for Other Diseases

OBJECTIVE

To summarize the results of 8 consecutive laparoscopic nephroureterectomies (LNUs) for tuberculous nonfunctioning kidneys and compare them with 10 LNUs performed for other benign etiologies (control group).

MATERIALS AND METHODS

From November 1999 to February 2004, 8 patients underwent LNU for tuberculous ureteric stricture with a nonfunctioning kidney at our center. During the same time period, 10 LNUs were performed for other benign conditions. Hospital records were reviewed to obtain demographic data. In addition, operative time, intraoperative and postoperative complications, duration of postoperative ileus, and hospital stay was recorded. The outcomes of surgery for tuberculosis were compared with that for the control group. Patients were followed up for long-term complications of laparoscopic surgery.

RESULTS

The two groups had a comparable demographic data. Nephroureterectomy was successfully performed laparoscopically in all 8 patients with tuberculosis. One patient in the control group, with a large staghorn renal and ureteral calculus, required conversion to open surgery due to dense perinephric adhesions. The outcome of surgery for tuberculosis was compared with outcomes in the control group using SPSS software. The mean operative time, blood loss, analgesic requirement, duration of postoperative ileus, and hospital stay of both groups was comparable, and the differences between them were statistically insignificant.

CONCLUSION

The results of this study indicate that LNU for a tuberculous nonfunctioning kidney is a safe, effective, and less invasive treatment modality. Comparing our results with those of nephroureterectomy for other, benign diseases shows that the procedure has similar safety and efficacy even for tuberculous kidneys. Tuberculosis should not be considered a contraindication for a laparoscopic approach. Laparoscopic nephroureterectomy should be offered as the treatment modality of choice to all patients with tuberculous nonfunctioning kidney whose disease involves the kidney and ureters.

A Minimally Invasive Technique for Harvesting Autologous Fascia Lata for Pubo-Vaginal Sling Suspension

OBJECTIVE

To access donor site morbidity associated with harvesting of autologous fascia lata for pubo-vaginal sling suspension in treating stress urinary incontinence.

METHODS

A retrospective study was performed of 25 female patients who underwent pubo-vaginal sling suspension for stress urinary incontinence. Autologous fascia lata strip was harvested in all patients with a minimally invasive approach using a fascial stripper. Demographic, intraoperative, and immediate postoperative data were recorded to determine the incidence of complications. Follow-up data was reviewed for documentation of long-term complications.

RESULTS

Adequate length of fascia lata was harvested in all of our patients. Ten patients required a single 2 cm incision just above lateral femoral epicondyle to harvest fascia lata. Twelve patients needed two incisions and remaining three required three incisions. There were no intraoperative complications. There was no incidence of wound related infection or hematoma in the immediate post-operative period. On follow-up no patient had bothersome problems pertaining to the site of graft harvesting.

CONCLUSIONS

Harvesting fascia lata with fascial stripper is a minimally invasive which is easy to learn and provides an excellent fascial strip with minimal morbidity.

Percutaneous nephrolithotomy for large and staghorn calculi

The treatment of choice for a stone load of up to 3 cm is indubitably extracorporeal shock wave lithotripsy (SWL). However, for larger stones, and particularly staghorn calculi, the choice is not that clearcut. Our experience with percutaneous nephrolithotomy (PCNL) for a stone load larger than 3 cm in 878 renal units over 9 years has left us convinced that a well-planned and determined effort at percutaneous clearance is the best option for these difficult cases. Our overall complete clearance rate in this group is 93% and ranges from 98.5% for solitary calculi to 71% for complete staghorn calculi. These results are comparable to those reported by other workers with percutaneous monotherapy and are superior to those achieved by SWL monotherapy. The complication rate was acceptably low at 4%. We conclude that the expeditiousness and the better stone-free rates of PCNL justify the slightly higher morbidity that it entails when compared with SWL monotherapy. We also prefer to aim for total clearance percutaneously, leaving for SWL only those stones that defy our best efforts.

Transitional cell carcinoma involving the prostate

Transitional cell carcinoma involving the prostate gland was studied in 27 patients. Three different groups were recognised on the basis of the clinical pattern and histological findings. Each group has a different prognosis and merits a different approach to treatment. Thus, stromal involvement of the prostate by transitional cell carcinoma is a sinister finding that requires radical treatment, whereas ductal involvement by either carcinoma in situ or non-invasive papillary tumours can be managed less aggressively. This study emphasises that the present classification for these tumours is unsatisfactory and that adequate histopathological information is essential for their management.