Introduction and Objective: Xanthogranulomatous pyelonephritis (XGP) is an infrequent, but life-threatening, chronic granulomatous pyelonephritis. Surgical intervention can be challenging because of severe inflammation and often a fibrotic reaction that obliterates anatomical landmarks. In addition, a high rate of open conversion has been reported when performing a laparoscopic nephrectomy. The aim of this study is to determine the risk factors for open conversion in patients with histologically confirmed XGP who underwent laparoscopic nephrectomy. Methods: A multicenter retrospective study was performed, including patients who underwent laparoscopic nephrectomy between 2018 and 2022 with histopathologic diagnosis of XGP. Clinical and laboratory parameters at initial presentation were evaluated. Extension of XGP was recorded as per the Malek clinical-radiological classification. Characteristics of laparoscopic nephrectomy and perioperative outcomes were obtained. The primary outcome was conversion to open surgery. Secondary outcomes included major complications, evaluated by Clavien-Dindo ≥3, and organ injuries during the procedure. Results: A total of 49 patients from 5 centers were included, with a mean age of 46.5 ± 17.7 years. Conversion to open surgery was reported in 10 cases (20.4%). Major complications were reported in 13 cases (26.5%), and organ injuries were reported in 10 patients (20.4%). Colonic (3 cases, 6.1%) and pleura injuries (3 cases, 6.1%) were the most frequently affected organ. The presence of renal abscess (odds ratio [OR]: 3.174, p = 0.003) and paranephric extension of disease (Malek stage 3) (OR: 14, p = 0.016) were independent factors related to conversion to open surgery. Conclusion: Laparoscopic nephrectomy for XGP is a technically challenging procedure because of extensive chronic inflammation and fibrosis. The presence of renal abscess and Malek stage III are independent predictors of conversion to open. Despite these challenges, laparoscopic nephrectomy remains a viable and effective approach for managing XGP, with the potential for reduced recovery time and postoperative morbidity compared with open surgery.

Introduction:Neoadjuvant chemotherapy (NAC) in the management of muscle-invasive bladder carcinoma has not been adopted universally. We studied the oncological outcomes and complications in patients who underwent radical cystectomy (RC) with or without NAC. Methods:A retrospective review of patients who underwent RC with or without NAC from June 2009 to June 2020 was conducted. Oncological outcomes, overall survival (OS) and recurrence-free survival (RFS), complications, and prognostic factors were analyzed. Results:Of the 314 patients who underwent RC, 83 patients received NAC (Group A), and 231 underwent RC alone (Group B). The median age was 58 years. The median follow-up duration was 22 (3-64) and 24 (3-62) months, respectively. The median OS in Group A was significantly higher than Group B (38 months [confidence interval (CI): 34-42] and 32 [CI: 29-35], respectively, [P = 0.033]). The RFS in Groups A and B was 34 (CI: 30-39) and 31 (CI: 28-34) months, respectively (P = 0.47). Higher pathological T stage (T3/4), node positivity and lymphovascular invasion (LVI) were predictors of poor OS and RFS (P < 0.0001). Clavien grades 3/4 complications were comparable (8% vs. 15%; P = 0.19). Glomerular filtration rate (GFR) <60 mL/min/1.73 m2 was associated with higher postoperative complications in both groups (P = 0.012). Conclusion:The OS with NAC was superior to upfront RC. RFS was, however, comparable. NAC was safe and well-tolerated. Pathologically, higher T stage, node positivity, and LVI were associated with poorer OS and RFS. Low GFR negatively influenced postoperative complications.

Mannitol is often used as a renoprotective agent in nephron-sparing surgery (NSS) prior to renal vessel clamping. Although there is some recent evidence questioning its role, these studies used a fixed dose of mannitol and studied a heterogeneous group that included both laparoscopic and open NSS. This trial aimed to investigate whether renal-functional outcomes in patients undergoing laparoscopic NSS are equivalent in patients receiving weight-based mannitol and those administered placebo. In this prospective, randomized, double-blinded, placebo-controlled trial, 100 patients who underwent laparoscopic NSS with an estimated glomerular filtration rate (eGFR) > 45 ml/min/1.73 m2 were randomized to receive either weight-based mannitol (0.25 g/kg) or placebo (0.9

Introduction:This study aimed to evaluate the efficacy of ultraslow shockwave (SW) lithotripsy compared with slow-rate SW lithotripsy (SWL) in the management of renal stones using a common power ramping protocol. Methods:This randomized trial enrolled patients with solitary renal calculus ≤2 cms between December 2021 and February 2024. Ultraslow lithotripsy (40 patients) was applied at a rate of 30 shocks per minute and slowrate lithotripsy (40 patients) was applied at a rate of 60 shocks per minute. Common power ramping protocol was followed for both the groups. Up to a maximum of three sessions were carried out with follow-up at 3 months after the last session. The primary outcome was the stone-free rate. Results:The overall stone-free rate (SFR) was 77.5% in the ultraslow arm and 72.5% in the slow-rate arm (P = 0.60). Ultraslow group attained a higher SFR after the first session (37.5% vs. 20%; P = 0.07) with significantly lesser number of shocks (1300 vs. 1500; P < 0.01). Complications were only mild and similar between both the groups (P = 0.06), with a longer treatment duration in the ultraslow group (100 min vs. 50 min; P < 0.01). Conclusions:In the setting of an electromagnetic lithotripter with a common ramping protocol and equal energy SWs, both ultraslow and slowrate SWL achieved a comparable overall stone-free rate with a similar safety profile. Higher number of patients in the ultraslow arm, almost double that of the slow arm, attained stone-free status after the first session itself with significantly fewer shocks.

Ischemic necrosis of the bulbar urethra after perineal urethroplasty can lead to complex, long-segment strictures. Traditional approaches often involve vascular reconstruction followed by transpubic urethroplasty. A 20-year-old man presented with a posterior urethral injury resulting in urethral distraction following a road traffic accident. He underwent anastomotic urethroplasty 10 months later, which then failed. We employed ascending colon substitution urethroplasty to manage a case of ischemic bulbar necrosis, offering an alternative to tubed flap or staged grafting procedures.

Abstract Background Laparoscopic partial nephrectomy (LPN) remains technically challenging for complex renal masses, and there are limited data regarding its safety and efficacy. This study aims to compare the perioperative outcomes of LPN for complex renal masses with RENAL nephrometry score ≥ 7 vs. simple renal masses with RENAL score < 7, focusing on achieving the "Trifecta" outcome. Materials and methods We retrospectively analysed data from 170 patients who underwent LPN for malignant renal masses between 2017 and 2021. Patients were divided into Group A (score < 7) and Group B (score ≥ 7) based on RENAL score. Demographics, blood parameters, renal mass characteristics, surgical details, and pathology findings were compared. Perioperative outcomes were assessed based on Trifecta criteria: negative pathological surgical margin (PSM), warm ischemia time (WIT) ≤ 25 min, and no > grade 2 Clavien–Dindo complications. Results Group A and Group B comprised 88 (51.7%) and 82 (48.2%) patients, respectively. Trifecta outcomes were comparable between Group A (68.1%) vs. Group B (62.2%) (p = 0.5). There was no significant difference in patients with WIT ≤ 25 min (77.2% vs. 78%, p = 0.88) and negative PSM (92% vs. 86.5%, p = 0.19). The incidence of major complications was low overall but significantly higher for Group B (9.7%) vs. Group A (2.2%), p = 0.04. Perioperative glomerular filtration rate drop (17.2 vs.16.1, p = 0.66), estimated intraoperative Hb drop (2.1 vs. 2.09, p = 0.15) gm%, mean blood loss (180 vs. 221 ml, p = 0.9) and mean operation time (135 vs. 120 min, p = 0.64) did not significantly differ between Group A vs. Group B, respectively. Conclusions LPN is a safe approach for managing complex renal masses, yielding acceptable overall Trifecta outcomes when performed by experienced surgeons in high-volume centers. However, surgeons should be cognizant of the increased risk of positive surgical margins and postoperative complications in tumours with a RENAL score greater than or equal to 7.

Metastatic carcinoma prostate with low serum prostate-specific antigen (PSA < 10 ng/ml) is usually poorly differentiated and has poor overall survival. This study aims to compare the clinicopathological profile and oncological outcomes between treatment-naïve metastatic carcinoma prostate with low PSA (< 10 ng/ml) and high PSA (> 10 ng/ml) at presentation. Data were collected retrospectively from the hospital’s database from January 2005 to December 2017. All treatment-naïve metastatic adenocarcinoma prostate cases with PSA < 10 ng/dl were included (n = 27), excluding one patient with prostatic rhabdomyosarcoma. Age-matched controls (± 2 years) in a 1 case:2 controls ratio were selected (n = 54). Patients were followed with PSA at 3, 6, and 12 months, and at the last follow-up. Most patients in both groups presented with lower urinary tract symptoms (LUTS). Neuroendocrine differentiation was more common in the low PSA group. The pattern of bone metastasis was similar in both groups. A higher percentage of patients (79.6

Introduction Pelvic fracture urethral injury (PFUI) is more severe in younger individuals. The adolescent group is prone to protracted morbidity due to severity of the injury and its impact on lifestyle. Hence, treatment options and data on outcomes are crucial in planning management. The adolescents are a subgroup in several series of PFUI, but literature exclusively studying this group is sparse. Materials & methods A retrospective review of all adolescents (aged between 10 and 19 years as defined by WHO) who underwent surgical repair for PFUI between January 2005 and December 2019 was conducted. Success was defined as a bell-shaped urine flow curve and Qmax of >15 ml/s, no evidence of re-stricture (on cystoscopy/MCU), and no re-intervention. Measurements of the length of the urethral defect and bulbar urethra were done using a digital scale by the radiologist from micturating cystourethrogram (MCU). The Gapometry/Urethrometry (GU) index was calculated as the ratio of the length of the urethral defect to that of the bulbar urethra. Data was analysed using SPSS software version 20.0 and Stata Version 16. The primary outcome was the success of anastomotic urethroplasty. Secondary outcomes were evaluating factors predicting operative complexity (simple perineal versus elaborate perineal approach). Results We studied 22 patients, out of which 8 were referred following prior failed intervention elsewhere. The mean age was 16.5 + 2.7 years. All the patients were treated using a perineal approach with an overall success rate of 90.9%. Two patients had a failure and were managed with Endoscopic Internal Urethrotomy (EIU), and urethral dilatation. The median follow-up was 24 months. All 8 patients with prior failed interventions had a successful outcome. Twelve patients required inferior pubectomy (elaborate perineal approach). The median length of the urethral defect (2.3 cm IQR- 1.45,3.30 vs. 1 cm, IQR-0.65, 1.6) and the mean GU index (0.45 +/- 0.18 cm vs. 0.25 cm +/- 0.12 cm) were significantly higher in those who required an elaborate perineal approach. Conclusions The perineal approach for surgical repair (anastomotic urethroplasty) of pelvic fracture urethral injury has a favourable success rate of 90.9% in adolescents. Re-do anastomotic urethroplasty for prior failed repairs also had a high success rate of 100%. Cases requiring an elaborate perineal approach were associated with a significantly higher Gapometry/Urethrometry Index (>0.45) and length of the urethral defect (>2.3 cm). This information may assist in patient counselling and preparation for additional steps during repair.

ABSTRACT Introduction: Chemotherapy, postchemotherapy retroperitoneal lymph node dissection (pcRPLND), and metastasectomy remain the standard of care for the management of advanced nonseminomatous germ cell tumor (NSGCT). Methods: We retrospectively studied 73 patients who had pcRPLND at a single tertiary-care center (2003–2022). Surgical and clinicopathological features and oncological outcomes are presented. Results: The mean age was 28.27 years (15–48). Three-fourths had Stage III disease at diagnosis. International Germ Cell Cancer Collaborative Group risk stratification was 54.54% and 21.21% in intermediate risk, and poor risk, respectively. Sixty-two patients had Standard, 7 had Salvage and 4 underwent Desperation pcRPLND. Eleven patients (15.06%) required adjunctive procedures. Thirteen patients (17.8%) had ≥ class 3 Clavien–Dindo complications and postoperative mortality occurred in 5 (6.8%) patients. The histopathologies (HPE) of the pcRPLNDs were necrosis, teratoma, and viable tumor in 39.7%, 45.2%, and 15.1%, respectively. Seven patients underwent metastasectomy. An 85% size reduction in the size of RPLN predicted necrosis. There was 71.4% concordance between pcRPLND and metastasectomy HPEs. The median follow-up was 26.72 months (inter-quartile range – 13.25–47.84). The 2-year recurrence-free survival (RFS) rate was 93% (95% confidence interval [CI]–83%–97%) and the overall survival (OS) rate was 90% (95% CI–80%–95%). This is the largest series of pcRPLND for NSGCT in India to our knowledge. Conclusion: Although most of the cohort belonged to stage III, an RFS and OS rate of >90% at 2 years was achieved. We believe that successful management of postchemotherapy residual masses in NSGCT is contingent on the availability of multidisciplinary expertise and is therefore best done at tertiary-care referral centers.

Background: Emphysematous pyelonephritis (EPN) is a necrotizing infection of the kidney and the surrounding tissues associated with considerable mortality. We aimed to formulate a score that classifies the risk of mortality in patients with EPN at hospital admission.Materials and methods: Patients diagnosed with EPN between 2013 and 2020 were retrospectively included. Data from 15 centers (70%) were used to develop the scoring system, and data from 7 centers (30%) were used to validate it. Univariable and multivariable logistic regression analyses were performed to identify independent factors related to mortality. Receiver operating characteristic curve analysis was performed to construct the scoring system and calculate the risk of mortality. A standardized regression coefficient was used to quantify the discriminating power of each factor to convert the individual coefficients into points. The area under the curve was used to quantify the scoring system performance. An 8-point scoring system for the mortality risk was created (range, 0-7).Results: In total, 570 patients were included (400 in the test group and 170 in the validation group). Independent predictors of mortality in the multivariable logistic regression were included in the scoring system: quick Sepsis-related Organ Failure Assessment score >= 2 (2 points), anemia, paranephric gas extension, leukocyte count >22,000/mu L, thrombocytopenia, and hyperglycemia (1 point each). The mortality rate was <5% for scores <= 3, 83.3% for scores 6, and 100% for scores 7. The area under the curve was 0.90 (95% confidence interval, 0.84-0.95) for test and 0.91 (95% confidence interval, 0.84-0.97) for the validation group.Conclusions: Our score predicts the risk of mortality in patients with EPN at presentation and may help clinicians identify patients at a higher risk of death.

A man in his 50s with diabetes presented with backache, left flank pain and fever. On evaluation, he was found to have emphysematous pyelonephritis of the left kidney with a paranephric abscess extending into the posterior abdominal wall and superiorly up to the posterior chest wall and inferiorly extending up to the posterior superior iliac spine. The management involved the initiation of broad-spectrum antibiotics and percutaneous drainage of the abscess. However, as he continued to worsen symptoms-wise, he underwent computed-enhanced CT of the abdomen and thorax. The imaging revealed the presence of a purulent collection in the left lumbar region with an extension along the posterior cervical region and the retropharyngeal space. He underwent a fasciotomy of the lumbar region. The occurrence of emphysematous pyelonephritis along with necrotising fasciitis is uncommon and requires early aggressive management with broad-spectrum antibiotics and adequate drainage. This emphasises the need for early reimaging if the patient does not settle with antibiotics or percutaneous drainage.

Prospective data on outcome of variant histology bladder cancer is scarce. We compared the neoadjuvant chemotherapy usage and oncological outcomes in patients undergoing radical cystectomy for variant versus pure urothelial histology bladder cancer. This was a retrospective comparative cohort study. Data was collected from the electronic database of our hospital from June 2009 to June 2018. Two hundred forty-one patients underwent radical cystectomy in the study period. Patients were divided into two groups (Group A — variant histology bladder cancer and Group B — pure urothelial histology). The primary outcome was overall survival. The secondary outcomes included recurrence free survival and complications. Of the 241 patients, 41 had variant histology. Histological variants were sarcomatoid (11), sarcoma (4), squamous cell (8), neuroendocrine (3), adenocarcinoma (8), and others (7). The median age was 59 years in both groups. The median duration of follow-up in Groups A and B was 12.5 and 24 months, respectively. NACT was given in 12 and 14

Xanthogranulomatous pyelonephritis (XGP) is an uncommon chronic granulomatous infection of renal parenchyma. XGP is often associated with long-term urinary tract obstruction due to stones and infection. We aimed to analyze the clinical, laboratory, and microbial culture profiles from bladder and kidney urine of patients who were diagnosed with XGP. Databases of patients with histopathological diagnosis of XGP from 10 centers across 5 countries were retrospectively reviewed between 2018 and 2022. Patients with incomplete medical records were excluded. A total of 365 patients were included. There were 228 (62.5%) women. The mean age was 45 ± 14.4 years. The most common comorbidity was chronic kidney disease (71%). Multiple stones were present in 34.5% of cases. Bladder urine culture results were positive in 53.2% of cases. Kidney urine culture was positive in 81.9% of patients. Sepsis and septic shock were present in 13.4% and 6.6% of patients, respectively. Three deaths were reported. Escherichia coli was the most common isolated pathogen in both urine (28.4%) and kidney cultures (42.4%), followed by Proteus mirabilis in bladder urine cultures (6.3%) and Klebsiella pneumoniae (7.6%) in kidney cultures. Extended-spectrum beta-lactamases producing bacteria were reported in 6% of the bladder urine cultures. On multivariable analysis, urosepsis, recurrent urinary tract infections, increased creatinine, and disease extension to perirenal and pararenal space were independent factors associated with positive bladder urine cultures. On multivariable analysis, only the presence of anemia was significantly more frequent in patients with positive kidney cultures. Our results can help urologists counsel XGP patients undergoing nephrectomy.

Hemifacial Microsomia (HFM) is second most common congenital craniofacial anomaly following cleft lip and palate. On contrary, microglossia is a very rare congenital anomaly. To the best of our knowledge, HFM associated with microglossia has not been reported in the literature. This is a case report of a 13-year-old girl who presented with features of hemifacial microsomia, blindness, microglossia, hypodontia, bilateral transposition between upper first premolar and canine, anterior crowding and deep bite. Her treatment was started with fixed orthodontic appliance and arches were aligned by maintaining the transposed position of the teeth. After completion of orthodontic treatment, maxillary right and left first premolars were contoured into lateral incisor and canine, respectively, to have satisfactory functional and aesthetic outcome.

OBJECTIVE:To ascertain whether low-dose tadalafil (5 mg) is more efficient than tamsulosin (0.4 mg) in facilitating calculus expulsion in those receiving extracorporeal shockwave lithotripsy for solitary upper urinary tract calculi. PATIENTS AND METHODS:This was a triple-blinded, prospective, superiority, randomized controlled, single-centre trial. A total of 250 patients with solitary renal or ureteric calculus measuring 6-24 mm were randomized (1:1) to receive either 0.4 mg tamsulosin or 5 mg tadalafil daily for 30 days or until calculus clearance, whichever was earlier. RESULTS:There was no difference in the primary outcome, namely, calculus expulsion rate at 30 days (tamsulosin vs tadalafil, n (%) 99 [81.1%] vs 98 [80.3%] respectively, 95% confidence interval = 0.8% [-9.0, 10.7], P = 0.874). Similarly, a lack of difference was also noted in the secondary outcome, number of days to expulsion (tamsulosin vs tadalafil, geometric mean [SD] 13.59 [2.39] vs 13.74 [2.39] respectively, P = 0.928). Four patients discontinued the drug due to adverse drug reactions in the tadalafil group. CONCLUSIONS:Low-dose tadalafil is not superior to tamsulosin in improving calculus expulsion when used as an adjunct to shockwave lithotripsy. In this study, we also noted that tadalafil was less tolerated.

PURPOSE:To determine the risk factors associated with major complications in patients with histologically confirmed Xanthogranulomatous pyelonephritis (XGP) who underwent nephrectomy.METHODS:A multicenter retrospective study was performed including patients who underwent nephrectomy between 2018 and 2022 with histopathological diagnosis of XGP. Clinical and laboratory parameters at the initial presentation were evaluated. Data on extension of XGP was recorded as per the Malek clinical-radiological classification. Characteristics of nephrectomy and perioperative outcomes were obtained. The primary outcome was major complications, defined as a CD ≥ grade 3 and the need for intensive care unit (ICU) admission. Secondary outcomes included the comparison of complications evaluating the nephrectomy approach (transperitoneal, retroperitoneal, and laparoscopic). A sub-analysis stratifying patients who needed ICU admission and Malek classification was performed.RESULTS:A total of 403 patients from 10 centers were included. Major complications were reported in 98 cases (24.3%), and organ injuries were reported in 58 patients (14.4%), being vascular injuries the most frequent (6.2%). Mortality was reported in 5 cases (1.2%). A quick Sepsis-related Organ Failure Assessment (qSOFA) score ≥ 2, increased creatinine, paranephric extension of disease (Malek stage 3), a positive urine culture, and retroperitoneal approach were independent factors associated with major complications.CONCLUSION:Counseling patients on factors associated with higher surgical complications is quintessential when managing this disease. Clinical-radiological staging, such as the Malek classification may predict the risk of major complications in patients with XGP who will undergo nephrectomy. A transperitoneal open approach may be the next best option when laparoscopic approach is not feasible.

This chapter addresses the episode of rise and fall of development financing in the modern economic history of India with particular reference to industrial funding. It highlights the changing role of the state from an agent of storing equality as was envisaged in the Constitution of India to an agent of speculative finance to widen the economic distance between rich and poor. The chapter illustrates the role of DFIs in industrialisation based on the catching-up theory of industrialisation. It describes the rising trend of DFIs in the overall bank-based financial system till the start of financial liberalisation in India. The chapter attempts to highlight different dimensions of the trend of DFIs' financing which highlight the decline of DFIs in India during the post-financial liberalisation period. It attempts to highlight the determinants of the decline of DFIs' role in the Indian financial system with specific emphasis on the state's role in favour of global finance.