Optimization of low pre-operative hemoglobin reduces transfusion requirement in patients undergoing transurethral resection of prostate

Objective: To identify factors that influence peri-operative hemorrhage in view of reducing the need for transfusions in patients undergoing trans uretheral resection of prostate (TURP). Methods: All patients undergoing TURP between January 1997 and December 1999 were identified using lCD 9CM coding and indexing system. Overall 430 patients were identified, however, 384 charts were included and reviewed for demographics, pre and intra-operative data and post-operative morbidity. Patients were divided into two groups on the basis of presence of significant hemorrhage. Results: Overall 384 patients were analyzed. Nineteen patients had hemorrhage - group I whereas 365had no significant hemorrhage - group II. Mean age and co-morbidities in the two groups were similar. However, in group I, 58% presented with urinary retention compared to 33% in group II. In group I, factors that reached statistical significance include; operative time (pConclusion: Operative time, weight of resected prostate tissue are inter related and are only partly controllable. Low pre-operative hemoglobin is the only reversible factor in reducing transfusion following TURP (JPMA 53:1 04;2003)

Intravesical foreign body: tertiary care center experience from Pakistan.

Foreign body in bladder is relatively uncommon condition with variable presentations. Literature is limited to case reports and small series from region. Therefore, we planned this study to review our experience regarding intravesical foreign body. This retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised 14 patients having intravesical foreign bodies from March 1989 to March 2013. Demographics, presentation, mode of insertion, type of foreign body and management were noted. Of the 11(78.6%) patients included in the study, 10(90.9%) patients were male and 1(9.1%) was female. The mean age was 51± 20 years. In 5(45.5%) patients, foreign bodies reached bladder by iatrogenic route followed by self-insertion in 4(36.4%) patients. Retrieved foreign bodes included piece of Foley\\u27s catheter, electric wire, ureteric stent, plastic material, double-J stent pusher, Endo gastrointestinal (GI) staples, sticks of broom and bomb shrapnel. All patients were managed successfully with endoscopic removal. However, 5(45.5%) patients required additional urological procedures. This could represent a urologic challenge. Careful history and symptoms could lead to further investigations

Is an excretory urogram mandatory in patients with small to medium-sized renal and ureteric stones treated by extra corporeal shock wave lithotripsy?

Background: An intravenous urogram (IVU) has traditionally been considered mandatory before treating renal and ureteric stones by extracorporeal shock wave lithotripsy (ESWL). This study was designed to see whether there is a difference in complications and the need for ancillary procedures in patients managed by ESWL for renal and ureteric calculi, according to preoperative imaging technique. Methods: This retrospective study compared 133 patients undergoing ESWL from January 2001 to July 2002. Patients were divided into three groups according to the preoperative imaging technique used: i) IVU; ii) non-contrast enhanced helical computed tomography (UHCT); and iii) ultrasound (US) + X-ray kidney, ureter and bladder (KUB). The groups were matched in terms of age and gender, as well as location, side and size of stones. Results: There was no statistically significantly difference for number of ESWL sessions, number of shock waves and use of ancillary procedures between the three groups. The stone-free rate was 98% for the IVU and UHCT groups, and 97% for the US + X-ray KUB group. Conclusions: The complication rate and need for ancillary procedures was comparable across the three groups. Patients imaged by UHCT or US + X-ray KUB prior to ESWL for uncomplicated renal and ureteric stones do not require IVU

Does the afferent tubular segment in an orthotopic bladder substitution compromise ureteric antireflux properties? an experimental study in dogs

Objective: To study the effects of a short ureter on renal function and histology in an orthotopic bladder substitution model using a long afferent limb, in a canine model. Materials and methods: The study included nine adult mongrel dogs. A 40-cm segment of ileum was isolated, the distal half detubularized, configured into a U-shape and sutured to form a flat plate; this was then used to augment the bladder. The proximal half of the isolated ileum remained in continuity with the enterocystoplasty to form an isoperistaltic ileal ‘chimney’. The left ureter was divided at its lumbar part and anastomosed to the chimney using a refluxing end-to-side Nesbit technique. The contralateral ureter was divided at its lower end and then anastomosed directly to the augmented segment of the bladder in a similarly refluxing manner to act as a control. The assessment after surgery included biochemical studies, ascending cystography, intravenous urography (IVU) and radioisotope renography at 6 weeks. The last two methods were repeated at intervals of 3 and 6 months after surgery. Urine culture was obtained and both kidneys were examined histopathologically at 6 months. Results: The biochemical values assessed in all dogs were comparable to those before surgery. The urine culture obtained from the augmented bladders showed significant bacterial growth in all dogs. IVU at all follow-up sample times showed a normal configuration of both kidneys. Ascending cystography showed reflux in four of nine dogs on the right and six on the left side. There was a progressive decrease in the mean selective renographic clearance values of each of the right and left kidneys at intervals of 6 weeks, 3 and 6 months. The mean percentage reduction of renographic clearance was significantly higher in the left kidneys at 6 weeks and 3 months. Histopathological examination showed evidence of interstitial nephritis in all nine dogs and pyelonephritis in four of the left kidneys, while none of the right kidneys showed evidence of inflammation. Conclusion: Adequate peristalsis in a healthy long ureter is superior to the ileal segment substitution for protecting the kidney tissue against inflammation in the absence of an anatomical antireflux mechanism

Validation of updated partin’s table in Pakistani patients undergoing radical prostatectomy for prostate cancer

Objectives: To establish the usefulness and validity of 2007 Partin’s table in our population with prostate cancer. Materials and methods: Between January 1998 to June 2009, all patients with clinically localized carcinoma prostate who were treated with intent of radical retro-pubic prostatectomy (RRP) were included. Clinical, operative and pathological data was gathered. All biopsy and final histopathology Gleason scores were re-assigned in a double blind manner. Pre-operative serum PSA, TNM clinical stage and biopsy Gleason scores were plotted on Partin’s table and its predictive value and pathological findings of specimen were compared and analyzed by using Receiver operating characteristic (ROC) analysis. Results: A total of 109 of 138 patients were included in final analysis. The median age was 65 ± 5.8 years. The pre-operative serum PSA values and clinical stages were higher in our cohort of patients as compared to Partin’s cohort. At pathological assessment of resected specimen, organ confined disease was present in 58 % of patients, seminal vesicles were involved in 22 % and lymph node metastasis was present in 12 % of patients. The accuracy of Partin’s table derived probability was high with area under curve (AUC) of 0.82 for organ confinement, 0.805 for seminal vesicle involvement and 0.714 for lymph node involvement respectively. Conclusions: The 2007 Partin’s table has a reasonably high predictive value for the final histo-pathological features. This predictive model can be used in Pakistani patients with carcinoma prostate with comparable accuracy

Expression of pS2 in prostate cancer correlates with grade and Chromogranin A expression but not with stage

BACKGROUND: The biological potential of prostate cancer is extremely variable. Particular interest is focused on markers not expressed in normal prostatic tissues. pS2 protein expression has been demonstrated in a range of malignant tissues in an oestrogen-independent pathway. Recently, it has been demonstrated that pS2, in prostate cancer, is closely associated with neuro-endocrine differentiation. In the present study, we have analyzed, the potential of Neuro-endocrine and pS2 (TFF1) expression in human prostate cancer determined by immunohistochemistry, in primary adenocarcinoma of the prostate and attempted to correlate this with the clinico-pathologic features of the patient and neuroendocrine expression. METHODS: Ninety-five malignant prostatic specimens from primary adenocarcinoma, obtained from either transurethral resection of prostate or radical retropubic prostatectomy, from 84 patients between January 1991 and December 1998 were evaluated by immuno-histochemical staining using selected neuroendocrine tumor markers i.e. chromogranin A (CgA) and estrogen inducible pS2 protein. The relationship between the expressions of pS2 was studied with CgA expression, clinical stage (TNM) and tumour grade (Gleason system). Fischer exact test was used for statistical analysis. RESULTS: The mean age of the patients was 70 + /- 9.2 years. The pS2 expression was seen in 10% of primary prostate cancers. Worsening histological grade was associated with greater expression of pS2 (p < 0.001). The expression of CgA was noted in 31% of malignant prostatic tissue. In pS2, positive cases 2/3rd of patients were also CgA +ve. However, there was no significant correlation between pS2 expression and the stage of disease. CONCLUSION: pS2 expression in prostate cancer significantly correlates with histological grade and the neuroendocrine differentiation, as demonstrated by Chromogranin A expression but not with the clinical stage of the disease. However, the overall expression was low consequently; no definitive conclusions can be drawn. We feel further work is required in a larger series, both in primary and metastatic cancer

Gender discrimination against female surgeons: A cross-sectional study in a lower-middle-income country

Introduction: Although gender discrimination and bias (GD/bias) experienced by female surgeons in the developed world has received much attention, GD/bias in lower-middle-income countries like Pakistan remains unexplored. Thus, our study explores how GD/bias is perceived and reported by surgeons in Pakistan.Method: A single-center cross-sectional anonymous online survey was sent to all surgeons practicing/training at a tertiary care hospital in Pakistan. The survey explored the frequency, source and impact of GD/bias among surgeons.Results: 98/194 surgeons (52.4%) responded to the survey, of which 68.4% were males and 66.3% were trainees. Only 19.4% of women surgeons reported \u27significant\u27 frequency of GD/bias during residency. A higher percentage of women reported \u27insignificant\u27 frequency of GD/bias during residency, as compared to males (61.3% vs. 32.8%; p = 0.004). However, more women surgeons reported facing GD/bias in various aspects of their career/training, including differences in mentorship (80.6% vs. 26.9%; p \u3c 0.005) and differences in operating room opportunities (77.4% vs. 32.8%; p \u3c 0.005). The source was most frequently reported to be co-residents of the opposite gender. Additionally, a high percentage of female surgeons reported that their experience of GD/bias had had a significant negative impact on their career/training progression, respect/value in the surgical team, job satisfaction and selection of specialty.Conclusion: Although GD/bias has widespread impacts on the training/career of female surgeons in Pakistan, most females fail to recognize this GD/bias as significant . Our results highlight a worrying lack of recognition of GD/bias by female surgeons, representing a major barrier to gender equity in surgery in Pakistan and emphasizing the need for future research

Correlation of three immunohistochemically detected markers of neuroendocrine differentiation with clinical predictors of disease progression in prostate cancer

<p>Abstract</p> <p>Background</p> <p>The importance of immuno-histological detection of neuroendocrine differentiation in prostatic adenocarcinoma with respect to disease at presentation and Gleason grade is gaining acceptance. There is limited literature on the relative significance of three commonly used markers of NE differentiation i.e. Chromogranin A (CgA), Neuron specific enolase (NSE) and Synaptophysin (Syn). In the current work we have assessed the correlation of immuno-histological detection of neuroendocrine differentiation in prostatic adenocarcinoma with respect to disease at presentation and Gleason grade and to determine the relative value of various markers.</p> <p>Materials and methods</p> <p>Consecutive samples of malignant prostatic specimens (Transurethral resection of prostate or radical retropubic prostatectomy) from 84 patients between January 1991 and December 1998 were evaluated by immunohistochemical staining (PAP technique) using selected neuroendocrine tumor markers i.e. Chromogranin A (CgA), Neuron specific enolase (NSE), and Synaptophysin (Syn). According to the stage at diagnosis, patients were divided into three groups. Group (i) included patients who had organ confined disease, group (ii) included patients with locally invasive disease, and group (iii) with distant metastasis. NE expression was correlated with Gleason sum and clinical stage at presentation and analyzed using Chi-Square test and one way ANNOVA.</p> <p>Results</p> <p>The mean age of the patients was 70 ± 9.2 years. Group I had 14 patients, group II had 31 patients and group III had 39 patients. CgA was detected in 33 cases, Syn in 8 cases, and NSE in 44 cases. Expression of CgA was seen in 7% of group I, 37% in group II and 35% of group III patients (p 0.059). CgA (p 0.024) and NSE (p 0.006) had a significantly higher expression with worsening Gleason grade.</p> <p>Conclusion</p> <p>CgA has a better correlation with disease at presentation than other markers used. Both NSE and CgA had increasing expression with worsening histological grade this correlation has a potential for use as a prognostic indicator. Limitations in the current work included small number and retrospective nature of work. The findings of this work needs validation in a larger cohort.</p

Objective cure of urinary retention following laparoscopic hysterectomy for a large uterine fibroid

Acute urinary retention (AUR) in women is not uncommon. Many reports have been published discussing the possible theories and pathogeneses of this condition. AUR induced by uterine fibroid is a rare entity that has been mentioned only in case reports. All the reported cases focused mainly on the different approaches for fibroid management. In this study, we present a 52-year-old female with recurrent episodes of urinary retention that was related to periods of menstruation. Pelvic magnetic resonance imaging revealed a markedly enlarged uterus with multiple fibroids. The patient had laparoscopic hysterectomy with postoperative resolution of patient’s symptoms and improved uroflow studies. This is the first article that proves the cure of AUR following hysterectomy using an objective tool