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H R H Patel

Publications and source records attributed to H R H Patel.

At least 19 recordsLinked to original sources
PubMed2006

Robotic extraperitoneal radical prostatectomy: an alternative approach.

PURPOSE: Laparoscopic radical prostatectomy with or without a robot has been increasingly performed worldwide, primarily using a transperitoneal approach. We report our experience with daVinci(R) robot assisted extraperitoneal laparoscopic radical prostatectomy. MATERIALS AND METHODS: A total of 325 patients underwent robot assisted extraperitoneal laparoscopic radical prostatectomy for clinically localized prostate cancer at our center during a 2-year period. Perioperative data, and oncological and functional results were prospectively recorded. RESULTS: Perioperative demographics included mean age, PSA and Gleason score, which were 60 years (range 42 to 76), 6.6 ng/ml (range 0.6 to 26) and 6 (range 5 to 9), respectively. Preoperative clinical stage was 81%, 16% and 3% for T1c, T2a and T2b, respectively. Average total operative time was 130 minutes (range 80 to 480). Intraoperative data included a mean blood loss of 196 cc with no open conversions. Bilateral, unilateral and nonnerve sparing prostatectomy was performed in 70%, 24% and 6% of patients, respectively. Of the patients 96% were discharged home within 8 to 23 hours of surgery. Pathological stage was pT2a, pT2b, pT3a and pT3b in 18%, 63%, 14% and 5% of all radical prostatectomy specimens, respectively, with an overall positive surgical margin rate of 13%. Two of 92 patients had positive nodal disease after lymph node dissection. Continence and erectile function were measured. CONCLUSIONS: The extraperitoneal approach offers the advantages of improved dexterity and visualization of the robot, while avoiding the abdominal cavity and potential associated morbidity. As surgeons gain more experience with this new technology, the extraperitoneal approach simulating the standard open retropubic technique is likely to gain popularity.

Adult↗
PubMed2005

Tension-free vaginal tape: avoiding failure.

A prospective, single-centre study to assess the outcome of incontinence surgery in the first 120 consecutive patients who had tension-free vaginal tape (TVT) by a single surgeon. All patients were initially seen at 3 months postsurgery, with a cough provocation test, measurement of residual urine volume and a satisfaction survey. At a mean of 26 months (6-42 months) after surgery, a validated telephone interview was performed. The operation was performed in accordance with the original technique described by Ulmsten et al. [Int Urogynecol J Pelvic Floor Dysfunct 1996; 7: 81-5]. A total of 87 of 120 patients completed the study with the others either not complying or having died. Sixty-three (72.4%) patients were completely dry on cough provocation test. Of these, four (4.5%) had a slow stream and 10 (11.4%) suffered persistent urgency. The remaining 24 patients had varying degrees of leakage (operative failure). Sixteen (18.3%) patients subjectively considered the procedure to have failed at 3 months follow-up, either because leakage occurred once or more a day, and/or the persistence of the preoperative frequency/urgency syndrome. Of these 16 TVT failures, two had previous pelvic radiotherapy, two had double incontinence and eight had TVT for recurrent incontinence. Among the failures, 81.3% had mixed incontinence with predominant urge and nocturia three times per twenty four hours. Our study highlights the need for selection when performing TVT. We recommend that TVT be performed for those who have simple stress incontinence failing conservative measures (pelvic floor exercises and physiotherapy), with no history of incontinence surgery, pelvic radiotherapy, faecal or mixed incontinence.

Adult↗
PubMed2005

Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly?

OBJECTIVES: Currently no consensus exists about the role of the foreskin or the effect circumcision has on penile sensitivity and overall sexual satisfaction. Our study assesses the effect of circumcision on sexually active men and the relative impact this may have on informed consent prior to surgery. MATERIALS AND METHODS: One hundred and fifty men between the ages of 18 and 60 years were identified as being circumcised for benign disease between 1999 and 2002. Patients with erectile dysfunction were excluded from the study. The data was assessed using the abridged, 5-item version of the International Index of Erectile Function (IIEF-5). Questions were also asked about libido, penile sensitivity, premature ejaculation, pain during intercourse and appearance before and after circumcision. IIEF-5 data was analysed using two-tailed paired t test to compare pre-operative and post-operative score changes across the study group. For the rest of the questions, data was analysed using 'Sign Test', calculating two-sided p values and 95% confidence intervals. RESULTS: Fifty-nine percent of patients (88/150) responded. The total mean IIEF-5 score was 22.41 +/- 0.94 and 21.13 +/- 3.17 before and after circumcision, respectively (p = 0.4). Seventy-four percent of patients had no change in their libido levels, 69% noticed less pain during intercourse (p < 0.05), and 44% of the patients (p = 0.04) and 38% of the partners (p = 0.02) thought the penis appearance improved after circumcision. Penile sensation improved after circumcision in 38% (p = 0.01) but got worse in 18%, with the remainder having no change. Overall satisfaction was 61%. CONCLUSIONS: Penile sensitivity had variable outcomes after circumcision. The poor outcome of circumcision considered by overall satisfaction rates suggests that when we circumcise men, these outcome data should be discussed during the informed consent process.

Adolescent↗
PubMed2004

Antibiotics on urethral catheter withdrawal: a hit and miss affair.

Globally, millions of patients undergo urethral catheterization every year. Our objective was to study the current use of prophylactic antibiotics on urinary catheter withdrawal. A questionnaire (N = 300) was sent to healthcare professionals involved in the management of patients with urinary catheters (consultant microbiologists, infection control nurses, consultant urologists, specialist nurses in urology, continence advisers and consultants in the care of older people). The questionnaire asked about their use of prophylactic antibiotics on the withdrawal of a urethral catheter. Sixty percent of healthcare professionals advocated the use of antibiotics for either all or selected groups of patients. The remainder did not. The use of prophylactic antibiotics varied among different groups. Of the healthcare professionals who used antibiotics, the majority cited more than one reason for their use (prevent bacteraemia, avoid an infection in a prosthesis or urinary tract infection). The course and type of antibiotic used varied. Our study has shown diversity in practice that is of concern. At present, just over one-half of patients with urinary catheters are being given antibiotics, although there is no evidence to suggest that such an intervention confers any benefit. If benefits do not exist, these patients are being exposed to the harm of antibiotics and providers are incurring costs unnecessarily. A formal trial to address this issue is urgently needed.

Aged↗
PubMed2004

Diclofenac suppository analgesia for transrectal ultrasound guided biopsies of the prostate: a double-blind, randomized controlled trial.

PURPOSE: A significant proportion of men undergoing transrectal ultrasound (TRUS) and prostate biopsy report pain during the procedure. A number of different methods of pain relief have been suggested in the literature. We prospectively evaluated the effect of diclofenac suppositories on pain experienced by men undergoing TRUS and prostate biopsy. MATERIALS AND METHODS: A prospective, randomized, double-blind, placebo controlled study was performed in 72 patients requiring prostate biopsy. Patients were randomly assigned to receive 100 mg diclofenac or placebo 1 hour prior to the procedure. They were asked to indicate on a 10 cm visual analogue scale the degree of discomfort during the procedure. The patients were then seen 2 weeks later and any morbidity, including infection and bleeding, was assessed. RESULTS: Patients given diclofenac had significantly lower pain scores than those given placebo (2.8 vs 4.9, p <0.001). The 2 groups were similar in regard to age, prostate volume, biopsy number, prostate specific antigen, histological diagnosis and complication rate. CONCLUSIONS: Rectal administration of diclofenac 1 hour prior to TRUS and prostate biopsy is a simple procedure that significantly relieves the pain experienced with no increase in morbidity. With the trend toward more core samples, screening for prostate cancer and the younger age of patients undergoing biopsy we urge urologists to provide analgesia for this painful procedure.

Aged↗
PubMed2004

Current trends in bladder cancer in England and Wales.

PURPOSE: We examined trends in bladder cancer (BC) incidence, mortality and survival in England and Wales during a 30-year period. MATERIALS AND METHODS: Age standardized incidence and mortality rates for BC, cohort incidence ratios, and 1 and 5-year relative survival from BC were calculated, and current trends were assessed. RESULTS: Between 1971 and 1998 the total number of cases of BC increased by 57% from around 7,200 to almost 11,400. Between 1971 and 1998 directly age standardized incidence increased by 16% in males and 37% in females. Directly age standardized mortality decreased by 26% in males and showed little change in females during the same period. Five-year relative survival improved by around 15% points in the 1970s and early 1980s. However, there was less improvement in survival thereafter in that 5-year relative survival for patients diagnosed in 1993 to 1995 was 67% in men and 58% in women. CONCLUSIONS: With an almost 60% increased incidence during the last 3 decades, BC incidence remains much higher in men but has increased more rapidly in women. There have been steady decreases in mortality rates, more marked in men than in women. Unusually, women have a significantly lower survival rate than men. Reasons for these patterns and trends are unclear. The trends in bladder cancer incidence by birth cohort suggest that the relationship with smoking may not be that strong and that other factors may be involved. Further research should focus on reasons for the recent increase in bladder cancer incidence in younger female birth cohorts.

Adolescent↗
PubMed2004

Modified ureterosigmoidostomy (Mainz II): a long-term follow-up.

OBJECTIVE: To assess the long-term results in patients treated using a modified ureterosigmoidostomy (Mainz II). PATIENTS AND METHODS: Between 1994 and 1999, 17 patients had their lower urinary tract reconstructed by a ureterosigmoidostomy, modified by reconfiguring the rectum to make a low-pressure reservoir (Mainz II). All patients were followed on a standard protocol. Data were extracted from the database and from a review of the case-notes. In 12 patients the procedure was with a radical cystectomy for carcinoma. Five had a failed conventional ureterosigmoidostomy for bladder exstrophy and therefore proceeded to a Mainz II. The data on continence and complications were retrieved for a retrospective analysis; the mean (range) follow-up was 6.4 (4-8.6) years. RESULTS: Ten of those with bladder cancer and one in the revision group were continent. Two patients in the revision group had sufficiently severe nocturnal incontinence to require conversion to a colonic conduit. Seven of the 17 patients had hyperchloraemic acidosis, one had pyelonephritis and one had renal stones. There were no anastomotic neoplasms. CONCLUSION: The Mainz II has a good outcome if used as the primary procedure. In patients with an existing ureterosigmoidostomy who are incontinent, detubularization of the rectosigmoid alone is unlikely to restore continence.

Adult↗
PubMed2004

Bladder neck stenosis after transurethral resection of prostate: does size matter?

AIM: To understand the risk factors associated with the incidence of bladder neck stenosis (BNS) after transurethral prostate surgery. PATIENTS AND METHODS: We retrospectively reviewed 900 patients who underwent transurethral prostate surgery over a 4-year period. The mean age of the men was 72.3 (47-94) years. The specific outcome data assessed related to BNS, including type of operation performed, resected tissue weight and history of previous surgery in the lower urinary tract. RESULTS: 29 (3.4%) patients developed BNS at a mean of 10.3 (3-33) months, with a mean resected prostatic tissue weight of 11+/-3.7 g. Four of the 29 patients with BNS were treated with bladder neck resection and re-stenosed. Fifty-four men underwent bladder neck incision for small prostates with a high bladder neck, measured by digital rectal examination and assessed cystoscopically, with no BNS. All the remaining patients from our series did not have a BNS, with a mean resected weight of 28+/-8.9 g, which is statistically greater than in the BNS group (p<0.05, unpaired t test). CONCLUSIONS: BNS after transurethral prostate surgery is a significant problem. It is clear from our study that resection in small prostates with no sign of a high bladder neck will increase the development of BNS. Thus, small prostates should be managed by an initial bladder neck incision, even if the bladder neck is not high.

Aged↗
PubMed2004

Tissue microarrays: a current medical research tool.

Recent research in molecular biology has identified a significant number of novel markers, which may have diagnostic, prognostic and therapeutic significance. This is particularly pertinent in the field of cancer. Validation of these markers in multiple clinical specimens is currently performed by traditional histopathological techniques, which are disappointingly time consuming, labour intensive and, therefore, economically costly. These limitations have hampered the introduction of many novel markers into everyday clinical practice. The tissue microarray (TMA) is a high throughput technique, which allows the rapid and cost effective validation of novel markers in multiple pathological tissue specimens. Tissue from up to a 1000 histology blocks can be arrayed accurately onto a newly created paraffin block, at designated locations. Subsequently, morphological and molecular investigations can be performed to determine the clinical significance of the novel markers tested. It is now firmly established that the TMA can significantly accelerate the processing of a very large number of tissue specimens with excellent quality, good reliability and preservation of original tissue, with ultimate clinical benefit.

Biomarkers, Tumor↗
PubMed2003

Long-term surveillance of bladder tumours: current practice in the United Kingdom and Ireland.

INTRODUCTION: Surveillance of transitional cell carcinoma of the bladder forms a major part of the workload of many urology units. Unfortunately, the policy for long-term surveillance of these cancers is neither clear nor agreed upon in the absence of evidence base. Our study was performed to provide current national practice data, and begin the debate on consensus guidelines. MATERIALS AND METHODS: A questionnaire was sent to Consultant Urologists (CUs) in the UK and Ireland (n=501) asking about their policy on the long-term surveillance of different bladder tumours once patients are free of recurrence. RESULTS: A 73% response rate was observed (365/501). Views varied considerably. They ranged from life long cystoscopic surveillance for low-stage low-grade tumours (pTaG1) to discharge after 5 years (or less) of a recurrence-free period for pT1G3 tumour. Once long-term surveillance with cystoscopy had been discontinued, 55% of CUs felt no role was indicated for urine cytology in further follow up, whereas 17% would use it for all tumour types and 28% are selective. CONCLUSION: Our study has shown the complete lack of consensus regarding the long-term surveillance of bladder cancer in the UK and Ireland. This has major implications for policy making, resources allocation and cancer survival. We highlight the need for national guidelines in this area for optimal surveillance of bladder cancer, as a good prospective evidence-based data will not be available for many years. We believe our study might form the basis for discussion on such guidelines.

Carcinoma, Transitional Cell↗
PubMed2003

The use of the Memokath stent in the treatment of detrusor sphincter dyssynergia in spinal cord injury patients: a single-centre seven-year experience.

AIMS: A retrospective analysis of our seven-year experience with the Memokath urethral stent for the treatment of detrusor sphincter dyssynergia (DSD) in spinal cord injured (SCI) patients. PATIENTS AND METHODS: Twenty five patients with SCI underwent rhabdosphincter Memokath stent insertion. The mean age was 45.5 years (range 32-65 years). The level of injury was cervical in 14 and thoracic in 11 patients. All patients were shown to have neurogenic detrusor overactivity with DSD associated with high detrusor pressures and incomplete emptying on pre-operative video-cystometrograms (VCMG). The Memokath stent was inserted using a standardized protocol. Follow-up assessment included blood chemistry, ultrasound scan (upper tracts and residual urine) at one and three months after insertion, and a follow-up VCMG at six months. The pre-operative and six-month post-operative VCMG results were analysed by the paired t-test and p value <0.05 was taken as significant. RESULTS: There was a significant reduction in maximum detrusor pressure, duration of contraction and residual urine volume (p<0.05) on the VCMG six months after insertion of the stent. At present six patients have a Memokath stent in situ at a mean of 34.7 months (range 6-86 months). Nineteen stents were removed for several reasons at a mean of 20.3 months (range 0.25-41 months). These include, exacerbation of autonomic dysreflexic symptoms (n=3); stent migration (n=7); encrustation and stone formation (n=5); incomplete bladder emptying without obstruction (n=3); entrance into fertility program (n=1). CONCLUSION: The Memokath stent is safe, easy and quick to insert with minimal trauma to the urethra. It is effective in the management of DSD and decreasing the detrusor pressure and residual urine volume in SCI patients. Moreover the ease of its removal in a non-traumatic fashion makes this stent an attractive option when patients are still contemplating the method of bladder management, in those wishing to be involved in fertility program and in recently SCI patients who may recover some manual dexterity to perform clean intermittent self-catheterisation. It must be remembered that this is a temporary stent, as our study clearly shows that the majority are removed within two years of insertion.

Adult↗
PubMed2003

Experience of tension-free vaginal tape for the treatment of stress incontinence in females with neuropathic bladders.

STUDY DESIGN: Retrospective. OBJECTIVE: To evaluate the safety and efficacy of the tension-free vaginal tape (TVT) for the treatment of stress incontinence in females with neuropathic bladders. SETTING: London Spinal Injuries Unit, Stanmore & Institute of Urology, London, UK. METHODS: Twelve women (mean age 53.3 years; range 41-80 years) with neuropathic bladder dysfunction and stress urinary incontinence were treated with tension-free vaginal tape (TVT) between November 1997 and December 2000. The group consisted of women with: (i) traumatic spinal cord injuries (n=3); (ii) post lumbar spinal surgery (n=6); (iii) spinal stenosis (n=3). Four of the 12 patients had previously failed surgery for stress incontinence. All patients underwent pre- and post-TVT evaluation with video-urodynamic studies. RESULTS: Mean follow-up was 27.1 months (range 17-54 months). Three patients were voiding spontaneously (stress voiding) before surgery and continued to do so post-operatively. The remaining 9 were performing clean intermittent self-catheterisation before the insertion of TVT and continued to do so after the surgery. At follow up 10 patients (83.3%) were dry. The procedure failed in one patient and the other complained of mild leakage, but she reported a decrease in the number of pads used. One patient developed detrusor hyperreflexia on post-operative video-urodynamics but there was no evidence of stress incontinence. One patient had a bladder perforation on insertion of TVT, managed successfully with extended use of a urethral catheter post-operatively. Three patients developed post-operative urinary tract infection successfully treated with oral antibiotics. CONCLUSIONS: Tension-free vaginal tape insertion is minimally invasive, safe and effective for the treatment of stress incontinence in females with bladder neuropathy with intrinsic sphincter deficiency. Previous surgery for incontinence did not affect post-operative complications or outcome.

Adult↗
PubMed2003

The treatment of male stress urinary incontinence with polydimethylsiloxane in compliant bladders following spinal cord injury.

STUDY DESIGN: Retrospective analysis. OBJECTIVES: To evaluate the safety and efficacy of polydimethylsiloxane (PDS, Macroplastique) submucosal injections, in the treatment of male genuine stress urinary incontinence secondary to spinal cord injury (SCI). SETTING: London Spinal Injuries Unit, Stanmore, UK and Institute of Urology and Nephrology, London, UK. PATIENTS AND METHODS: A retrospective analysis identified 14 patients treated with PDS for stress urinary incontinence secondary to SCI between 1997 and 2001. A single surgeon at a specialist spinal injuries unit managed all patients. A total of 13 patients had suffered a traumatic SCI (T11:n=2; T12:n=5; L1:n=5; L2:n=1), while one developed stress incontinence after spinal surgery. The mean age was 41 years (range 26-69 years) and the mean duration of injury was 9.6 years (range 1.5-48 years). The preoperative investigations included video cystometrogram (VCMG) confirming the presence of urodynamically proven stress incontinence without evidence of urge incontinence. Complete cure was defined as a cessation of pad usage with no evidence of leakage on VCMG. Incomplete cure with improvement was defined as a >50% reduction in the number of pads used, with incontinence present on VCMG. RESULTS: The follow-up ranged from 12 to 58 months (mean 34.7 months). Five patients (36%) reported complete success, confirmed by VCMG. Three patients (21%) reported improvement with >50% reduction in the use of pads. The procedure failed completely in six patients (43%). No immediate or late complications were noted with the procedure. CONCLUSIONS: The use of PDS is a safe and minimally invasive treatment for genuine stress urinary incontinence in males following SCI with a stable compliant bladder. We achieved complete cure in 36% of our patients with confirmation on VCMG. A further 21% reported greater than 50% reduction in usage of pads; however, on VCMG stress incontinence was demonstrated in these patients. We suggest that PDS can be used as the first line of treatment in this difficult group of patients with complex problems.

Adult↗
PubMed2003

Epididymo-orchitis risk factors in traumatic spinal cord injured patients.

STUDY DESIGN: Retrospective audit and interview-based study of a traumatic spinal cord injured cohort, assessing the incidence and risk of epididymo-orchitis (E-O). OBJECTIVES: Assess the potential risk factors for E-O in this cohort (spinal cord injured patients). SETTING: Janbazan Clinic for Spinal Cord Injuries, Mashad, Iran. METHODS: A retrospective notes audit of 169 male traumatic spinal cord injured (SCI) patients was performed. In addition, interviews were performed to confirm any equivocal data. The following risk factors were assessed: history of recurrent urinary tract infections (UTIs), urethral stricture, urethral diverticuli, urinary fistula, urinary calculi, spinal injury type, neurogenic bladder type, autonomic dysreflexia, vesico-ureteral reflux, sphincterotomy, vasectomy, marriage status, bladder residual and emptying method, ejaculation, spinal injury level, micturation control, and muscular spasm, which included detrusor, external sphincter or lower limb spasm. RESULTS: A total of 65 patients from our group (38.5%) had suffered E-O at least once. E-O presented on average, 3.9 years after the SCI. Patients with a history of muscular spasm appeared less likely to develop E-O (P<0.05). None of the vasectomised patients developed E-O. The relation between all the other factors and E-O were not significant. CONCLUSIONS: Our study has shown that the presence of muscular spasm decreases the risk of E-O, although the mechanism remains unclear. Surprisingly, the other historical risk factors showed no clear relation with E-O occurrence.

Adolescent↗
PubMed2003

The mesh wallstent in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury: a 12-year follow-up.

OBJECTIVE: To assess the long-term effectiveness of the UroLume trade mark wallstent (Pfizer Inc., UK) in the treatment of detrusor external sphincter dyssynergia (DESD) in quadriplegic patients. PATIENTS AND METHODS: Twelve patients with quadriplegia secondary to spinal trauma underwent external striated sphincter stenting with the UroLume wallstent instead of an external sphincterotomy for DESD (mean age 41.8 years, range 26-65). The level of injury was C4 in two, C5 in four, C6 in four, C7 in one and T6 in one. All patients were shown by preoperative video-cystometrography (VCMG) to have DESD and high-pressure, hyper-reflexic bladders with incomplete emptying. RESULTS: Seven of the 12 patients had a mean (range) follow-up of 12.7 (12.17-13.6) years; two others were lost to follow-up at 1 and 3 years and both remained free of complications during that time. Two patients developed encrustation causing obstruction, requiring stent removal within a year of insertion. Another patient with an adequately functioning stent died 7 years after surgery (chest infection). Urodynamic follow-up of the seven patients showed a significantly sustained reduction in maximum detrusor pressure and duration of detrusor contraction at> 10 years of follow-up. Five of the seven patients developed bladder neck dyssynergia of varying degrees, as shown on VCMG; all were successfully treated with bladder neck incision. There were no problems with stent migration, urethral erosion, erectile dysfunction or autonomic dysreflexia. CONCLUSION: Permanent urethral stenting using the UroLume wallstent is effective in managing DESD and provides an acceptable long-term alternative to sphincterotomy. Subsequent bladder neck dyssynergia is the main complication but this can be managed successfully with bladder neck incision. Importantly, unlike sphincterotomy, there is no significant interference with erectile function. Also, the procedure is reversible, minimally invasive and requires a shorter hospital stay.

Adult↗
PubMed2003

Catheter-associated urinary tract infections: prevalence of uropathogens and pattern of antimicrobial resistance in a UK hospital (1996-2001).

OBJECTIVE: To assess the change in the bacterial profile and pattern of antibiotic resistance of catheter-associated urinary tract infections (CAUTIs, the most prevalent form of nosocomial infections) between 1996 and 2001. MATERIALS AND METHODS: Catheter samples of urine (CSUs) submitted in 1996, 1998 and 2001 (2451, 2460 and 3349 specimens, respectively) were analysed. The distribution of different uropathogens in bacterial CAUTIs and their in vitro antimicrobial resistance was evaluated over the study interval. The likelihood ratio test was used to assess whether there was a linear trend according to calendar year. RESULTS: Escherichia coli was the most frequently isolated pathogen in all years, but its frequency declined over time (35.6%, 32.5% and 26.6%, respectively). Enterococcus was the second most frequent overall, with a significant increase in frequency with time (11.8%, 15.3% and 22.0%, respectively). There was also a considerable change in resistance patterns to antibiotics. As a result, in 1996, CAUTIs were least often resistant to ciprofloxacin (8.0%) followed by co-amoxiclav (18.5%) and cephalexin (25.4%). In 2001, CAUTIs were least often resistant to co-amoxiclav (22.5%), followed by ciprofloxacin (27.2%) and nitrofurantoin (28.8%). CONCLUSION: The types of organisms associated with CAUTI have changed over the last 5 years in a UK institution, as have the patterns of antibiotic resistance. Currently, the most appropriate agents for the empirical management of CAUTIs seem to be co-amoxiclav, ciprofloxacin and nitrofurantoin.

Anti-Bacterial Agents↗