Glycolate oxidase-1 gene variants influence the risk of hyperoxaluria and renal stone development

PURPOSE

Oxalate is an excellent calcium ion attractor with great abundance in the human body, and the liver is the major source of oxalate. The Glycolate oxidase-1 (GOX1) gene is solely responsible for the glycolate and glyoxylate metabolism and produces oxalate. This study has been designed to comprehend the association of genetic variants of the GOX1 gene with the risk of hyperoxaluria and renal stone disease in the Indian population.

METHOD

The present study is a candidate gene approach prospective case-control study carried out on 300 participants (150 cases and 150 controls) at Muljibhai Patel Urological Hospital, Gujarat, India. Biochemical parameters, including serum levels of calcium, creatinine, parathyroid hormone, and 24-h urine metabolites, were performed. The genotyping of GOX1 gene variants rs6086287, rs2235250, rs2255183, and rs2294303 was performed using a customized TaqMan assay probe by RT-PCR.

RESULT

Parathyroid hormone, serum creatinine, and urine metabolites were significantly elevated in nephrolithiasis compared to healthy individuals. All mutated homozygous genotypes GG (rs6086287), TT (rs2235250), GG (rs2255183), and CC (rs2294303) were significantly associated with a high risk of renal stone disease. Individuals diagnosed with hyperoxaluria and carrying TG (rs6086287), AG (rs2255183), and TT (rs2294303) genotypes have a significantly high risk of renal stone disease. Moreover, haplotype analysis and correlation analysis also confirmed the strong association between genetic variants and nephrolithiasis.

CONCLUSION

Genetic variants of the GOX1 genes were associated with renal stone disease. In the presence of risk genotype and hyperoxaluria, the susceptibility to develop renal stone disease risk gets modulated.

Initial experience of comparison between two slimmest single-use flexible ureteroscopes: Indoscope Sleek (Bioradmedisys™) Versus Uscope PU3033A (Pusen™): A single-center prospective study

PURPOSE

A single-use digital flexible ureteroscope (fURS) has become a cost-effective alternative option to reusable fURS. The requirement of large-diameter access sheath for passage of 9.5 Fr single-use fURS has not always achieved in the first attempt in all cases leading to stage stone clearance. Recently, two slimmest single-use digital disposable fURSs have been introduced by Bioradmedisys™ and Pusen™ to mitigate the accessibility problem, without or with small size access sheath. Primary objective was to compare in vivo performance and surgical outcomes with two single-use fURS: 7.5Fr Indoscope (Bioradmedisys™, Pune, India) and 7.5Fr Uscope PU3033A (Pusen, Zhuhai, China).

METHODS

60 patients undergoing Retrograde Intrarenal Surgery (RIRS) with < 2 cm renal stones were prospectively randomized into: Group A (30 patients) for Indoscope and Group B (30 patients) for Uscope PU3033A. Pre-operative, intra-operative, and post-operative parameters were evaluated. In vivo visibility and maneuverability were rated on 5-point Likert scale by the operating surgeon. At one-month stone clearance was assessed with ultrasound and X-ray KUB. Data were analyzed using SPSS 23.0.

RESULTS

Patient demographics and stone characteristics were comparable in both groups. Indoscope had significantly higher visibility (p < 0.05) than Uscope; however, the maneuverability scores were comparable between both the groups (p > 0.05). 28 patients in group A and 26 patients in group B achieved complete stone clearance (p = 0.38). Scope failure was observed in 1 case of group B (p = 0.31).

CONCLUSION

We conclude that 7.5Fr Indoscope has better vision than 7.5Fr Uscope and the rest of in vivo performances were comparable with similar outcomes and complications among both scopes.

Study of the predictive factors affecting outcomes of patients undergoing transperitoneal laparoscopic donor nephrectomy

PURPOSE

We aim to study the preoperative and intraoperative factors and compare against specific outcomes in patients undergoing transperitoneal laparoscopic donor nephrectomy and see if we could find what were the predictive factors for these outcomes.

METHODS

This is a prospective cohort study done in a single high-volume transplant center. 153 kidney donors were evaluated over a period of 1 year. The preoperative factors such as age, gender, smoking status, obesity, visceral obesity, perinephric fat thickness, number of vessels, anatomic abnormalities, comorbidities, and side of kidney and intraoperative factors such as lay of colon on the kidney, height of splenic or hepatic flexure of colon, loaded or unloaded colon, and sticky mesenteric fat were compared against specific outcomes such as duration of surgery, duration of hospital stay, postoperative paralytic ileus, and postoperative wound complications.

RESULTS

Multivariate logistic regression models were used to study the variables of interest against the various outcomes. There were three positive risk factors for increased hospital stay, which were perinephric fat thickness and height of splenic or hepatic flexure of colon and smoking history. There was one positive risk factor for postoperative paralytic ileus which is lay of colon with relation to kidney and there was one positive risk factor for postoperative wound complication which was visceral fat area.

CONCLUSION

The predictive factors for adverse postoperative outcomes after transperitoneal laparoscopic donor nephrectomy were perinephric fat thickness, height of splenic or hepatic flexure, smoking status, lay or redundancy of colon with relation to kidney and visceral fat area.

Stage Migration in Renal Malignancies in COVID Era: A Single-Center Analysis

The COVID-19 disease, caused by SARS-CoV-2 virus, attained the status of a pandemic by March 2020. There was apprehension among patients suffering from renal malignancies about balancing cancer treatment and preventing COVID-19 infection transmission. We analyzed 184 patients with renal malignancies retrospectively, who presented to our institute over 2 years: 91 patients of renal malignancies in pre-COVID era (March 2019-Feb 2020) and 93 patients in COVID era (March 2020-Feb 2021). The parameters analyzed were age, tumor size, clinical presentation, clinical stage, pathological stage, nuclear grade, and presence of metastasis. Level of significance was kept at 95%, and p value <0.05 was considered significant. The age of patients was comparable in both groups (p: 0.381). Clinical presentation was also similar in both groups whereas there were more cases diagnosed during routine evaluation in pre-COVID era (p: 0.022). Tumor size was 5.84 ± 3.03cm vs. 7.10±3.83cm (p: 0.017) in pre-COVID vs. COVID era, respectively. Patients in COVID era had significantly higher clinical stage (p = 0.041), pathological stage (p =0.027), nuclear grade (p = 0.007), and presence of metastasis (p = 0.005) as compared to pre-COVID era. Patients, who underwent Nephron-sparing surgery, also had higher pathological stage in COVID era. COVID overshadowed the management of renal malignancies. There was a clear shift and stage migration in patients of renal malignancies in COVID era as compared to pre-COVID era, probably because of less routine health check-ups and patients deferring hospital visits due to fear of contracting COVID infection.

SPP1 and UMOD gene variants are synergistically associated with risk of renal stone disease

OBJECTIVE

Calcium and oxalate are the most abundant metabolites present in the stone matrix. The SPP1 and UMOD gene has specific expression in kidneys and are involved in various stages of stone formation. Therefore, genetic variants in the SPP1 and UMOD genes may enhance the development of renal stone disease. This study has been designed to understand the association of genetic variants of SPP1 and UMOD genes with renal stone disease.

MATERIALS AND METHOD

A prospective study has been carried out, including 150 renal stone disease patients and 150 healthy individuals. Biochemical parameters were performed, including serum calcium levels, creatinine, parathyroid hormone, and 24-Hour urine metabolites. The genotyping of SPP1 (rs1126616) and UMOD (rs4293393) gene variants were performed using a customized TaqMan probe. T-test was used for continuous biochemical data analysis. The Chi-square test has been applied to assess the risk of a particular genotype associated with renal stone disease. In addition, correlation analysis for biochemical parameters and genetic variants with the renal stone disease has been performed using Shapley additive explanations (SHAP) values calculated with the help of the pycaret library.

RESULT

Renal stone patients had significantly higher levels of parathyroid hormone (93.37 ± 52.78 pg/ml vs 64.67 ± 31.50 pg/ml, P=<0.0001), serum creatinine (0.94 ± 0.38 mg/dl vs 0.77 ± 0.17 mg/dl, P=<0.0001) and 24hr urine metabolites in comparison to the healthy controls. Heterozygous (CT) variant of SPP1 and homozygous (GG) variant of UMOD genes were significantly associated with an increased risk of developing the renal stone disease (p = 0.0100, OR = 2.06, 95 %CI = 1.13-3.75; p=<0.0001, OR = 5.773, 95 % CI = 2.03-16.38, respectively). Individuals with hyperparathyroidism and CC (SPP1) and GG (UMOD) genotypes have a high risk (P = 0.0055, OR = 2.75, 95 %CI = 1.35-5.67; P = 0.0129, OR = 10.03, 95 %CI = 1.60-110.40, respectively) of developing a renal stone. In addition, individuals with hypercalciuria and TT genotype of SPP1 (P = 0.0112, OR = 2.92, 95 % CI = 1.33-6.35), AG genotype of UMOD (P=<0.0001, OR = 5.45, 95 %CI = 2.24-13.96) and GG genotype of UMOD (P=<0.0001, OR = 10.02, 95 %CI = 3.53-24.63) have high risk of developing renal stones. Moreover, Individuals with hyperoxaluria and AG + GG (UMOD) genotype have a greater risk (P=<0.0001, OR = 7.35, 95 % CI = 3.83-13.68) of developing a renal stone. The renal stone risk was persistent (P=<0.0002, OR = 2.44, 95 % CI = 1.52-3.86) when analyzed for the synergistic effect of risk genotypes of SPP1 (CT) and UMOD (GG) gene. Further, correlation analysis also confirmed the strong association between genetic variants and renal stone development.

CONCLUSION

Genetic variants of the SPP1 and UMOD genes were associated with renal stone disease. In the presence of risk genotype and hyperparathyroidism, hypercalciuria, and hyperoxaluria, the susceptibility to develop the renal stone disease risk gets modulated.

Haplotype of CaSR gene is associated with risk of renal stone disease in West Indian population

Calcium is the most abundant metabolite involved in the stone matrix. The CaSR gene controls calcium homeostasis, and genetic variation in the CaSR gene could lead to the development of renal stone disease. Therefore, the current study has been designed to assess the association of genetic variants of CaSR gene polymorphisms with renal stone disease. A single-centric prospective study has been carried out on a total of 300 participants (150 cases and 150 controls). Serum levels of calcium, creatinine, parathyroid hormone, and 24 h urine metabolites were measured. Two polymorphisms, rs1801725 and rs1042636, of the CaSR gene, have been genotyped for each participant. T test, binary logistic regression, and Chi-square analysis were used for statistical analysis. Renal stone patients had significantly higher levels of serum parathyroid hormone, creatinine, and 24-h urine metabolites in comparison to the controls. CaSR gene variants, rs1801725 (GG) and rs1042636 (AA), both have shown significant association with renal stone disease. In addition, individuals having specific genotypes along with metabolic abnormalities such as hypercalcemia and hyperparathyroidism are found to be at a higher significant risk of developing the renal stone disease. In the present study, the haplotype of the CaSR gene has shown an association with renal stone disease. Individuals with hyperparathyroidism and hypercalcemia and risk genotype have a higher susceptibility to developing renal stone disease.

Supine Percutaneous Nephrolithotomy

Percutaneous nephrolithotomy (PCNL) has evolved many a fold and was originally described in supine position by Valdivia et al. In this position, the direction of the tract is posterior and thus preserves a low pressure in the renal pelvis, and thereby reduces the risk of fluid absorption and allows spontaneous clearance/washout of fragments by gravity-directed flow of fluid. Supine PCNL is feasible in most situations. It is an important tool for patients who have musculoskeletal abnormalities precluding prone positioning. It gives the surgeon a simultaneous opportunity to do flexible ureteroscopy. Mobility of the kidney may make the puncture difficult. Suctioning of the dust using the suction sheath in supine PCNL makes the procedure more effective.

Laparoscopic Heminephrectomy in Horseshoe kidney: single-center experience of four cases

Background

Horseshoe kidney (HSK) is the most common congenital fusion anomaly and found in 1 in 400 of the general population (Grainger et al. in Ir Med J 76:315–317, 1983 Jul). Impaired drainage due to anomalous anatomy leads to ureteric obstruction resulting in hydronephrosis and nonfunctioning kidney.

Conventionally heminephrectomy is done by open technique; however, in the era of minimally invasive surgery, laparoscopic heminephrectomy in HSK has been described. Kidney location, aberrant vasculature and isthmus division are the most common obstacle encountered by the operating surgeon. Here we report our single-center experience in laparoscopic heminephrectomy in four patients with HSK.

Methods

Retrospective data were analyzed for four cases of laparoscopic heminephrectomy for nonfunctioning moiety in HSK operated between 2012 and 2020. Of these four patients, one case was converted to open approach in view of intra-operative bleeding. Computed tomography urogram (CTU) was done pre-operatively in all patients. Laparoscopic surgery was performed via transperitoneal approach.

Results

The mean age of the patients was 37 ± 5.38 years. Flank pain was noted in all cases while dysuria seen in two patients and one patient had fever. Mean operative time was 145 ± 26.92 min and estimated blood loss was 85 ± 55 ml. Various techniques for isthmectomy and lower pole resection were used including use of monopolar hook in laparoscopic suite, Ligasure and bipolar scissor in minimal invasive milieu and monopolar cautery in laparoscopic conversion to open procedure. Histopathological examination revealed chronic pyelonephritis in three cases and squamous cell carcinoma of renal pelvis in one case which was converted to open.

Conclusions

Laparoscopic heminephrectomy in HSK is doable. Preoperative CT urography along with CT angiography may provide important anatomical and vascular information which reduces intra-operative risks of vascular injury or calyceal entry. Vascular control of isthmus and transection of dilated and thinned out lower pole with cauterization of pelvicalyceal mucosa will provide uneventful surgical course.

Partial inclusion complex assisted crosslinked β-cyclodextrin nanoparticles for improving therapeutic potential of docetaxel against breast cancer

The present investigation demonstrates the development of crosslinked β-cyclodextrin nanoparticles (β-CD NPs) for enhancing the therapeutic efficacy of docetaxel (DTX) against breast cancer. Initially, a partial inclusion complex between β-CD and polypropylene glycol (PPG) was formed to induce self-assembly. This was followed by crosslinking of β-CDs using epichlorohydrin (EPI) and removal (by solubilization) of PPG to yield uniform β-CD NPs. The formed particles were used for loading DTX to form DTX β-CD NPs. The resultant DTX β-CD NPs exhibited particle size of 223.36 ± 17.73 nm with polydispersity index (PDI) of 0.13 ± 0.09 and showed entrapment efficiency of 54.53 ± 2%. Increased cell uptake (~5-fold), cytotoxicity (~3.3-fold), and apoptosis were observed in MDA-MB-231 cells when treated with DTX β-CD NPs in comparison to free DTX. Moreover, pharmacokinetic evaluation of DTX β-CD NPs revealed ~2 and ~5-fold increase in AUC0-∞ and mean residence time (MRT) of DTX when compared to Docepar®. Further, the anti-tumor activity using DMBA-induced cancer model showed that DTX β-CD NPs were capable of reducing the tumor volume to ~40%, whereas Docepar® was able to reduce tumor volume till ~80%. Finally, the toxicity evaluation of DTX β-CD NPs revealed no short-term nephrotoxicity and was confirmed by estimating the levels of biomarkers and histopathology of the organs. Thus, the proposed formulation strategy can yield uniformly formed β-CD NPs which can be effectively utilized for improving the therapeutic efficacy of DTX.

Primary adenocarcinoma of renal pelvis or ureter: an uncommon histopathological entity seen in three cases

Background

Primary adenocarcinoma of renal pelvis or ureter is rarest (< 1%) among all urothelial tumors. Regrettably, no characteristic symptoms, radiological features and treatment for this tumor are reported. We report three cases of adenocarcinoma of renal pelvis and ureter.

Case presentation

Case 1 had grossly hydronephrotic non-functional right kidney and underwent percutaneous nephrostomy followed by laparoscopic simple nephrectomy. Incidentally, histopathological examination reported adenocarcinoma of renal pelvis. Whole-body positron emission tomography-CT (PET-CT) ruled out malignancy at other sites. Patient refused adjuvant chemotherapy. Case 2 presented with previous history of right pyelolithotomy, right ureteroscopic lithotripsy and right flank pain with intermittent discharge via previous percutaneous site. On biochemical and radiological investigations, right poorly functioning pyonephrotic kidney was confirmed. Patient underwent right open nephrectomy which incidentally reported adenocarcinoma of renal pelvis. Patient is disease-free at 18 months of follow-up. Case 3 had left ureteric wall thickening on CT scan when evaluated for hematuria. Ureteroscopic-guided biopsy showed villous adenoma. Laparoscopic left nephroureterectomy with bladder cuff excision specimen showed well-differentiated adenocarcinoma in ureter with extension into periureteric fat. Patient died 32 months after surgery.

Conclusion

Primary adenocarcinoma of renal pelvis or ureter is very rare and urologists should suspect it in patients with mucinous material in nephrostomy tube. We should have a low threshold for performing radical nephrectomy with complete ureterectomy in these unusual cases to improve the prognosis.

Single ileal segment in a cat-tail configuration for bilateral ureteric strictures

Introduction

Management of bilateral long length ureteric strictures is difficult with few options for reconstruction. In this report, we describe our experience with the use of a single, 15- 20 cm ileal segment for reconstruction of bilateral long length (involving more than 2/3^rd ureter) ureteric strictures.

Patients and Methods

A retrospective analysis of 5 cases operated between 2015 and 2020for bilateral long length ureteric strictures, using a single segment ileal interposition in a cat tail configuration was performed. We evaluated renal function, surgical success, incidence of urinary tract infection and complications of the procedure. Surgical success was defined as an asymptomatic patient with no hydronephrosis and/or prompt drainage of the kidney on radiological investigations.

Results

The average age of presentation was 42.8 ± 7.4 years (33-53) years). All the cases were secondary to a gynaecological intervention. The mean creatinine prior to surgery was 0.81 ± 0.36 mg % (range 0.5 -1.4 mg%). Mean duration of follow-up was 28.6 ± 20.6 months (Range 10 - 56 months). Mean hospital stay was 14.4 ± 3.36 days (range 12-20 days). Two patients developed ileus and one patient developed deep venous thrombosis in the post-operative period. One patient developed pyelonephritis within one month of surgery. There was no deterioration of renal function with the mean serum creatinine at last follow-up being 0.9 ± 0.36 mg% (range 0.6 - 1.5 mg%).

Conclusion

The use of an ileal segment in cat-tail configuration for bilateral simultaneous ileal replacement is a feasible and safe option. The medium-term result states that it is effective in the preservation of renal function and provides a good conduit for drainage.

BPH nomogram using IPSS, prostate volume, peak flow rate, PSA and median lobe protrusion for predicting the need for intervention: development and internal validation

OBJECTIVE

The aim of the present study was to develop a nomogram to accurately predict the need for intervention in patients suffering from LUTS due to benign prostatic hyperplasia (BPH) and internally validate it.

MATERIAL AND METHODS

The data was collected from the community subjects from the state of Gujarat in western India. All the demographic data, physical examination, PSA, uroflowmetry and prostatic ultrasound was collected in 92 subjects and were followed up after 2 years. The data was analyzed and logistic regression model was used to build a predictive model. A nomogram was build using R software. Nomogram was internally validated using 50 subjects.

RESULTS

92 subjects were analyzed for developing the nomogram. Out of these, 17 patients needed intervention. 8 patients were started on medical therapy and 9 patients were taken up for surgical intervention. Of all the statistically significant predictors, peak flow rate was the most significant and was followed by median lobe enlargement, PSA, prostate volume and IPSS. These variables were used to develop a prediction model for the intervention required using reduced logistic regression model. The predictive accuracy of the model was 95.65% with a sensitivity of 88.28%, a specificity of 97.33%, a positive predictive value (PPV) of 88.24%, and a negative predictive value (NPV) of 97.33%. The AUC of the model was 0.799. Internal validation was done on 50 subjects which had sensitivity, specificity and AUC of the model at 89.66%, 90.48% and 0.968 respectively.

CONCLUSION

The study demonstrates the clinical application of nomogram which uses IPSS, PSA, peak flow rate, prostate volume and median lobe enlargement (intravesical prostatic volume). It has a sensitivity of 88.24%, specificity of 97.33%. It predicts the need for intervention in BPH patients with accuracy of 95.65% which was internally validated with an accuracy of 90%.

Initial experience with slimmest single-use flexible ureteroscope Uscope PU3033A (PUSEN™) in retrograde intrarenal surgery and its comparison with Uscope PU3022a: a single-center prospective study

PURPOSE

Single-use disposable digital flexible ureterorenoscope has become an attractive option to reusable scope with many advantages. Currently available single-use digital fURS have outer shaft diameter above 9 Fr which requires large access sheath insertion and sometimes double J stent placement. Recently, 7.5 Fr single-use digital fURS is introduced in market by Pusen. Objective of this study is to compare two Pusen single-use scopes in the clinical setting: 7.5 Fr Uscope PU3033A and 9.5 Fr Uscope PU3022A.

METHODS

30 patients, having renal stones < 2 cm, planned for RIRS were prospectively randomized to two groups: group 1 had 15 patients in which 7.5 Fr Uscope PU3033A and group 2 had 15 patients in which 9.5 Fr Uscope PU3022A was used. The various pre-operative, intra-operative, and post-operative parameters at 1 month along with complications were evaluated for both the scopes by a single surgical team.

RESULTS

Pre-operative parameters including stone characteristics were comparable in both the groups. Three patients in group 2 needed ureteric dilatation prior to 11/13 access sheath insertion, while 10/12 Fr access sheath was placed in all patients in group 1 without manipulation (p = 0.06). Intra-operative vision was comparable in both scopes with an empty working channel and with laser. Hazy vision while lasing in two and one patient in group 1 and group 2, respectively (p = 0.54). In group 1, one had fever and UTI, while in group 2, one had fever post-operatively.

CONCLUSION

7.5 Fr Uscope PU3033A could be introduced with smaller access sheath. The vision, deflection, maneuverability is comparable to 9.5 Fr Uscope PU3022a.

A fruit-tissue (apple) based training model for transurethral resection of prostate: face, content and construct validation

AIMS AND OBJECTIVES

To establish face, content and construct validity of an innovative fruit-tissue (apple) based transurethral resection of prostate (TURP) training model devised at our institute.

METHOD AND MATERIAL

Six consultants, three fellows and 16 residents performed TURP on the new fruit-tissue (apple) based TURP model for ten minutes after watching a demo-video. The procedure was videographed. At the end, participants answered a set of questionnaires regarding their experience. The video and the apple both were examined by blinded separate assessors based on pre-decided parameters. Statistical analysis was done to find out the face, content and construct validity of the training model.

RESULTS

Participants were divided into two groups, expert and novice, based TURP surgery experience. The model was positively rated (lowest median value 4) by all novice for its 'realism' and 'acceptability'. The expert group also felt that the model reproduced real TURP experience (lowest median value 4). Thus, both face and content validity were established. The expert group resected more tissue (18.3±2.5 gm vs 10.3±3.4 gm; P<0.001) with less irrigation fluid (1566.6±187.0 ml vs 2112.5±344.2 ml; P<0.001) removing more chips (39.8±6.2 vs 25.6±3.0; P<0.001) and orientated themselves faster (63.3±12.2 sec vs 90.3±12.7 sec; P<0.001). The assessors' subjective evaluation of videos and apples both favored the experts. The model can differentiate 'expert' from 'novice', thus establishing 'construct validity'.

CONCLUSION

The new fruit-tissue (apple) based TURP model is a realistic and acceptable TRUP training model with proven face, content and construct validity.

Multitract percutaneous nephrolithotomy in staghorn calculus

Staghorn calculi are branched stones which occupy a majority portion of the pelvicaliceal system. An untreated staghorn calculus over time can damage the kidney and deteriorate its function and/or cause life threatening sepsis. Total stone clearance is an important goal in order to eradicate any infective focus, relieve obstruction, prevent recurrence and preserve the kidney function. Percutaneous nephrolithotomy (PCNL) is currently the accepted first-line treatment option for staghorn calculi. The options available are single-tract PCNL with an auxiliary procedure like shockwave lithotripsy, single-tract PCNL with flexible nephroscopy, or multitract PCNL. Each has its own pros and cons. But the ultimate goal of treatment for any patient with staghorn calculi should be safety, cost-effectiveness, and to achieve total stone clearance. With this article, we review the management of staghorn calculi with multiple percutaneous (“multitract”) access, its advantages and disadvantages and its current position by studying the various published materials across the globe.

Iliac fossa vs Pfannenstiel retrieval incision in laparoscopic donor nephrectomy: A critical analysis

Objective: To compare two retrieval incisions, Pfannenstiel vs iliac fossa incision, in terms of operative technique-related variables and variables related to patient satisfaction postoperatively, in patients undergoing laparoscopic donor nephrectomy (LDN).

Patients and methods: This prospective randomised study was conducted between May 2016 and April 2017. All the voluntary kidney donors aged 18–60 years were randomised into two groups. Group 1, comprised patients undergoing graft retrieval via an iliac fossa incision, and Group 2 comprised those undergoing graft retrieval via a Pfannenstiel incision. Intraoperative assessment of the incision by the surgeon was done using a Likert scale-based questionnaire. Other variables studied were the operative time, retrieval time, warm ischaemia time, and length of incision. Postoperatively, visual analogue scale pain scores, analgesia consumption, and hospital stay were compared. During follow-up cosmetic outcome was compared.

Results: In all, 108 patients were enrolled in the study with 54 patients in each group. The mean operative time was shorter in Pfannenstiel-incision group, at 155.2 vs 171.67 min (P = 0.01). The retrieval incision length was significantly less in the Pfannenstiel arm, at 9.29 vs 9.85 cm (P < 0.001). In the surgeon Likert scale-based questionnaire, the Pfannenstiel incision scored better than the iliac fossa incision for ease of specimen retrieval (P = 0.015), ease of immediate check laparoscopy (P = 0.002), and ease of incision closure (P < 0.001). The Pfannenstiel-incision group required less postoperative analgesia, at a mean (SD) of 7.03 (8.82) vs 15.55 (11.1) mg nalbuphine (P < 0.001). During follow-up the Manchester Scar Scores were lesser in the Pfannenstiel-incision group (P < 0.001).

Conclusion: The Pfannenstiel incision was considered preferable during the critical steps of the LDN and had a smaller retrieval incision, lesser operative time and postoperative analgesia requirement, and better cosmesis than the iliac fossa incision.

Abbreviations: BMI: body mass index; LDN: laparoscopic donor nephrectomy; VAS: visual analogue scale; WIT, warm ischaemia time

Changing trends in the endourological management of urolithiasis in anomalous kidneys

OBJECTIVES

To present our single-centre experience of urolithiasis management in anomalous kidneys, highlighting the need for an algorithm-based approach in deciding the appropriate treatment method for each type.

PATIENTS AND METHODS

We retrospectively reviewed the data of all the patients who presented to our renal unit with urolithiasis in an anomalous kidney between January 1990 and July 2014. The peri-operative characteristics of all the patients, along with management approach, were studied.

RESULTS

Percutaneous nephrolithotomy (PCNL) was the most common surgical technique used, followed by flexible ureterorenoscopy (URS). Pain was the most common presentation in these patients. The overall stone clearance rate associated with PCNL and flexible URS was 85.8% in cases of anomalous kidneys in this series. The stone clearance rates in ectopic kidneys, horseshoe kidneys, malrotated kidneys and autosomal dominant polycystic kidneys associated with PCNL and flexible URS were similar: 86%, 88%, 76% and 83%, respectively, and 81.2%, 80%, 92% and 100%, respectively . Based on our results, we developed a stone management algorithm.

CONCLUSION

The management of renal calculi in patients with renal anomalies may vary based on the stone size, location, density, pelvicalyceal system anatomy and drainage. An algorithm-based approach could help surgeons decide the appropriate treatment in this population.

Vascular injuries during laparoscopic donor nephrectomy and proposed risk reduction strategies

Introduction:

Laparoscopic donor nephrectomy (LDN) has become the standard of care and popular among most of the transplant centres across the globe.

Objective of this video is to report different vascular injuries, their management during LDNs and propose risk reduction strategies.

Patient and methods:

This was a retrospective analysis of all the LDNs performed between January 2011 and March 2016. All donor nephrectomies were performed laparoscopically by transperitoneal route, under ideal operative conditions by expert laparoscopic surgeons and by novice surgeons.

Results:

858 LDNs (left, n = 797; right, n = 61) were performed during the study period with 5 cases of vascular injuries. Mean (SD) donor age was 45.5 (± 10.76) years and the operative time was 165 (± 44.4) min. Of these five cases, two had renal vein injury, while the three others had renal artery, inferior vena cava and aortic injury (one each). Four injuries occurred during left LDN and only one during a right LDN. Vascular injuries were managed using the Rescue stitch or metallic clips as indicated. Risk reduction strategy was developed to avoid vascular injuries during LDN, which include - meticulous attention to port placement, addition of fourth port, complete dissection of upper pole and pedicle before clipping, and judicious use of ultrasonic diathermy.

Conclusions:

Careful evaluation of computed tomography angiography just before surgery will act like a global positioning system (GPS) for the operating surgeon. Rescue stitch is a saviour. Not to panic and being well versed with the risk reduction strategies of laparoscopy and rescue measures is of paramount importance.

Laparoscopic and robotic specimen retrieval system (Modified Nadiad Bag): Validation and cost-effectiveness study model

Aim:

To construct and validate a cost-effective indigenously made retrieval system (Modified Nadiad bag) in minimal access urology.

Method:

The components of the modified Nadiad bag are a polyethylene roll, fishnet thread, and a 5 Fr ureteral catheter. The bag is indigenously made in our institute and used for organ retrieval after proper sterilization. The video recordings of entrapments and retrievals done over the past few months were reviewed. The procedures under review in which the bag was used were: Robot Assisted Radical Prostatectomy (50 cases), laparoscopic radical nephrectomy (50 cases), laparoscopic simple nephrectomy (50 cases) and laparoscopic adrenalectomy (18 cases). We also compared the retrieval time with experts and novices.

Results:

The retrieval times, the organ size (largest dimension) and specimen weight were records for each case. Multivariate analysis of the data was done and we extrapolated the retrieval time with organ size, specimen weight and expertise of the surgeon. There was no significant difference among expert surgeons and novice surgeons with regards to retrieval times (p value = 0.29), with regards to organ size (p value = 0.83) and with regards to specimen weight (p value = 0.99).

Conclusion:

Our design of retrieval system offers a cost-effective option which is easy to make, without the risk of tumor seeding and without the need for separate access sheath. It's a retrieval system which has proved its efficacy in laparoscopic as well as robotic procedures with no bearing on the expertise of the surgeon involved.

Robotic buccal mucosa graft ureteroplasty (inlay and onlay) for upper ureteric stricture: Point of technique

Ureteral stricture resulting from chronic inflammations such as tuberculosis, recurrent stone disease and multiple endourological interventions are complex in nature; these may lead to severe adhesions to surrounding structures. Endourological management of these cases is difficult with poorer outcomes. In such situations, reconstructive surgical corrections remain a reliable option. We describe the technique of onlay and inlay buccal mucosal graft ureteroplasty using a robotic platform in management of complex ureteral strictures.

Face, content, and construct validity of a novel chicken model for laparoscopic ureteric reimplantation

Introduction:

Simulation-based training in laparoscopic urology is essential, as these surgeries require a different skill set. We validated a chicken model for laparoscopic left modified Lich Gregoir type of ureteric reimplantation.

Materials and Methods:

Prospective observational study was conducted from August 2016 till February 2017. Thirty novice surgeons and 20 trained laparoscopic surgeons were included in the study. The relevant chicken anatomy and surgical steps were described to all the surgeons. The surgeons were asked to fill an eight-point questionnaire after finishing the procedure and score it on a scale of 1–5. The trainee's performance was also recorded by an investigator on a proforma. The investigator recorded dissection time, suturing time, quality of dissection, quality of suturing, and integrity of anastomosis on a scale of 1–5.

Results:

All the participants in the study gave a mean score of 3 or more to all the questions asked, except for one question pertaining to tissue feel. Both the groups rated the usefulness of the model very highly with a mean score of 4.20 and 4.15, respectively. Difference in the time taken for dissection and suturing along with the quality of suturing was statistically significant in favor of the expert group.

Conclusions:

The chicken model for laparoscopic left modified Lich Gregoir type of ureteric reimplantation is a useful, effective, cognitive training tool. This model has a face, content, and construct validity to be used as a teaching and learning tool in laparoscopic urology.

Extending indications of micropercutaneous nephrolithotomy: It is not just about cracking stones

Objective

To describe our experience and results of using the MicroPerc™ micropercutaneous nephrolithotomy armamentarium (PolyDiagnost, Germany) for unusual indications unexplored using this modality.

Patients and methods

We used the MicroPerc™ system for stone clearance in three ureteric calculi, two bladder calculi, one case of urethral calculus, for antegrade biopsy in a case of upper tract urothelial carcinoma, for Deflux® (dextranomer/hyaluronic copolymer, Salix Pharmaceuticals, Uppsala, Sweden) injection in three cases of vesico-ureteric reflux (VUR), and three cases of posterior urethral valve (PUV) fulgurations. A 4.85-F ‘All-Seeing Needle®’ (PolyDiagnost) was used in most of the cases. An 8-F mini-micro sheath was used where stability was deemed necessary. Clinical data were collected in a dedicated database. Intraoperative variables, postoperative complications, and outcomes were assessed.

Results

All patients were successfully treated with complete stone clearance at 1 month with no residual fragments. The antegrade biopsy confirmed a high-grade papillary neoplasm. There were no technical difficulties with injection of Deflux or PUV fulgurations. Follow-up at 1 year revealed no stone recurrence, resolved reflux in all three cases, and all the children that had had PUVs were voiding well. The small sample and retrospective nature of the analysis are the limitations of this study.

Conclusion

MicroPerc™, besides its usual use for minimally invasive percutaneous nephrolithotomy, can also be feasibly used for ureteric, bladder and urethral stones, and for treating non-calculus diseases such as PUVs and VUR. True to its name, it may be an ‘All-Seeing Needle’ in reality with much more to offer and harvest from.

Critical appraisal of consecutive 36 cases of post renal transplant lymphocele: a proposed algorithm

INTRODUCTION

Lymphyocele by definition is the collection of lymph that is contained by a pseudomembrane. Management of lymphocele varies from simple aspiration or aspiration with sclerothreapy to more invasive technique, such as internal/external drainage. We present the results of 36 patients who developed pelvic lymphocele after renal transplant.

MATERIALS AND METHODS

A total of 1720 patients underwent living related donor renal allograft transplant at our centre. Of the total 1720 transplants 36 patients developed symptomatic lymphocele and underwent definitive management. Retrospectively analysis of the clinical data of these 36 patients was done.

RESULTS

Thrirt six patients (2.09%) had a clinically significant lymphocele, which needed definitive management. All these patients underwent ultrasound guided drain placement and sclerosant injection. Fifteen out of 36 patients (41.6%) had successful treament with percutaneous drain placement. Laparoscopic marsupialization of lymphocele was done in 21 patients who failed percutaneous drain insertion therapy after diagnostic aspiration. Laparoscopic Marsupilization was successful in 18 out of 21 patients (85.7%). The 3 patients with failed laparoscopic marsupialization were managed with open surgical marsupialization.

CONCLUSION

Significant number of lymphocele post renal transplant may be asymptomatic but still cause deterioration of renal function even without causing obstructive uropathy. Lymphoceles causing renal deterioration or symptoms should be managed in a step ladder fashion starting from percutaneous drainage to laparoscopic marsupilization to open surgical approach. Asymptomatic recurrences post marsupialization are common and should be only closely observed unless they become symptomatic or cause deterioration of renal function. A systematic protocol may help in treating these patients better.

Robot-assisted ureterocalycostomy: A single centre contemporary experience in adults

Objective

To present our technique and experience of robot-assisted ureterocalycostomy (RAUC) in managing secondary pelvi-ureteric junction obstruction (PUJO) in adults.

Patients and methods

We retrospectively reviewed all patients from our centre who underwent RAUC, between 2011 and 2015, for secondary PUJO resulting from previous surgical intervention. Six procedures in five patients, including a bilateral RAUC were performed. The median (range) patient age was 33.7 (18–41) years. The outcome variables included operative time, duration of hospital stay, and objective evidence of unimpeded drainage on urography.

Results

The mean (range) operating time was 172 (144–260) min and estimated blood loss was 100 (50–250) mL. There were no conversions to open or laparoscopic surgery, and no intraoperative complications. Two patients had Clavien–Dindo Grade I complications that were managed conservatively and one patient had a Grade IIIb complication, which required balloon dilatation and re-stenting. After a median (range) follow-up of 11 (7–48) months, five of the six renal units had successful outcomes.

Conclusion

The robot-assisted approach appears to be ideally suited for redo cases demanding fine dissection with meticulous suturing. In our present series of adult patients, we could safely and successfully perform RAUC with minimal morbidity. However, a larger multi-institutional outcome analysis is required to substantiate the role of the robot-assisted approach in performing UC.

Urethral Balloon Dilatation: Factors Affecting Outcomes

Background/Aims/Objectives: The study aims to review our experience with balloon dilatation of urethral strictures and retrospectively analyze predictors of improved success rates.

METHODS

One hundred and forty-four cases were analyzed from January 2011 to December 2012. Patients underwent balloon dilatation using 6-Fr Balloon dilator set (Cook Urological, Spencer, Ind., USA). Patients analyzed with respect to demography, uroflowmetry (Qmax) and need for auxiliary procedures in the immediate postoperative period, at 6 months and at 1 year. Comparisons were made between those who performed self-calibration against those who did not.

RESULTS

Overall success rate of balloon dilatation in our study was 84.4%. Procedural failure was observed with 3 patients (2.1%). Auxiliary procedure was required in 21 cases (15.6%) during follow-up. The mean Qmax (ml/s) in those who regularly performed self-calibration (n = 73) and in those who did not perform self-calibration (n = 39) in the immediate postoperative period, at 6 months and at 1 year were 24.2 ± 10.5, 16.5 ± 7.5, 14.4 ± 6.3 and 21.2 ± 10.6, 14.5 ± 7, 10.8 ± 5.6, respectively. Statistical significance was noted at 1 year (p = 0.003). Lesser re-treatments were required in those who performed self-calibration (12.3 vs. 20.5%). Improved success rates were noted with focal and bulbar strictures. Iatrogenic strictures and pan-anterior urethral strictures had poor outcomes despite self-calibration.

CONCLUSIONS

Balloon dilation with self-calibration significantly improves flow rates at 1 year and lessens auxiliary procedures required. It is simple, easy to perform under local anesthesia and repeatable in case of re-strictures.

Prospective study of preoperative factors predicting intraoperative difficulty during laparoscopic transperitoneal simple nephrectomy

OBJECTIVE

To prospectively study and identify, the preoperative factors which predict intraoperative difficulty in laparoscopic transperitoneal simple nephrectomy.

PATIENTS AND METHOD

Seventy seven patients (41 males and 36 females) with mean age of 43 ± 17 years, undergoing transperitoneal laparoscopic simple nephrectomy at our institute between February 2012 to May 2013 were included in this study. Preoperative patients' characteristics recorded were: Gender of patients, history of intervention, palpable lump, BMI, urine culture, side, size of kidney, fixity of kidney on USG, perinephric fat stranding on preoperative CT scan, periureteral fat stranding, perinephric collection, enlarged hilar lymph nodes, renal vascular anomalies, differential renal function on renogram. Preoperative factors of these patients were noted and intraoperative difficulty in the surgery was scored between 1 (easiest) to 10 (most difficult or open conversion) by a single surgeon (who was a part of all studies either as operating surgeon or assistant). Using SPSS 15.0 software, multivariate and univariate analysis was done.

RESULTS

In multivariate analysis presence of pyonephrosis on preoperative evaluation and BMI < 25kg/m(2) were found to be statistically significant factors predicting intraoperative difficulty during laparoscopic simple nephrectomy. On univariate analysis following factors were associated with increased surgeon's score: Lower BMI, palpable kidney, pyonephrosis, history of renal intervention, perinephric fat stranding, right side, fixity of kidney on USG with surrounding structures.

CONCLUSION

Our findings suggest that presence of pyonephrosis as identified on preoperative imaging and a BMI of less than 25 Kg/m(2) are the most significant factors predicting intraoperative difficulty during laparoscopic simple nephrectomy.

Which is the preferred modality of renal access for a trainee urologist: ultrasonography or fluoroscopy? Results of a prospective randomized trial

BACKGROUND AND PURPOSE

In percutaneous nephrolithotomy (PCNL), placement of the access tract into the kidney is an important aspect of the procedure and is responsible for the steep learning curve associated with the operation. The aim of the current prospective randomized trial was to assess the duration of radiation exposure along with the safety and efficacy of PCNL done by a trainee, utilizing either ultrasonography (US) or fluoroscopic guidance to obtain access.

PATIENTS AND METHODS

Sixty-four patients with ≤3 cm renal calculi undergoing single-tract PCNL by trainee urologists (experience of <25 PCNL's) were randomized into US- and fluoroscopic-guided access groups (32 in each). In Group 1 (US guided), puncture was done using a 3.5/5 MHz US probe with a puncture attachment, whereas the triangulation technique with biplanar C-arm fluoroscopy was utilized in group 2 (fluoroscopic guided). Patient demographics, stone parameters, intraoperative characteristics, fluoroscopy durations, and postoperative outcomes were analyzed.

RESULTS

Both groups were comparable as far as patient and stone characteristics were concerned. The fluoroscopy exposure during the puncture phase (T2) and overall (T) was significantly lower in the US group at 9.0±20.8 vs 43.8±34.8, (p<0.0001) and 204.3±84 vs 239.9±77.5, (p=0.04). Six patients in group1 required fluoroscopic adjustment (p=0.03). All other intra- and postoperative parameters were similar in both the groups.

CONCLUSION

Both ultrasound and fluoroscopic guidance for renal access are equally safe and feasible in the hands of a trainee urologist. Total fluoroscopy duration and exposure time during puncture were both significantly less in the ultrasound group. Expertise in fluoroscopic-guided access is essential for a novice to effectively achieve access in all possible situations.

Robotic-assisted laparoscopic partial nephrectomy: A single centre Indian experience

BACKGROUND:

We summarise our experience with RPN emphasising on learning curve, techniques and outcomes.

PATIENTS AND METHODS:

A retrospective chart review of 57 patients was done. The preoperative workup included a triple phase CT angiography. The parameters analyzed were demographics, tumor characteristics, operative details, postoperative outcome, histopathology and follow-up. The data were compared with historical cohort of the laparoscopic partial nephrectomy (LPN).

RESULTS:

58 renal units in 57 patients (45 males and 12 females) underwent RPN. The mean age was 53.08 ± 13.6 (30-71) years. The mean tumor size was 4.96 ± 2.33 (2-15.5) cm. Average operative time was 129.4 ± 29.9 (70-200) min.; mean warm ischemia time was 20.9 ± 7.34 (9-39) min. 8 renal units in 7 patients were operated with the zero ischemia technique. The average follow-up was 5.15 months (1-18). There was no recurrence. 15 patients underwent LPN. The mean tumor size was 4.3 ± 1.6 (1.6-8) cm. operative time was 230.7 ± 114.8 (150-300) min.; mean warm ischemia time was 31.8 ± 9 min. The nephromerty score in the LPN group was 7.1 ± 0.89, in the RPN group was 8.75 ± 1.21.

CONCLUSION:

Our results suggest that prior experience of LPN shortens the learning curve for RPN as seen by shorter warm ischemia time and operative time in our series. The nephrometry score in RPN were higher suggesting that complex tumour can be managed with robotic approach.

Complete Transperitoneal Laparoscopic Nephroureterectomy in Circumcaval Ureter with Upper Tract TCC: Initial Case Report

Transitional-cell carcinoma (TCC) of the upper tract in a case of circumcaval ureter (CCU) is a rare entity. Laparoscopic transperitoneal nephroureterectomy in such case represents a unique challenge in the era of minimally invasive surgery. We report a case of complete transperitoneal laparoscopic nephroureterectomy with bladder cuff excision done for TCC in a case of CCU. This case report describes the first point of technique of the procedure done for this rare entity. A 38-year-old male patient underwent the procedure for high-grade TCC of right lower calix. The essential tenets of the procedure included performance of the technique in a manner contrary to the conventional nephroureterectomy. The case report describes the procedure in the following steps: management of lower ureter and bladder cuff followed upper tract procedure after transposition of bladder cuff posterior to inferior vena cava. The procedure was accomplished utilizing four ports and a 6 cm Pfannenstiel incision with operative time of 220 minutes and blood loss of 50 mL.

ROLE OF MICROPERC IN MINIMAL INVASIVE EXTRACTION OF Renal STONES IN CHILDREN

BACKGROUND

Microperc using all-seeing needle is associated with reduced tract-related morbidity.

AIM & OBJECTIVES

The purpose of this study was to examine the effectiveness and safety of microperc in children.

PATIENTS & METHODS

From July 2010 to August 2014, a total of 17 children with renal stones underwent microperc at Muljibhai Patel Urological Hospital, Nadiad, India. Renal access was achieved through 4.85-Fr (16 gauge) all-seeing needle (PolyDiagnost, Pfaffenhofen, Germany). and fragmentation with 200 µm holmium:YAG laser fiber. The patient's demographic data, clinical features, operating time, hemoglobin drop, stone clearance, complications (Clavien-Dindo), and length of hospital stay were prospectively studied.

RESULTS

A total of 17 patients with a median age of 9 years were studied. The stone size ranged from 5.3mm to 24.9mm. The median operative time was 40 minutes. The median decrease in haemoglobin was 1.2 mg/dl. The stone-free rate at first postoperative day and at the first month after the procedure were 82.4% and 88.2% respectively. The mean hospital stay was 56.4 hours. None of the patients required blood transfusion. An overall success rate of 94.1% was achieved at median follow-up of 4 months. Comparing small size stones (< 1cm) and moderate size stone (1-3cm); the immediate clearance rates were 100% and 75% respectively (p=0.331). There was no statistically significant difference in the operating time (40 vs 43mins; p=0.592), haemoglobin drop (0.85 vs 1.25 g/dl; p=0.595) and the length of hospital stay. One patient in each group had conversion to miniperc to remove residual stone fragment. There was one minor intra-operative pelvic perforation (Clavien II). There were two postoperative complications in patients with moderate stone; one of the patients had right lower lobar pneumonia and the other had colic pain and both cases were managed conservatively (Clavien I).

CONCLUSION

This study has demonstrated that microperc is a safe and effective procedure in the extraction of small to medium size renal stones in children.

Congenital duplication of the urethra with urethral diverticulum: a case report

Duplication of the urethra is a rare congenital anomaly. Urethral duplication with the presence of diverticulum is a rare combination and to the best of our knowledge has  not been previously reported. We report a case of a 16 month old male child with duplication of the urethra and diverticulum arising from the ventral urethra. We also cover the intricacies and challenges in the management of such a case.The opening of the narrowed accessory dorsal urethra at the verumontanum was cauterized and gradually the dorsal urethra became atrophied. The ventral urethral diverticulum was excised. This case is unique due to:The unusual presentation of swelling over the dorsum of the penis, together with duplication of the urethra with diverticulum.The use of cauterization as a treatment modality. Cauterization of the ventral urethra with a Bugbee electrode and diverticulectomy was performed. A glidewire helped in identifying the small opening of the dorsal urethra at the level of the verumontanum. The case also highlights the importance of endoscopic management of this clinical entity.

Staghorn classification: Platform for morphometry assessment

Introduction:

The majority of staghorn classifications do not incorporate volumetric stone burden assessment. Accurate volumetric data can easily be acquired with the ever-increasingly available computerized tomography (CT) scan. This manuscript reviews the available staghorn stone classifications and rationalizes the morphometry-based classification.

Materials and Methods:

A Pubmed search was performed for articles concerning staghorn classification and morphometry. Twenty abstracts were shortlisted from a total of 43 published abstracts. In view of the paucity of manuscripts on staghorn morphometry (4), older staghorn classifications were analyzed with the aim to determine the most optimum one having relevance to the percutaneous nephrolithotomy (PCNL) monotherapy outcome.

Results:

All available staghorn classifications are limited with non-widespread applicability. The traditional partial and complete staghorn are limited due to non-descript stone volumetric data and considerable overlap of the intermediate ones in either group. A lack of standardized definition limits intergroup comparison as well. Staghorn morphometry is a recent addition to the clinical classification profiling of a staghorn calculus. It comprises extensive CT volumetric stone distribution assessment of a staghorn in a given pelvi–calyceal anatomy. It allowsmeaningful clinical classification of staghorn stones from a contemporary PCNL monotherapy perspective.

Conclusions:

Morphometry-based classification affords clinically relevant nomenclature in predicting the outcome of PCNL for staghorn stones. Further research is required to reduce the complexity associated with measuring the volumetric stone distribution in a given calyceal system.

Transrectal ultrasound-guided aspiration in the management of prostatic abscess: A single-center experience

Objectives:

The safety and efficacy of transrectal ultrasound (TRUS) guided aspiration of prostatic abscess (PA) is known. The objective of this study is to describe a treatment algorithm for management of PA with TRUS-guided aspiration, emphasizing on indications and factors predicting the treatment outcome.

Materials and Methods:

After the institutional review board approval was obtained, a retrospective study was done of all patients suspected with PA on digital rectal examination (DRE) and confirmed on TRUS. An 18-gauge two-part needle was used for aspiration. The real-time TRUS-guided aspiration of PA was done in the longitudinal axis. The aspiration of pus and the sequential collapse of cavity was seen “real time.” A suprapubic catheter was placed, if the patient had urinary retention, persistent dysuria, and/or severe lower urinary tract symptoms (LUTS). Success was defined as complete resolution of the abscess and/or symptoms.

Results:

Forty-eight patients were studied with PA, with a mean age of 54.6 ± 14.6 (range 26-79) years. The DRE diagnosed PA in 22 (45.83%) patients, while abdominal sonography diagnosed PA in 13 (27.08%) patients. TRUS revealed a hypoechoic area with internal echoes in all 48 (100%) patients. The diagnosis was confirmed in all 48 cases with aspiration. The mean size of the lesion was 3.2 ± 1.2 (range 1.5-8) cm. Mean volume aspirated was 10.2 ml (range 2.5-30 ml). Complete resolution after first aspiration was observed in 20 (41.66%) patients. An average of 4.1 (range 1-7) aspirations was required for complete resolution which was seen in 41 patients (85.42%). Seven (14.58%) patients required transurethral resection (deroofing) of the abscess cavity. We formulated a treatment algorithm based on the above findings.

Conclusion:

The proposed algorithm based on our experience suggests that patients with PA larger than 2 cm with severe LUTS and/or leukocytosis benefit from TRUS-guided aspiration. In addition, these patients are benefitted from urinary drainage (either perurethral or suprapubic). The algorithm also suggests that if two attempts of TRUS aspiration fail, these patients benefit from transurethral drainage.

Balloon dilatation for male urethral strictures "revisited"

Aims:

To analyze the results of balloon dilatation for short segment male urethral strictures.

Materials and Methods:

Retrospective analysis was done of 120 patients undergoing urethral balloon dilatation since January 2004 to January 2012. The inclusion criteria for analysis was a short segment (less than 1.5 cm) stricture, exclusion criteria were pediatric, long (more than 1.5 cm), traumatic, malignant strictures. The parameters analyzed included presentation of patients, ascending urethrogram (AUG) and descending urethrogram findings, pre- and postoperative International prostate symptoms score (IPSS), uroflowmetry (Q_max), and post-void residue (PVR). Need for self calibration/ancillary procedures were assessed. Failure was defined as requirement for a subsequent endoscopic or open surgery. A urethral balloon catheter (Cook Urological, Spencer, Indiana) is passed over a guide wire after on table AUG and inflated till 180 psi for 5 minutes under fluoroscopy till waist disappears. Dilatation is followed by insertion of a Foley catheter. Patients were followed up at 1, 3, and 6 months.

Results:

Mean age was 49.86 years. Mean follow-up was 6 (2–60) months. IPSS improved from 21.6 preoperative to 5.6 postoperatively. Q_max increased from 5.7 to 19.1 and PVR decreased from 90.2 to 28.8 (P < 0.0001*) postoperatively. At 1, 3, and at 6 monthly follow-up, 69.2% (n = 82) patients were asymptomatic.

Conclusions:

Balloon dilation is a safe, well-tolerated procedure with minimal complications. Further randomized studies comparing balloon dilatation with direct internal visual urethrotomy are warranted.

Role of multi-detector computed tomography (MDCT) in management of post percutaneous nephrolithotomy (PCNL) bleeding

Objective: To evaluate the role of multidetector computerized tomography (MDCT) angiography in post percutaneous nephrolithotomy (PCNL) bleed and compare findings with conventional angiography (CA).

Material and methods: We conducted a retrospective analysis of patients who had post PCNL bleeding and subsequently underwent a MDCT angiography followed by CA. We reviewed eight patients, who presented between January 2009 and January 2013. We performed a MDCT angiography on a 16 slice GE bright speed CT scanner. All angiographies were done by using the Digital Subtraction Angiography Suite. The angioembolisation, if required, was conducted by an interventional nephrologist, specializing in therapeutic embolisation.

Results: The mean age of the patients was 42±17 years. Mean time of post PCNL bleed presentation was 10.06±7.9 days. Five patients presented with aneurysm and three presented with an AV fistula with pseudoaneurysm. The right renal unit was involved in six cases and the left in two cases. The lower polar segmental artery was involved in six cases and the upper polar artery in two cases. The CA and MDCT findings matched in all cases and the MDCT helped the clinician to assess and embolise the appropriate arterial tree.

Conclusion: MDCT is rapid, reproducible and noninvasive. MDCT angiography performed in the setting of post PCNL bleeding provides an accurate assessment of the site and nature of bleeding. The MDCT angiography matched the CA findings in all patients in the present study.

Microperc for the management of renal calculi in pelvic ectopic kidneys

Management of stone disease in an ectopic kidney is challenging. Laparoscopy or ultrasound guided percutaneous nephrolithotomy and retrograde intra-renal surgery are the preferred techniques for these stones. We performed ultrasound guided microperc using a 16 G needle for the management of renal calculi in pelvic ectopic kidneys in two patients. There was no intraoperative or post-operative complication. Both patients had complete stone clearance and were discharged on the first post-operative day. Ultrasound guided microperc is a safe and effective option for the management of small renal calculi in pelvic ectopic kidneys.

Management of nephrolithiasis in autosomal dominant polycystic kidney disease - A single center experience

PURPOSE

To evaluate available options for the management of nephrolithiasis in patients with autosomal dominant polycystic kidney disease (ADPKD).

MATERIALS AND METHODS

Case files of all the patients with ADPKD treated in our hospital in the last 18 years were evaluated. Their demographic details, clinical presentations, investigations, treatments, and outcomes were critically analyzed.

RESULTS

There were a total of 19 patients (23 renal units) with nephrolithiasis among 452 consecutive cases of ADPKD. Male-to-female ratio was 3.75:1. The mean age of the patients was 43.3 years (range 23 to 60 years). The most common presentations were pain and hematuria (27.7% each). Mean serum creatinine was 7.2 mg/ dl (range 0.8-18.1 mg/dl) at presentation. The mean stone size was 115 mm(2) (range 36 to 980 mm(2)). The majority of the stones were calyceal (n = 10). Ten renal units (nine patients) required intervention, while the rest were treated conservatively. Treatment offered included open nephrectomy for non-functioning infected kidney (n = 1), extracorporeal shock wave lithotripsy (ESWL, n = 3), ureterorenoscopy (URS, n = 3), and percutaneous nephrolithotomy (PCNL, n = 3). All patients undergoing URS and PCNL had complete clearance, while those undergoing ESWL had a residual stone. Two failed ESWL patients required an auxiliary procedure (retrograde intrarenal surgery, RIRS) and the other was kept under observation. Mean follow-up after treatment was 4.2 years (one month to six years). None of the patients had major complications.

CONCLUSION

Careful selection of the endourological procedure can give good results in patients of ADPKD with nephrolithiasis.

What's new in percutaneous nephrolithotomy

INTRODUCTION

The goal of percutaneous nephrolithotomy (PCNL) is to ensure complete stone clearance with minimal morbidity. The key to complete clearance is accurate technique, expertise and instrumentation.

METHODS

We systematically reviewed available reports that were identified using a PubMed/Medline search. The keywords used were 'PCNL' and 'advances in PCNL'. The findings were reviewed under the topics of newer developments in imaging, techniques and a review of outcomes with an emphasis on stone clearance and complications.

CONCLUSION

The newer developments in imaging methods, such as cone-beam computed tomography and staghorn morphometry, help the surgeon to plan the procedure for a safe and better outcome. The highlight of these newer developments is the miniaturisation of instruments. This has translated into developing newer techniques such as the 'microperc' and 'miniperc'. The data-collection initiative by the Clinical Research Office of the Endourological Society has helped in obtaining a high level of evidence.

Comparative performance of high-fidelity training models for flexible ureteroscopy: Are all models effective?

Objective:

We performed a comparative study of high-fidelity training models for flexible ureteroscopy (URS). Our objective was to determine whether high-fidelity non-virtual reality (VR) models are as effective as the VR model in teaching flexible URS skills.

Materials and Methods:

Twenty-one trained urologists without clinical experience of flexible URS underwent dry lab simulation practice. After a warm-up period of 2 h, tasks were performed on a high-fidelity non-VR (Uro-scopic Trainer™; Endo-Urologie-Modell™) and a high-fidelity VR model (URO Mentor™). The participants were divided equally into three batches with rotation on each of the three stations for 30 min. Performance of the trainees was evaluated by an expert ureteroscopist using pass rating and global rating score (GRS). The participants rated a face validity questionnaire at the end of each session.

Results:

The GRS improved statistically at evaluation performed after second rotation (P<0.001 for batches 1, 2 and 3). Pass ratings also improved significantly for all training models when the third and first rotations were compared (P<0.05). The batch that was trained on the VR-based model had more improvement on pass ratings on second rotation but could not achieve statistical significance. Most of the realistic domains were higher for a VR model as compared with the non-VR model, except the realism of the flexible endoscope.

Conclusions:

All the models used for training flexible URS were effective in increasing the GRS and pass ratings irrespective of the VR status.

Ultrasound-guided antegrade access during laparoscopic pyeloplasty in infants less than one year of age: A point of technique

BACKGROUND

Access to urethras and ureters of infants may be hazardous and injurious through an endoscopic route. Placement and removal of stents in infants requires anaesthesia and access through these small caliber urethras. We describe our technique of placing antegrade splint during a laparoscopic pyeloplasty in these infants.

MATERIALS AND METHODS

An ultrasound-guided percutaneous renal access is obtained. Telescopic metal two part needle is passed into the kidney over a guide wire. A second guide wire is passed through the telescopic metal two part needle. The tract is dilated with 14 Fr screw dilator. Over one guide wire, a 5 Fr ureteric catheter is passed and coiled in the renal pelvis. Over the other wire, a 14 Fr malecot catheter is placed as nephrostomy. Laparoscopic pyeloplasty is then done. During pyelotomy, the ureteric catheter is pulled and advanced through the ureter before the pyeloplasty is completed. The ureteric catheter thus acts as a splint across the anastomosis. Ureteric catheter is removed on the 3(rd) post operative day and nephrostomy is clamped. Nephrostomy is removed on 4(th) post operative day if child is asymptomatic. The modified technique was successfully done in five patients aged less than one year old. All patients tolerated the procedure well. Post operative period was uneventful in all.

CONCLUSION

Ultrasound-guided ante grade nephroureteral ureteral splint for infant laparoscopic pyeloplasty is safe. It avoids the need for urethral instrumentation for insertion and removal of stents in these small patients.