Efficacy and Safety of Percutaneous Nephrolithotomy in Patients with Chronic Kidney Disease: Outcomes from a Tertiary Care Center.

Background: The management of renal stone disease in the presence of chronic kidney disease (CKD) is a challenging scenario, both in terms of surgical safety and perioperative outcomes. The aim of the present study is to study the efficacy, safety, and outcomes of percutaneous nephrolithotomy (PCNL) in patients with CKD. Materials and Methods: A prospective study was conducted including adult patients with renal stone disease and a creatinine clearance of <90 mL/min (Stage 2 CKD or more) who underwent PCNL. Pre- and postoperative serum creatinine and glomerular filtration rates (GFRs) were compared. Patients were divided into CKD Stages 1 to 5 having creatinine clearance >90 mL/min, 60 to 90 mL/min, 30 to 60 mL/min, 15 to 30 mL/min, and <15 mL/min, respectively. Based on up migration or down migration of CKD stages, patients were classified as improved, deteriorated, or stable. Perioperative complications and outcomes were also compared. Results: A total of 185 patients with CKD Stage ≤2 underwent PCNL. The mean age of the patients was 43.24 ± 14.32 years. The mean preoperative estimated glomerular filtration rate (eGFR) was 62.88 ± 23.42 mL/min/1.73 m2. Preoperative CKD stage distribution was as follows: Stage 2 to 121 (65.4%), Stage 3 to 34 (18.4%), Stage 4 to 24 (13%), and Stage 5 to 6 (3.2%). On last follow-up of patients, the mean creatinine was 1.07 ± 0.65 mg/dL and the mean eGFR was 82.75 ± 31.22 mL/min/1.73 m2. The median change in creatinine and mean change in GFR were 0.23 (0.16-0.27) g/dL and 19.87 ± 19.77 mL/min/1.73 m2, respectively. Improvement in kidney function with a stage down migration was seen in 115 cases (62.2%), slight improvement with no change in stage in 69 cases (37.3%), and deterioration of CKD stage was present in one case (0.5%). Conclusion: PCNL is associated with favorable functional outcomes in CKD patients including severe CKD (Stages 4 and 5). Improvement or stabilization of CKD stage was seen in 99.5% of patients post-PCNL.

Robot-Assisted Laparoscopic Approach in a Patient of Zinner Syndrome with Hematuria: A Rare Presentation.

Congenital malformations of the seminal vesicles (SVs) are rare and are often associated with abnormalities of the ipsilateral upper tracts as embryologically both the ureteral buds and SVs arise from the mesonephric ducts. The triad of SV cysts, ipsilateral renal agenesis, and ejaculatory duct obstruction is known as the Zinner syndrome. We herein present the case of Zinner syndrome with hematuria as the mode of presentation. A 52-year-old gentleman presented with complaints of gross and painless hematuria for 3 months. An initial ultrasound revealed absent right kidney with a cystic structure abutting the urinary bladder. Cystoscopic examination revealed a high bladder neck. Magnetic resonance imaging of the abdomen revealed an absent right kidney and a large tubular structure in the region of the right ureter extending up to right SV with blood content and stones within. It was distally seen communicating with one of the cysts of the right SV. The cystic structure was removed with a robot-assisted laparoscopic approach. The console time was 110 min with minimal blood loss. Postoperative course was uneventful. Histopathology of the cyst wall revealed chronic inflammation. The patient is doing well on 6 months follow-up. This case was unique in terms of it presenting with a large intra-abdominal cyst with sharp stones within, probably first of its kind to be ever reported. Surgery is mandated for such symptomatic cysts and the daVinci robot with its minimally invasive approach offers the perfect platform for treating such challenging cases.

Ganglioneuroma presenting as an adrenal incidentaloma: Feasibility of adrenal-sparing surgery.

Adrenal ganglioneuromas (GNs) are very rare tumours that originate from neural crest cells. Most of the time, they are diagnosed incidentally as they are usually non-functional and remain asymptomatic. Nowadays, they are being detected more often due to better availability of imaging facilities such as computed tomography (CT)/magnetic resonance imaging (MRI). Minimally invasive adrenalectomy (laparoscopic or robotic) remains the standard of care for such lesions. Hereby, we report a case of a 15-year-old young girl with right adrenal incidentaloma which was diagnosed on CT with the features suggestive of GN. She underwent robot-assisted excision of the mass with adrenal-sparing surgery. Histopathology revealed benign GN and no adjuvant treatment was required. As GN is not known for recurrence or metastasis, minimal invasive adrenal-sparing surgery should be a preferred modality of choice.

Subcapsular Renal Hematoma Following Ureteroscopic Lithotripsy: An Uncommon Complication of a Common Procedure-A Report of Two Cases.

Objective: To highlight the unusual complication of subcapsular renal hematoma (SRH) after a seemingly simple ureteroscopic lithotripsy (URSL), to try and identify the predisposing factors that lead to this complication, and steps that can be taken to further decrease the incidence of this rare but potential life-threatening complication. Methods: We highlight two cases of obstructed ureteral stones with upstream hydronephrosis who presented with colicky pain. Both underwent URSL with 8F/9.8F semirigid ureteroscope and were found to have postprocedure SRH. Results: Both our patients were managed conservatively with culture-directed intravenous antibiotics. One patient needed intervention in the form of aspiration of the hematoma. Follow-up ultrasound revealed complete resolution of the hematoma in both the cases and are doing fine on follow-up. Conclusion: Various risk factors have been identified, which predispose an individual to this complication and all endourologists must take certain precautionary measures such as decreased operative time and perfusion pressures, treating urinary tract infections and preoperative optimization of hypertension, diabetes, and chronic kidney disease (CKD) to further decrease the incidence of SRH. Management is conservative in majority of cases with percutaneous drainage and antibiotics, with surgery being reserved for hemodynamically unstable patients.

Source apportionment and health risk assessment of airborne particulates over central Indo-Gangetic Plain.

Sources of airborne particulates (PM10) were investigated in two contrasting sites over central Indo-Gangetic Plain (IGP), one representing a rural background (Mirzapur) and another as an urban pollution hotspot (Varanasi). Very high PM10 concentration was noted both in Varanasi (178 ± 105 µgm-3; N:435) and Mirzapur (131 ± 56 µgm-3; N:169) with 72% and 62% of monitoring days exceeded the national air quality standard, respectively. Particulate-bound elements contribute significant proportion of PM10 mass (15%-18%), with highest contribution from Ca (7%-10%) and Fe (2%-3%). Besides, presence of Zn (1%-3%), K (1%-2%) and Na (1%-2%) was also noted. Water-soluble ionic species contributed 15%-19% of particulate mass, primarily by the secondary inorganic aerosols (SIA). Among the SIA, sulphate (5%-7%) and nitrate (4%) were prominent, contributing 59%-62% of the total ionic load, especially in winter. Particulate-bound metallic species and ions were selectively used as signatory molecules and source apportionment of PM10 was done by multivariate factor analysis. UNMIX was able to extract particulate sources in both the locations and crustal resuspensions (dust/-soil) were identified as the dominant source contributing 57%-63% of PM10 mass. Secondary aerosols were the second important source (17%-23%), followed by emissions from biomass/-refuse burning (10-19%). Transport of airborne particulates from upper IGP by prevailing westerly were identified as the important contributor of particulates, especially during high particulate loading days. Health risks associated to particulate-bound toxic metal exposure were also assessed. Non-carcinogenic health risk was within the permissible limit while there is possibility of elevated risk for PM10-bound Cr and Cd, if adequate control measures are not in place.

Scrotal abscess consequent on syphilitic epididymo-orchitis.

Syphilis is notorious and a great imitator of all diseases. It is a chronic bacterial infection, caused by the sexually transmitted spirochete, Treponema pallidum. Though it has drastically reduced in prevalence, its recent resurgence (especially with HIV disease) is worrying. Without treatment, the disease can progress over years through a series of clinical stages and lead to irreversible neurological or cardiovascular complications. The disease may occur in any organ, including the testis, and is commonly mistaken for malignancy. We report a case of scrotal abscess consequent on epididymo-orchitis, confirmed by histopathological examination to be syphilitic in origin, in an immunocompromised HIV-positive patient.