Robotic reconstruction of necrosed ileal ureter: Technical challenges, intra-operative difficulty, and learning points.

This video explores the challenges faced during a re-do robotic intra-corporeal ileal ureter reconstruction in a previously operated case. A 24-year-old woman presented with a 12-cm long stricture after robotic ileal ureter replacement surgery. A proper preoperative evaluation in the form of ureteroscopy and a nephrostogram is essential and the key steps include adhesiolysis, identification of the necrotic ileal ureter, and meticulous dissection. A 13-cm long segment of the ileum was isolated and was anastomosed to the renal pelvis and the bladder. The surgery lasted for 420 min with 300 ml of blood loss. Post-operatively, the patient recovered well and had a normal drainage with no complications at 1-year of follow-up. The factors such as a broad mesentery, a tension-free anastomosis, and avoiding the twisting of the pedicle are crucial for success of robotic ileal ureter replacement surgery.

Bacteriuria due to Typhoidal and Nontyphoidal Salmonella: A Report of Three Cases from South India.

Urinary tract infection (UTI) with Salmonella is uncommon, accounting for merely 0.01% to 0.1% of cases of UTIs. It is reported more frequently in the presence of predisposing factors such as structural abnormalities of the urinary tract or weakened immune system. We present a case series of three patients with Salmonella bacteriuria and their susceptibility patterns. All three patients had underlying urologic features such as neurogenic bladder, chronic kidney disease, and urethral stricture, and two presented with urinary tract involvement symptoms.

Robot-assisted complex urinary tract reconstruction using intestinal segments: redefining the paradigm.

Complex urinary tract reconstruction has significantly advanced with the increasing use of robot-assisted procedures. Robotic surgery aims to achieve the same outcomes as open surgery while minimizing morbidity by causing less blood loss, faster postoperative recovery, and reducing complications. This article shares our technique, challenges encountered, and experience of robot-assisted complex urinary tract reconstruction using intestinal segments. Between January 2020 to March 2022, 6 patients who underwent robot-assisted complex urinary tract reconstruction using intestinal segments at our centre were retrospectively reviewed. Demographic, clinical, and operative data were recorded. Patients underwent renal function tests, blood gas analysis, and radiographic imaging in the follow-up. Symptomatic and radiologic relief were the criteria for success. Out of 6 cases, three patients underwent ileal ureter replacement, two combined ileal ureter with augmentation ileo-cystoplasty and one augmentation ileo-cystoplasty alone. The mean age, estimated blood loss, length of hospital stay, and follow-up period were 32.6 years, 110 ± 13.1 mL, 7.0 ± 1.1 days, and 11.3 months, respectively. The indications for surgery were either benign ureteral stricture following lithotripsy or sequelae of genitourinary tuberculosis. No intra-operative complications were found. Clavien-Dindo grade-II and Grade-IIIa were found in three and one patient, respectively. During follow-up, none had compromised renal function or acidosis. Robot-assisted complex urinary tract reconstruction using intestinal segments is safe and offers the advantages of minimally invasive techniques. Techniques demonstrated in this article make these reconstructions feasible with good surgical and clinical outcomes.

Clinical and videourodynamic study characteristics in female primary bladder neck obstruction and outcomes of bladder neck resection: A tertiary care center experience in India.

Introduction: Video urodynamic study (VUDS) with clinical correlation helps in diagnosing primary bladder neck obstruction (PBNO) in women. Bladder neck incision/bladder neck resection (BNR) though effective is not commonly practiced for the fear of complications and limited literature available. Methods: The records of ten women diagnosed with PBNO between 2017 and 2019 were reviewed and data pertaining to their clinical features, laboratory results, findings on abdominal ultrasonography, uroflowmetry, and VUDS was noted. Type of operative procedure performed and outcomes on follow-up were also assessed. Results: Out of ten patients, two presented with lower urinary tract symptoms (LUTS), three with voiding LUTS and chronic retention and five had acute urinary retention. Mean serum creatinine was 3.4 mg/dl. In those able to void, mean maximum flow rate (Q max) was 7 ml/sec, and mean postvoid residual volume (PVR) was 360 ml. On VUDS, mean detrusor pressure at maximum flow (pdet@Qmax) was 54.2 cm of H20. Three patients opted conservative treatment and 7 had a successful surgical outcome with mean Q max of 26.2 ml/s (range: 13.9-41 ml/s), insignificant PVR and resolution of renal failure. Patients with pdet@Qmax <20 cm H2O (n = 3, mean 18.3 cm H2O) did equally well as compared to those with pdet@Qmax >20 cm H2O (n = 4, mean 93 cm H2O). None of the patients developed any complications on follow-up. Conclusions: Clinical assessment supported with VUDS correlation holds a key in identifying patients with PBNO. BNR is a safe and effective treatment of PBNO in women who fail or are not candidates for conservative treatment.

Study of ureteral and renal morphometry on the outcome of ureterorenoscopic lithotripsy: The critical role of maximum ureteral wall thickness at the site of ureteral stone impaction.

PURPOSE: The purpose is to study the association of stone, ureteral, and renal morphometric parameters with the relevant outcome variables, i.e., complication rate, stone-free rate (SFR), and operating time of ureterorenoscopic lithotripsy. Although a safe procedure, it still occasionally has major complications. Computed tomography (CT) scan is often performed to diagnose ureteral calculi, providing opportunities for ureteral morphometry that may have a bearing on the outcome of the procedure. MATERIALS AND METHODS: Ureteric, renal, and stone morphometric parameters were measured from CT of the abdomen and pelvis of the 110 patients with ureteral calculi who underwent ureteroscopic lithotripsy (URSL). Data were collected retrospectively in 25 patients and prospectively in 85 patients. Association of these parameters with the outcome variables of the procedure mentioned above was studied. RESULTS: On univariate analysis, body mass index, stone size, and maximum ureteral wall thickness (MUWT) were found to have a significant association with URSL complications, SFR, and duration of surgery. On multivariable analysis, only MUWT was found to be an independent risk factor for URSL complications. In 90% of total patients with residual stones, MUWT was found to be >4.8 mm. CONCLUSION: Ureteral wall thickness of >4.8 mm is associated with prolonged duration of surgery and lower SFR. Patients with ureteral wall thickness of >4.8 mm at the site of ureteral stone who are planned for URSL must be counseled about the higher chances of residual stones and the need for additional procedure.

Eosinophilic Leukemoid Reaction with Eosinophilic Tumor Tissue Infiltration as an Extermely Poor Prognostic Factor in Urinary Bladder Cancer- a Known Entity Revisited.

Eosinophilia can be a manifestation of a variety of causes such as infections, allergic reactions and autoimmune processes. Also, it is described in various solid malignancies in the presence of tumour eosinophilic infiltration. We report a patient of high-grade urinary bladder cancer with eosinophilic leukemoid reaction and tumour histopathology demonstrated diffuse infiltration of eosinophils. Though the entity is described to carry a good prognosis in literature, our experience is totally different as the patient deteriorated rapidly in a matter of days, was deemed inoperable in view of worsening performance status and was referred for palliative management.

Prospective audit of complications after ultrasonography-guided percutaneous nephrostomy for upper urinary tract obstruction using modified Clavien classification system.

INTRODUCTION: Percutaneous nephrostomy (PCN) is a commonly performed intervention in urology for various benign and malignant conditions causing upper urinary tract obstruction. We present a prospective audit of complications of ultrasonography (USG) guided PCN using modified Clavien classification system (mCCS). METHODS: The data were prospectively collected for 368 PCN performed in 344 patients from June 2015 to January 2017, for various benign and malignant diseases causing upper urinary tract obstruction. Patients were followed for 1 month, and complications arisen of PCN were noted. RESULTS: PCN was successful in 356 renal units. The 12 patients in which PCN failed was due to minimal pelvicalyceal dilatation and PCN was successfully performed after 48 h by a senior urologist. 207 patients had malignant disease and 161 patients had benign condition. Most common malignant disease was carcinoma cervix. 238 were noninfected while 130 had infected renal units. 62 (16.84%) patients had Grade I (self-limiting hematuria/cot/debris/fever). 37 (10.0%) patients had Grade II (7 - transfusion and 30 - urinary tract infection). 34 (9.2%) had Grade III a (repositioning/change/reinsertion of PCN tube under local anesthesia) and 4 (1.1%) had Grade III b (repositioning under anesthesia). 8 (2.2%) Grade IV a (Sepsis), 0 Grade IV b, and 0 Grade V complications were observed. CONCLUSION: USG-guided PCN is a safe, minimally invasive, and effective procedure for upper urinary tract diversion with a low rate of morbidity. Individual complications are within the threshold limits set by the American College of Radiology, the Society of Interventional Radiology. mCCS is well applicable and easily reproducible tool for reporting the complications of PCN.