Robot-assisted Foley Tie Ureteric Tapering and Reimplantation.

Objective: This study aimed to introduce and evaluate the feasibility and outcomes of a novel surgical technique, robot-assisted Foley tie ureteric tapering (RAFUT) and reimplantation, specifically designed for intravesical ureteral tapering during pediatric robotic-assisted ureteric reimplantation. Materials and Methods: A retrospective analysis was conducted on pediatric patients diagnosed with primary vesicoureteric reflux (VUR), who underwent RAFUT between January 2019 and July 2021. Patient records were reviewed to assess preoperative characteristics, operative details, and postoperative outcomes. RAFUT involved meticulous patient positioning, precise port placement with a 6 mm separation, and bladder anchoring to maintain pneumovesicum. Ureteric tapering was performed with the Foley tie technique to enhance surgical precision. The primary outcome measures included operative time, complications, and postoperative VUR resolution. Results: All four patients underwent successful intravesical RAFUT without any intraoperative or postoperative complications. The age of the patients ranged from 3 to 12 years, with varying bladder capacities (range: 210-550 mL). The operating times ranged from 180 to 210 min, and the estimated blood loss was 35-50 mL. None of the patients required conversion to open surgery. Patients demonstrated resolution of VUR on postoperative imaging, and none experienced recurrent urinary tract infections during follow-up, which ranged from 1.5 to nearly 4 years. Conclusion: RAFUT represents a safe and effective surgical technique for intravesical ureteral tapering during pediatric robotic-assisted ureteric reimplantation. This innovative approach addresses the challenges posed by intravesical surgery for dilated ureters, maintains anatomical orientation, and offers precise excision and suturing capabilities.

Comparing T2-T3 staging of penile cancer according to the American Joint Committee on cancer 8th edition with two modified staging systems in predicting survival outcome: A single-center experience.

Introduction: Penile cancer is a rare malignancy of the genitourinary tract. We aimed to validate the recent changes in the T2 and T3 stages of penile cancer in the American Joint Committee on Cancer (AJCC) 8th edition and to compare its predictive ability with two other modified staging systems for survival outcomes. Methods: This is a retrospective study of patients diagnosed with penile cancer from June 2015 to March 2020. The AJCC 8th edition and two other newly proposed systems by Li et al. and Sali et al. were used for staging the tumor. All variables were categorized and correlated with lymph node (LN) metastases and overall survival (OS). Results: Fifty-four patients were eligible for this study. The mean age was 58 years (range 46-72 years). The tumor stage (P = 0.016), clinical LN stage (P = 0.001), the involvement of the spongiosa (P = 0.015) and the cavernosa (P = 0.002), lymphovascular invasion (LVI) (P = 0.000), and PNI (P = 0.021) were found to be the significant predictors of LN metastases. When the 5 year OS was compared between the T2 and T3 stages of the AJCC 8th edition, Li staging and the Sali staging systems, it was 91% and 50.1% (P = 0.001), 97.5% and 10.3% (P = 0.000), 94.4% and 14.7% (P = 0.000), respectively. The presence of LVI (P = 0.001) was the most significant independent predictor of OS. Conclusions: The recent changes in the AJCC 8th edition pertaining to the T2-T3 stage are relevant, although the other two newly proposed staging systems were more precise in predicting the survival outcomes.

Reduced insulin signaling and high glucagon in early insulin resistance impaired fast-fed regulation of renal gluconeogenesis via insulin receptor substrate.

Gluconeogenesis is one of the key processes through which the kidney contributes to glucose homeostasis. Urinary exosomes (uE) have been used to study renal gene regulation noninvasively in humans and rodents. Recently, we demonstrated fast-fed regulation of phosphoenolpyruvate carboxykinase (PEPCK), the rate-limiting enzyme for gluconeogenesis, in human uE. The regulation was impaired in subjects with early insulin resistance. Here, we studied primary human proximal tubule cells (hPT) and human uE to elucidate a potential link between insulin resistance and fast-fed regulation of renal PEPCK. We demonstrate that fasted hPTs had higher PEPCK and insulin receptor substrate-2 (IRS2) mRNA and protein levels, relative to fed cells. The fast-fed regulation was, however, attenuated in insulin receptor knockdown (IRKO) hPTs. The IRKO was confirmed by the blunted insulin-induced response on PEPCK, PGC1α, p-IR, and p-AKT expression in IRKO cells. Exosomes secreted by the wild-type or IRKO hPT showed similar regulation to the respective hPT. Similarly, in human uE, the relative abundance of IRS-2 mRNA (to IRS1) was higher in the fasted state relative to the fed condition. However, the fast-fed difference was absent in subjects with early insulin resistance. These subjects had higher circulating glucagon levels relative to subjects with optimal insulin sensitivity. Furthermore, in hPT cells, glucagon significantly induced PEPCK and IRS2 gene, and gluconeogenesis. IR knockdown in hPT cells further increased the gene expression levels. Together the data suggest that reduced insulin sensitivity and high glucagon in early insulin resistance may impair renal gluconeogenesis via IRS2 regulation.

Risk of tuberculosis among renal transplant recipients receiving rituximab therapy.

BACKGROUND: Rituximab is an anti-CD 20 agent used widely in renal transplant recipients. Its use is associated with various infections; however, its association with tuberculosis (TB) is not well established and has not been studied in post renal transplantation patients. METHODS: This is a single-center, retrospective analysis of 56 renal transplant recipients who received rituximab as a part of desensitization protocol or as rescue therapy for rejections and 287 post-renal transplant patients who did not receive rituximab during the study period from January 2013 to June 2017. The association between use of rituximab and occurance of TB was studied. Other factors associated with TB were also investigated. RESULTS: Baseline characteristics were similar in both the groups. Mean time for occurrence of TB was 18.4 ± 10.6 months after renal transplantation. Rituximab use was not significantly associated with TB or any other infection. Higher number of rejection episodes (60% vs. 32.72%, p = .029) was the only factor associated with greater incidence of TB. However, no specific type of rejection was associated with TB. Use of plasmapheresis in post-transplant period for treatment of humoral rejections was associated with significantly higher incidence of TB (33.33% vs. 13.41%, p = .031); however, when pre-transplant plasmapheresis was also considered, there was no significant difference. The choice of induction agent was not associated with higher incidence of TB. CONCLUSION: Use of rituximab is not associated with higher incidence of TB when compared to other immunosuppressive agents. Routine screening and prophylaxis may not be advisable, especially in a country like India with high prevalence of TB, as it will further delay transplantation and may adversely affect the outcome of the patients.

Noninvasive Evaluation of Bladder Bowel Dysfunction and its Extrapolation as Biofeedback Therapy to Train Pelvic Floor Muscles.

Aims: This study aimed to evaluate the noninvasive methods to diagnose bladder bowel dysfunction (BBD) and its extrapolation on biofeedback therapy and pelvic floor exercises (PFE) to treat these children. Settings and Design: A retrospective cohort study at a tertiary care center was conducted between January 2010 and December 2020, on 204 children, aged 4-18 years, arbitrarily divided into two groups-4-12 and 13-18 years. Subjects and Methods: Details of lower urinary tract dysfunction were recorded as International Children's Continence Society nomenclature. Bowel habits were recorded and functional constipation was graded using ROME IV. The data recorded were urine analysis, a voiding diary, a dysfunctional voiding symptom score, and uroflowmetry with or without electromyography. Ultrasonography, voiding cystourethrogram, and magnetic resonance imaging were done in appropriate cases. Dysfunctional Voiding Severity Score was used to assist the evaluation and outcome. The treatment protocol included urotherapy, uroflow biofeedback, PFEs, prophylactic antibiotics, pharmacotherapy, and treatment of constipation. Statistical Analysis Used: Statistical analysis was done using SPSS version 26 and paired t-test was used for comparison and calculating P value. Results: There was a significant improvement in DVSS and uroflow parameters. However, the magnitude of change produced varied among the age groups. Patients who failed to show any clinical benefit were subjected to alternative therapies such as intrasphincteric Botulinum A toxin with or without neuromodulation. Conclusions: Integrated uroflow biofeedback (IUB) and PFE expedites the recovery by supplementing the effect of urotherapy; hence, this should be offered to all children with BBD.

Prostate-specific antigen screening of men with lower urinary tract symptoms (opportunistic screening) and of asymptomatic men undergoing executive health check: an audit from two institutions.

INTRODUCTION: We evaluated incidence ofprostate-specific antigen (PSA) positivity (>4ng/mL) and cancer detection rate on prostate biopsy in two populations of men, one undergoing opportunistic testing for lower urinary tract symptoms and another during routine health checks. METHODS: Data regarding PSA screening, rectal examination (RE), transrectal ultrasound-guided biopsy, clinical stage, and risk assessment grouping according to NCCN guidelines were studied. Group A included patients with lower urinary tract symptoms (LUTS) (opportunistic screening) at SGPGIMS, Lucknow and Group B included healthy men who had executive health check-up with PSA testing at Medanta the Medicity, Gurugram. RESULTS: PSA positivity rate in 9906 symptomatic men for LUTS (Group A) and 24919 healthy men (Group B) was 28.4% and 3% respectively. In group A, PSA positivity rate was 28.4% but only around half of all men with an indication underwent a biopsy. Among men with PSA of 4-10 ng/mL, cancer was detected in 93 of 241 who underwent a biopsy (38.5%). In Group B, only 69 men (9.3% of those with an elevated PSA) underwent a prostate biopsy, of which 38/57 (with PSA of 4-10 had cancer. In Group A, the cancers was metastatic in 61.5% men, while none in-Group B had metastatic disease. CONCLUSION: Opportunistic screening and executive health check with PSA identifies a significant number of men with PSA positivity and may help decrease the proportion of men diagnosed in metastatic prostate cancer.

Role of positron emission tomography/computed tomography in the evaluation of renal cell carcinoma.

INTRODUCTION: Positron emission tomography (PET) is not a standard recommendation in most of the major guidelines for the evaluation of renal cell carcinoma (RCC). Earlier studies evaluating PET scan in patients with RCC have provided discordant results. However, with the advent of newer hybrid PET/computed tomography (CT) scanning systems, this modality has shown increased efficacy in the evaluation of primary renal masses along with the detection of extrarenal metastases, restaging recurrent RCC, and also in monitoring response to targeted therapy. We performed a systematic review of the existing literature on the role of PET scan in the evaluation of RCC. METHODOLOGY: We systematically searched the databases of PubMed/Medline, Embase, and Google Scholar to identify studies on the use of PET scan in RCC. Using Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, 94 full-text articles were selected, of which 54 relevant articles were then reviewed, after a consensus by the authors. RESULTS: Several studies have shown similar sensitivity and specificity of fluoro-2-deoxy-2-d-glucose-PET (FDG-PET) scan as compared to conventional CT scan for the initial diagnosis of RCC, and an improved sensitivity and specificity for the detection of metastases and recurrences following curative therapy. The PET scan may also play a role in predicting the initial tumor biology and pathology and predicting the prognosis as well as the response to therapy. CONCLUSION: The current guidelines do not recommend PET scan in the staging armamentarium of RCCs. However, FDG-PET scan is as efficacious, if not better than conventional imaging alone, in the evaluation of the primary and metastatic RCC, as well as in evaluating the response to therapy, due to its ability to pick up areas of increased metabolic activity early on. Newer tracers such as Ga68 prostate specific membrane antigen-labeled ligands may help in opening up newer avenues of theragnostics.

Experience with management of renal cell carcinoma with inferior vena cava/right atrial tumor thrombus.

INTRODUCTION: We aimed to present our experience in managing renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus. METHODS: Records of all patients aged 18 years and older, with a diagnosis of primary renal masses with IVC thrombus, presenting to our institute from January 2012 to August 2020 were retrospectively reviewed. Patients with tumor thrombus limited only to renal vein were excluded from the analysis. Their hospital course and outcomes were recorded and evaluated for predictors of survival. RESULTS: During the study period, we treated 61 patients with a renal mass and concurrent IVC thrombus and 56 of these underwent surgery. 7 of them had level III and 6 had level IV thrombus. A total of six patients received neoadjuvant tyrosine kinase inhibitor (TKI) therapy and all of them showed a decrease in size and level of tumor thrombus and cardiopulmonary bypass was safely avoided. Fourteen patients had distant metastasis and underwent cytoreductive surgery and of these 12 patients received TKI therapy after surgery with a mean survival of 26.8 months. The overall survival at 2 and 5 years of nonmetastatic group was 81.1% and 47.5% respectively and in metastatic group was 35.1% and 0%, respectively. Poor performance status, distant metastasis, higher T stage, higher thrombus levels, and positive surgical margins were all predictors of decreased survival. CONCLUSIONS: Complete surgical resection in both nonmetastatic and metastatic RCC with IVC thrombus has long-term survival benefits. Neoadjuvant TKI therapy, with adequate preoperative planning, helps in decreasing the size of the thrombus and in safely avoiding bypass in level III and IV IVC thrombi.

Radical cystectomy and W-shaped ileal orthotopic neobladder reconstruction with serosa-lined tunneled ureteroileal anastomoses: A critical analysis of the short-term voiding patterns and urodynamic and functional outcomes.

INTRODUCTION: We present the short-term voiding patterns and functional and urodynamic outcomes of W-shaped ileal orthotopic neobladder (ONB) following radical cystectomy (RC). MATERIALS AND METHODS: Forty-one patients who underwent RC and W-shaped ONB creation between July 2015 and January 2018 were enrolled. Data were analyzed in terms of voiding patterns, urodynamic findings, and functional outcomes at 6 months after surgery. Pouch-related quality of life (QoL) was assessed using European Organization for Research and Treatment of Cancer (EORTC) Generic (QLQ C30), Bladder Cancer-Specific Instruments (QLQ BM30), and IONB-Patient-Reported Outcome (IONB-PRO). RESULTS: The mean length of follow-up was 19.4 months. At first follow-up, three patients had developed acidosis and rising serum creatinine, and one of them required temporary hemodialysis. One patient developed urethral-pouch anastomotic stricture, which required bladder neck incision. Balloon dilatation was performed for ureteroileal anastomotic stricture and mesh repair for incisional hernia was required in one patient each. Upper tract changes were observed in two patients. During the first and second follow-up, maximum flow rate, voided volume, and postvoid residual urine were 12 ± 4.7 mL/s, 212 ± 120 mL, and 72 + 81 mL and 14.7 ± 5.3 mL/s, 254 ± 168 mL, and 123.7 ± 42.5 mL, respectively. The mean pouch capacity and compliance were 436 ± 103.5 mL and 50.6 ± 17.8 mL/cm H2O. No patient required clean intermittent catheterization for bladder emptying. In EORTC QLQ-C30 questionnaire, the "Cognitive" domain had the highest and "global QoL" domain had the lowest level of functional scores. "Nausea and vomiting and abdominal bloating and flatulence" domain had the lowest level and "financial difficulties and urinary symptoms" had the highest level of symptomatology in EORTC QLQ questionnaire. The IONB-PRO questionnaire showed the highest level of functioning in "relation life" and the lowest level in "emotional life" domain. CONCLUSION: The Ghoneim pouch has a low complication rate with near-normal voiding patterns with an acceptable QoL impairment.

Safety and outcome of percutaneous nephrolithotomy in patients with solitary kidney: A tertiary care center experience.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) for stones in solitary kidney poses a significant challenge and potential threat for acute kidney injury or progression of chronic kidney disease (CKD). We present our experience of PCNL in solitary functioning kidney (SFK) to evaluate the safety, efficacy, and postoperative complications and highlight the differences between these outcomes with respect to the stage of CKD. METHODS: We carried out a retrospective study of patients with SFK, who underwent PCNL at our center from April 2010 to March 2018. Patients who had a minimum of 6 months of follow-up were included. Patients were classified into CKD groups based on the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative. Group 1 included Stages 1, 2, and 3A and Group 2 included Stages 3B, 4, and 5. Postoperative complications and stone-free rate were recorded and graded according to the Clavien-Dindo classification and compared between the two groups. RESULTS: We had a total of 128 patients (Group 1 - 84 and Group 2 - 44). Stone-free rate after the first PCNL was higher in Group 1 as compared to Group 2 (88.1% [n = 74] vs. 50% [n = 22], P = 0.02). Overall, 48 patients (37.5%) had postoperative complications, but most were minor. Clavien Grade 1 and 2 complications were seen in 34 patients (Group 1, n = 18 and Group 2, n = 16, P = 0.069), whereas Grade 3 and 4 complications were seen in 14 patients (Group 1, n = 2 and Group 2, n = 12, P < 0.001), respectively. Need for postoperative (number of sessions) dialysis was seen with increased frequency in patients with higher chronic kidney stages (Group 1 vs. Group 2; 6 vs. 22 sessions, P < 0.001). CONCLUSION: PCNL in SFK is safe, with satisfactory outcome, but patients with advanced CKD stage have higher risk of complications including need for dialysis and may require multiple sessions for complete stone clearance. Hence, they should be managed at high output tertiary centers.

Deceased organ donation and transplantation in India: Promises and challenges.

Organ transplantation has improved the lives of hundreds of thousands of patients all the world. The total organ donation shortage of the country can be met with if even 5 to 10% of the victims involved in fatal accidents serve as organ donors. The challenges include an interplay of sociocultural factors, beliefs and superstitions, lack of communication and organizational support, and negative views by the media. Several initiatives to encourage deceased organ donation include the Indian Network for Organ Sharing, a subdivision of the National Organ and Tissue Transplant Organization, the Transplantation of Human Organ Act (THOA), as well as the Transplantation of Human Organs and Tissue Rules. There are stringent criteria instituted for the retrieval, preservation and transportation of donor organs. This article reviews the ongoing efforts being implemented to encourage organ transplantation.

A retrospective analysis of complications of laparoscopic left donor nephrectomy using the Kocak's modification of Clavien-Dindo system.

INTRODUCTION: Kocak described a modification of Clavien-Dindo classification system (CDCS) for reporting procedure-related complications in laparoscopic donor nephrectomy (LDN). We used the Kocak modification in grading and reporting the severity of complications in patients who underwent LDN and in evaluating various parameters that predict them. METHODS: In all, 1430 patients who underwent left LDN from 2000 to 2016 were included in this study. All data was retrospectively collected and analyzed for complications occurring in the postoperative period. All complications were classified according to the four grades of Kocak-modified CDCS. RESULTS: 124 patients (8.6%) suffered a total of 235 postoperative complications. Most of the complications were Grade I and Grade II (Grade I: 79.5% [n = 187] and Grade II 16.2% [n = 38]), 2.5% of the complications were Grade III (n = 6) and Kocak Grade IVa complications occurred in three patients. There was one death (Grade IVb: 0.4%, overall mortality rate: 0.06%). The incidence of complications was significantly greater for male patients, those with body mass index ≥25 kg/m2, and if the operating surgeon had ≤ 1 year of experience in performing LDN surgery. CONCLUSION: LDN is a safe procedure with low morbidity. The rate of complications is 8.6% and most of these complications are of low grade. The use of a standardized system for reporting the complications of LDN allows appropriate comparison between reported data.

Reduced Insulin Receptor Expression Enhances Proximal Tubule Gluconeogenesis.

Reduced insulin receptor protein levels have been reported in the kidney cortex from diabetic humans and animals. We recently reported that, targeted deletion of insulin receptor (IR) from proximal tubules (PT) resulted in hyperglycemia in non-obese mice. To elucidate the mechanism, we examined human proximal tubule cells (hPTC) and C57BL/6 mice fed with high-fat diet (HFD, 60% fat for 20 weeks). Immunoblotting revealed a significantly lower protein level of IR in HFD compare to normal chow diet (NCD). Furthermore, a blunted rise in p-AKT308 levels in the kidney cortex of HFD mice was observed in response to acute insulin (0.75 IU/kg body weight, i.p) relative to NCD n = 8/group, P < 0.05). Moreover, we found significantly higher transcript levels of phosphoenolpyruvate carboxykinase (PEPCK, a key gluconeogenic enzyme) in the kidney cortex from HFD, relative to mice on NCD. The higher level of PEPCK in HFD was confirmed by immunoblotting. However, no significant differences were observed in cortical glucose-6-phosphatase (G6Pase) or fructose-1,6, bisphosphosphatase (FBPase) enzyme transcript levels. Furthermore, we demonstrated insulin inhibited glucose production in hPTC treated with cyclic AMP and dexamethasone (cAMP/DEXA) to stimulate gluconeogenesis. Transcript levels of the gluconeogenic enzyme PEPCK were significantly increased in cAMP/DEXA-stimulated hPTC cells (n = 3, P < 0.05), and insulin attenuated this upregulation Furthermore, the effect of insulin on cAMP/DEXA-induced gluconeogenesis and PEPCK induction was significantly attenuated in IR (siRNA) silenced hPTC (n = 3, P < 0.05). Overall the above data indicate a direct role for IR expression as a determinant of PT-gluconeogenesis. Thus reduced insulin signaling of the proximal tubule may contribute to hyperglycemia in the metabolic syndrome via elevated gluconeogenesis. J. Cell. Biochem. 118: 276-285, 2017. © 2016 Wiley Periodicals, Inc.

Ureterocalicostomy for Reconstruction of Complicated Ureteropelvic Junction Obstruction in Adults: Long-Term Outcome and Factors Predicting Failure in a Contemporary Cohort.

PURPOSE: Ureterocalicostomy is a well established treatment option in patients who have recurrent ureteropelvic junction obstruction with postoperative fibrosis and a relatively inaccessible renal pelvis. We evaluated the long-term outcome of ureterocalicostomy and factors predicting its failure. MATERIALS AND METHODS: We retrospectively analyzed data on 72 patients who underwent open or laparoscopic ureterocalicostomy from 2000 to 2014. Variables that may affect the outcomes of ureterocalicostomy were assessed with regard to primary pathology findings, patient age, serum creatinine, preoperative renal size (less than and greater than 15 cm), renal cortical thickness (less than and greater than 5 mm), hydronephrosis grade and preoperative renal function (glomerular filtration rate less than and greater than 20 ml/minute/1.73 m2). The surgery outcome was calculated in terms of success or failure. Factors predicting failure were evaluated by univariate and multivariate analysis. Failure was defined as an additional procedure required postoperatively due to persistent symptoms and/or followup renal scan showing persistent significant obstruction with deterioration of renal function on at least 2 occasions 3 months apart. Patients with less than 2-year followup were excluded from study. RESULTS: We analyzed data on 72 patients who underwent ureterocalicostomy during this period. Mean ± SD age of the study group was 28.9 ± 12.3 years and mean baseline serum creatinine was 1.1 ± 0.3 mg/dl. The mean glomerular filtration rate was 27.8 ± 11.6 ml/minute/1.73 m2 and mean cortical thickness of the operated kidney was 7 ± 3.86 mm. Common indications for ureterocalicostomy were failed previous pyeloplasty and/or endopyelotomy in 35 patients (48.6%) and secondary ureteropelvic junction obstruction after pyelolithotomy or percutaneous nephrolithotomy in 24 (33.3%). The most common complication was urinary tract infection, which was seen in 22 patients (30.6%). At a mean followup of 60.3 ± 13.6 months 50 patients (69.5%) had a successful outcome. Treatment failed in 22 patients (30.5%), including 6 who required nephrectomy, while 13 were treated with frequent changes of Double-J® stents or with balloon dilation. In 3 patients ureterocalicostomy was repeated. The rate of failed ureterocalicostomy was higher in patients with a low preoperative glomerular filtration rate (less than 20 ml/minute/1.73 m2), attenuated cortical thickness (less than 5 mm) and higher creatinine (greater than 1.7 mg/dl) on univariate analysis. However, on multivariate analysis poor cortical thickness and a low glomerular filtration rate were independent predictors of failure. CONCLUSIONS: Ureterocalicostomy is an acceptable salvage option with a satisfactory long-term outcome. Patients with a low preoperative glomerular filtration rate (less than 20 ml/minute/1.73 m2) and a thinned out cortex (less than 5 mm) showed a poor outcome after ureterocalicostomy.

Multidimensional assessment of quality of life of children and problems of parents in Indian society after pediatric renal transplant: Beyond the conventional thoughts.

This study evaluated multidimensional QoL after renal transplant to find the physical, psychosocial, and economic issues after pediatric transplant. Sixty-two patients under the age of 18 at the time of assessment were asked to complete WHOQOL questionnaires. Assessment of behavioral, emotional status of child, problems of parents, and SEC of family were also performed. The beneficial effect of transplantation was observed across all domains of QoL (physical, psychological, social, environmental, and overall QoL). The greatest change was observed in QoL domains that dealt with overall satisfaction (81.28±15.76 vs 45.32±10.98; P<.0001). The domain dealing with environmental factors showed the least variation after transplantation (65.58±17.45 vs 51.34±17.81; P<.0001). Feelings of happiness and peer group socialization were reported in 81% and 69% of patients, respectively. There was no marital disharmony in 52% of families. However, SEC deteriorated in 16% of families and 59% of the families availed financial assistance. Sixty-nine percent of children had not attended school after one year of transplantation, but return to school after transplant was reduced to 8% at 5 years. Pre- and post-transplant social and psychological support may help these patients and their families adjust in society and have a positive outlook for their future.

Single-centre experience of retroperitoneoscopic approach in urology with tips to overcome the steep learning curve.

CONTEXT: The retroperitoneoscopic or retroperitoneal (RP) surgical approach has not become as popular as the transperitoneal (TP) one due to the steeper learning curve. AIMS: Our single-institution experience focuses on the feasibility, advantages and complications of retroperitoneoscopic surgeries (RS) performed over the past 10 years. Tips and tricks have been discussed to overcome the steep learning curve and these are emphasised. SETTINGS AND DESIGN: This study made a retrospective analysis of computerised hospital data of patients who underwent RP urological procedures from 2003 to 2013 at a tertiary care centre. PATIENTS AND METHODS: Between 2003 and 2013, 314 cases of RS were performed for various urological procedures. We analysed the operative time, peri-operative complications, time to return of bowel sound, length of hospital stay, and advantages and difficulties involved. Post-operative complications were stratified into five grades using modified Clavien classification (MCC). RESULTS: RS were successfully completed in 95.5% of patients, with 4% of the procedures electively performed by the combined approach (both RP and TP); 3.2% required open conversion and 1.3% were converted to the TP approach. The most common cause for conversion was bleeding. Mean hospital stay was 3.2 ± 1.2 days and the mean time for returning of bowel sounds was 16.5 ± 5.4 h. Of the patients, 1.4% required peri-operative blood transfusion. A total of 16 patients (5%) had post-operative complications and the majority were grades I and II as per MCC. The rates of intra-operative and post-operative complications depended on the difficulty of the procedure, but the complications diminished over the years with the increasing experience of surgeons. CONCLUSION: Retroperitoneoscopy has proven an excellent approach, with certain advantages. The tips and tricks that have been provided and emphasised should definitely help to minimise the steep learning curve.

Management of venous hypertension following arteriovenous fistula creation for hemodialysis access.

INTRODUCTION: Venous hypertension (VH) is a distressing complication following the creation of arteriovenous fistula (AVF). The aim of management is to relieve edema with preservation of AVF. Extensive edema increases surgical morbidity with the loss of hemodialysis access. We present our experience in management of VH. METHODS: A retrospective study was conducted on 37 patients with VH managed between July 2005 to May 2014. Patient demographics, evaluation, and procedures performed were noted. A successful outcome of management with surgical ligation (SL), angioembolization (AE), balloon dilatation (BD) or endovascular stent (EVS) was defined by immediate disappearance of thrill and murmur with resolution of edema in the next 48-72 h, no demonstrable flow during check angiogram and resolution of edema with preservation of AVF respectively. RESULTS: All 8 distal AVF had peripheral venous stenosis and were managed with SL in 7 and BD in one patient. In 29 proximal AVF, central and peripheral venous stenosis was present in 16 and 13 patients respectively. SL, AE, BD, and BD with EVS were done in 18, 5, 4, and 3 patients, respectively. All patients had a successful outcome. SL was associated with wound related complications in 11 (29.73 %) patients. A total of 7 AVF were salvaged. One had restenosis after BD and was managed with AE. BD, EVS, and AE had no associated morbidity. CONCLUSIONS: Management of central and peripheral venous stenosis with VH should be individualized and in selected cases it seems preferable to secure a new access in another limb and close the native AVF in edematous limb for better overall outcome.

Impact of changing trends in technique and learning curve on outcome of hypospadias repair: An experience from tertiary care center.

INTRODUCTION: Apart from numerous clinical factors, surgical experience and technique are important determinants of hypospadias repair outcome. This study was aimed to evaluate the learning curve of hypospadias repair and the impact of changing trends in surgical techniques on the success of primary hypospadias repair. MATERIALS AND METHODS: We retrospectively analyzed of data of 324 patients who underwent primary repair of hypospadias between January 1997 and December 2013 at our center. During the initial 8 years, repairs were performed by multiple 5 different urologists. From 2005 onwards, all procedures were performed by a single urologist. The study cohorts was categorized into three groups; Group I, surgeries performed between 1997-2004 by multiple surgeons, Group II, between 2005-2006 during the initial learning curve of a single surgeon, and Group III, from 2007 onwards after completion of the learning curve of the single surgeon. The groups were compared in respect to surgical techniques, overall success and complications. RESULTS: Overall 296 patients fulfilled the inclusion criterion, 93 (31.4%), 50 (16.9%), and 153 (51.7%) in Group I, II, and III, respectively. Overall success was achieved in 60 (64.5%), 32 (64%), and 128 (83.7%) patients among the three groups respectively (P < 0.01). Nineteen (20.4%), 20 (40%), and 96 (62.7%) patients underwent tubularized incised plate repair in Group I, II, and III, with successful outcome in 12 (63.2%), 15 (75%), and 91 (94.8%) patients, respectively (P < 0.01). The most common complication among all groups was urethrocutaneous fistula, 20 (21.5%) in Group I, 11 (22%) in Group II, and 17 (11.1%) in Group III. CONCLUSION: There is a learning curve for attaining surgical skills in hypospadias surgery. Surgeons dedicated for this surgery provide better results. Tubularized incised plate urethroplasty appear promising in both distal and proximal type hypospadias.

Socioeconomic rehabilitation of successful renal transplant patients and impact of funding source: Indian scenario.

INTRODUCTION: Socio-economic rehabilitation is an important outcome parameter in successful renal transplant recipients, particularly in developing countries with low income patients who often depend on extraneous sources to fund their surgery costs. We studied the socioeconomic rehabilitation and changes in socioeconomic status (SES) of successful renal allograft recipients among Indian patients and its correlation with their source of funding for the surgery. MATERIALS AND METHOD: A cross-sectional, questionnaire-based study was conducted on 183 patients between January 2010 to January 2013. Patients with follow up of at least 1 year after successful renal transplant were included. During interview, two questionnaires were administered, one related to the SES including source of funding before transplantation and another one relating to the same at time of interview. Changes in SES were categorized as improvement, stable and deterioration if post-transplant SES score increased >5%, increased or decreased by <5% and decreased >5% of pre-transplant value, respectively. RESULTS: In this cohort, 97 (52.7%), 67 (36.4%) and 19 (10.3%) patients were non-funded (self-funded), one-time funded and continuous funded, respectively. Fifty-six (30.4%) recipients had improvement in SES, whereas 89 (48.4%) and 38 (20.7%) recipients had deterioration and stable SES. Improvement in SES was seen in 68% patients with continuous funding support whereas, in only 36% and 12% patients with non-funded and onetime funding support (P = 0.001) respectively. Significant correlation was found (R = 0.715) between baseline socioeconomic strata and changes in SES after transplant. 70% of the patients with upper and upper middle class status had improving SES. Patients with middle class, lower middle and lower class had deterioration of SES after transplant in 47.4%, 79.6% and 66.7% patients, respectively. CONCLUSIONS: Most of the recipients from middle and lower social strata, which included more than 65% of our patient's population, had deteriorating SES even after a successful transplant. One-time funding source for transplant had significant negative impact on SES and rehabilitation.

Spiral laminar flow, the earliest predictor for maturation of arteriovenous fistula for hemodialysis access.

INTRODUCTION: Arteriovenous fistula (AVF) is the gold standard vascular access for hemodialysis (HD). A thrill or murmur immediately after creation of AVF is considered a predictive sign of success. However, this does not ensure final maturation for successful HD. Our objective was to determine different clinical and duplex parameters within AVF to predict maturation and subsequent successful HD. MATERIALS AND METHODS: A prospective observational study was conducted on 187 patients who had AVF formation from July 2012 to May 2013. Following surgery, all patients had Doppler ultrasound (DU) on Days 0 and 7. Doppler parameters noted in the outflow vein were: Thrill, broadening of spectral waveform with increased peak systolic velocity (PSV) and spiral laminar flow (SLF). Patients with at least one positive parameter at Day 0 were followed-up serially and underwent repeat Doppler imaging on Day 7. Patients with the absence of all three parameters on Day 0 were excluded from the study. Endpoint was maturation of AVF, i.e. successful HD. Statistical analysis was performed with binary logistic regression, to find out the strongest and earliest predictor for maturation of AVF using SPSS version 20. RESULTS: SLF and broadening of spectral waveform with increased PSV were found to have a significant association with maturation (P = 0.0001). Presence of SLF on Day 0 most strongly predicted maturation. Presence of thrill or murmur could not predict the maturation. CONCLUSIONS: SLF pattern in AVF is the most important and the earliest predictor of maturation.