A Comparison of Analgesic and Recovery Profiles of Ketamine, Lignocaine, and Dexmedetomidine (KeLiDex) Versus Fentanyl-Based Anesthesia in Laparoscopic Nephrectomies: A Randomized, Single-Blind, Pilot Study.

BACKGROUND: In the search for opioid-free anesthesia, notable numbers of drugs, singly or in combinations, have been tested with variable results. However, most of the drugs used are not as strong as opioids. Even if some non-opioid drugs are potent enough, they cause significant untoward effects, necessitating the use of lower effective dosages of multiple drugs as a substitute. The present pilot study evaluated low-dose combinations of ketamine, lignocaine, and dexmedetomidine (KeLiDex) against fentanyl-based anesthesia for analgesia and recovery profiles in laparoscopic nephrectomies. METHODS: Twenty patients (10 in each group) randomly received KeLiDex or fentanyl infusion as an analgesic component for balanced general anesthesia. Entire patients also received paracetamol and quadratus lumborum block-2. Anesthesia depth, neuromuscular blockade, and reversal were standardized. Intraoperative hemodynamic variation, time to extubation after reversal (T-tEAR) administration, postanesthesia care unit (PACU) discharge readiness assessed using modified Aldrete score, sedations using Richmond Agitation Sedation Scale, postoperative pain, and rescue analgesia consumptions were compared using different validated scales. P-value <0.05 was considered significant. RESULTS: The KeLiDex group had a significantly lower heart rate (HR) between 45-90 minutes and at the time of reversal. Mean arterial pressure (MAP) (mean ± standard deviation (SD)) differed significantly at only a 60-minute interval (KeLiDex group 80.90 ± 9.50 versus fentanyl group 92.60 ± 16.13 mmHg, p-value 0.041). The Friedman test for change in HR and MAP over time within each group was also insignificant. The mean ± SD of T-tEAR was 6.37 ± 2.13 in KeLiDex, and 8.18 ± 2.92 minutes in the fentanyl group, p-value 0.27. Sedation scores, Modified Alderette scores, pain scores, and rescue analgesic requirements were also comparable. CONCLUSION: KeLiDex could effectively control hemodynamics and pain both at rest and in movements in line with fentanyl-based anesthesia for laparoscopic nephrectomies. Further, recovery from the anesthesia, sedation, and PACU discharge readiness were similar.

Comparison of narrow band imaging versus white light imaging in detecting non muscle invasive bladder cancer.

BACKGROUND: In the present study, we compared Narrow Band Imaging (NBI) and White Light Cystoscopy (WLC) in Non-muscle invasive bladder cancer (NMIBC) for detection and its impact on recurrence. MATERIALS AND METHODS: This prospective study was conducted in the department of Urology at a tertiary institution from August 2021 to April 2023. The main aim was to determine the benefit of addition of NBI during TURBT in NMIBC. All patients with Urinary Bladder Mass (size less than 5 cm on USG/CT) aged >18 years of age planned for TURBT were included. RESULTS: Amongst 63 patients, the mean age was 59.84 ± 11.3 years; 80% were males. Sixty percent of patients had history of Tobacco consumption and Type II DM was the most common comorbidity (59%). Commonest symptom was gross haematuria. Posterior wall was most commonly involved and papillary lesions were commonest. A total of 125 lesions were identified on WLI, with mean 1.98 ± 1.75 and 78 additional lesions were identified only on NBI with mean 1.24 ± 1.63 lesions. Four patients had intra-operative complications. Five patients had recurrence at 6 weeks and eight patients had recurrence at 3 months. NBI had detected more lesions in patients who developed recurrence at 6 weeks and 3 months (mean: 1.41 and 1.43). CONCLUSION: NBI has additive role in detecting NMIBC lesions missed on WLI. NBI has significant role in preventing recurrence at 3 months and more so by detecting high grade tumours.

Extraperitoneal Laparoscopic Simple Prostatectomy for large prostatic adenomas: A single-centre experience on 14 patients with significant lower urinary tract symptoms.

INTRODUCTION AND OBJECTIVES: There are various approaches available for surgical management of large prostatic adenomas - open, laparoscopic as well as laser enucleation - but there are no available clear cut consensus or guidelines. We present our experience in Extraperitoneal Laparoscopic Simple Prostatectomy on 14 patients with large prostatic adenoma (>100 g). MATERIALS AND METHODS: This is a retrospective analysis on 14 patients with large prostatic adenoma who underwent extraperitoneal laparoscopic prostatectomy (LSP) over a period of 2 years (2021-2023). All selected patients underwent extraperitoneal LSP. The case records were retrospectively reviewed and data were collected regarding age, clinical presentation, prostate size, median surgical time, intra-operative and post-operative events, pre-operative and post-operative assessment of IPSS score, Uroflowmetry and PVR values and duration of hospital stay. RESULTS: A total of 14 patients underwent LSP. The median age was 64.2 years and the median prostatic size was 123.25 g. Median operative time was 150 min. None of the patients required blood transfusion; mean Post-operative day (POD) for drain removal was 2.5 days. The mean duration of hospital stay was 3.5 days. Only one patient had urinary leak and vesico-cutaneous fistula which was managed conservatively by prolonged catheterisation. At 3 months follow-up, there was significant improvement in IPSS Score (mean 7.8 vs 21.3 pre-operatively), uroflow values (mean Qmax of 27.3 vs 6.8 pre-operatively) and PVR (mean 30.5 vs 350 ml pre-operatively). CONCLUSION: Laparoscopic Simple Prostatectomy is a safe and feasible approach for large prostatic adenomas with lesser morbidity and complications and satisfactory outcome.

Preferring Lateral Video Endoscopic Inguinal Lymph Node Dissection Over Classic Video Endoscopic Inguinal Lymph Node Dissection in Squamous Cell Carcinoma of Penis: Lessons Learnt from Twenty-One Patients at a Single Center.

OBJECTIVE: Inguinal lymphadenectomy is essential for staging and disease control. Minimally invasive techniques are recently replacing open techniques to reduce complications. We present our experience and lessons learnt from 21 patients who underwent lateral video endoscopic inguinal lymphadenectomy (L-VEIL) for penile malignancy. METHODS: All patients above 18 years of age with histopathology-confirmed squamous cell carcinoma penis with stages ≥ T1b and T1a with persistent lymphadenopathy who underwent L-VEIL over a period of 2 years (2020-2022) were included. The data were analyzed on the basis of intraoperative and postoperative complications, lymph node yield, hospital stay, and histopathology report. RESULTS: Forty-one lower limbs of 21 patients underwent L-VEIL during the abovementioned period. Median age was 52 years. Mean operative time (on 1 side) was 80 minutes. Median lymph node yield per side was 7.2. Intraoperatively, 1 patient had a vascular injury at the saphenofemoral junction, requiring conversion to open. Postoperative complications were superficial surgical site infection (n=4), lymphedema (n=1), and lymphocoele (n=3), one of which was drained by pigtail catheter. One patient required exploration on the second postoperative day because of vascular injury. Average duration of hospital stay was 3 days. The median time of drain removal was 13 days. Histopathology suggested seminoma in 1 patient and mature teratoma in 1 patient; the rest of the patients' reports were negative for malignancy. CONCLUSION: The L-VEIL is safe and feasible, and there is a reduction (~30%) in complications; oncological outcomes are also not affected. It has better ergonomics, resulting in ease and comfort for surgeons when compared with classical VEIL.

Report of testicular tumour in a toddler: management beyond the testis.

Testicular tumours in prepubertal children tend to be pure yolk sac tumours detected in stage I and have good prognosis. We describe a case of a 2-year old male child with a mixed testicular tumour presenting with stage IIC disease and managed with retroperitoneal lymph node dissection for residual retroperitoneal disease post adjuvant chemotherapy.

An elderly male with lower urinary tract symptoms during COVID-19 pandemic: Extraperitoneal perforation of bladder diverticulum.

CASE: We present a case of spontaneous extra-peritoneal rupture of an acquired diverticulum an elderly male with symptoms of bladder outlet obstruction who presented in emergency with acute abdomen. OUTCOME: The acute phase was managed conservatively with bladder drainage and intravenous antibiotics. He recently underwent Transurethral Resection of Prostate. He is asymptomatic on follow-up. CONCLUSIONS: Acquired bladder diverticulum are rare in adults and are mostly seen in patients with high pressure bladder due to bladder outlet obstruction. Atraumatic extraperitoneal ruptures of diverticulum are uncommonly reported.

Gossypiboma: An uncommon but avoidable dreadful complication.

Gossypiboma or retained surgical sponge in abdominal cavity is an avoidable complication which has wide variety of clinical presentations and associated medico-legal issues as well. The incidence is under-reported. Pre-operative diagnosis is difficult and management is surgical. We present a case of gossypiboma in a male with multiple vesico-cutaneous and colo-vesical fistulae.

Laparoscopic Vesicovaginal Fistula Repair with Limited Cystotomy: A Rewarding Treatment Option.

INTRODUCTION: Vesicovaginal fistula (VVF) is the most common type of urogenital fistula. Gynecologic surgery is the most common cause associated with it. Laparoscopic approach for VVF repair gives the benefit of minimally invasive surgery with principles similar to open transabdominal approach. MATERIALS AND METHODS: We retrospectively reviewed data of 13 patients who underwent laparoscopic vesicovaginal repair at our department from December 2012 to December 2014. Transperitoneal transvesical laparoscopic vesicovaginal repair using 4 ports was performed in all cases. Small cystotomy was performed instead of classical bivalving of the bladder. In most of the cases, the sigmoid epiploic appendix was used for augmentation. Per urethral catheter was kept for 10 days. RESULTS: In all patients, the procedure was successfully completed. Repairs were performed between 8 and 28 weeks (mean 15.8 ± 5.7) following the injury. All fistulas were at supratrigonal region. Fistula size ranged from 1 to 3.5 cm (mean 2.2 ± 0.9). Mean operative time was 157 ± 29.8 min (range 110-210), and estimated blood loss was 73.8 ± 18.2 ml (range 45-110). Average hospital stay was 4.6 days. In the postoperative period, three patients had urinary tract infection, which was treated with oral antibiotics. Apart from these, no major complications were seen. Follow-up time ranged from 4 to 27 months (mean 15.7). During the follow-up, no patient had recurrence or voiding symptoms. CONCLUSIONS: Laparoscopic transabdominal transvesical VVF repair with limited cystotomy and sigmoid epiploic appendix flap coverage can be performed safely with short operative time, good success rate, less morbidity, and quick convalescence.

A randomized clinical trial comparing intracorpus spongiosum block versus intraurethral lignocaine in visual internal urethrotomy for short segment anterior urethral strictures.

OBJECTIVES: The primary objective was to compare the effectiveness in pain relief of intracorpus spongiosum block (ICSB) versus intraurethral topical anesthesia (TA) using 2% lignocaine jelly for performing visual internal urethrotomy (VIU) for short segment anterior urethral strictures. MATERIALS AND METHODS: It was a randomized, parallel group controlled trial. Participants are adult patients with a single anterior urethral stricture up to 2 cm in length. Patients were allocated to two intervention groups with thirty patients in each group. For anesthesia of the urethra, Group 1 patients received ICSB whereas Group 2 patients received intraurethral TA using 2% lignocaine jelly before VIU. Patient discomfort was assessed with visual analog scale (VAS) during the procedure and 1 h postprocedure. The increase in pulse rate and the change in systolic blood pressure (BP) during the procedure were recorded. The procedure was considered successful if there was absence of symptoms or signs of recurrent stricture and ability to pass freely 18Fr catheter during urethral calibration at last follow-up. RESULTS: From March 2014 to June 2015, sixty patients were randomized into two groups of thirty patients each. The mean (±standard deviation) intraoperative VAS score was 2.8 ± 1.1 in Group 1, which was significantly less (P < 0.05) than the 5.6 ± 1.7 score in Group 2. The mean 1 h postoperative VAS score was also significantly lower in Group 1 patients (1.0 ± 1.0) than in Group 2 patients (3.2 ± 1.5). The change in pulse rate was significantly greater in Group 2 (21.3 ± 10.1 beats/min) than in Group 1 (10.6 ± 4.6 beats/min, P < 0.05). The change in systolic BP was also significantly higher in Group 2 (16.3 ± 8.6 mmHg) than in Group 1 (9.1 ± 4.4 mmHg, P < 0.05). The stricture-free rate at 6-month after VIU in Group 1 and Group 2 patients were 88.5% and 89.6%, respectively. CONCLUSIONS: ICSB has better pain control with similar complication and recurrence rate than intraurethral lignocaine jelly alone in VIU.

Outcome and erectile function following treatment of priapism: An institutional experience.

INTRODUCTION: Priapism has a devastating consequence on the sexual function of men if not promptly managed. We are presenting our experience of the treatment of priapism and the status of sexual function even following successful detumescence achieved after treatment. MATERIALS AND METHODS: Nineteen patients, who presented with priapism from January 2012 to December 2014, were included in the study. After obtaining a detailed history; color Doppler ultrasonography of penis and blood gas analysis of the initial corporal aspirate were done to ascertain the type of priapism. Standard protocol in our institute for management of priaprism was to start with conservative treatment by corporal aspiration and intracorporeal injection (ICI) of phenylephrine. On the failure of conservative management, distal shunts were performed. Proximal shunts were performed on the failure of distal shunt procedures. Erectile function was evaluated with International Index of Erectile Function-5 questionnaire on admission and during follow-up. RESULTS: All the patients had ischemic type priapism. Age of the patients ranged from 22 to 55 years. Duration of priapism varied from 20 to 480 h (mean 96.7). Etiologies attributed were; over-the-counter sildenafil use, chlorpromazine, opium intake and intracorporeal papaverine injection, chronic myeloid leukemia, and idiopathic. Five patients had preserved erectile function during follow-up. Preservation of normal erectile function following aspiration and ICI, proximal and distal shunt procedures were 66.7%, 18.1% and 20%, respectively. CONCLUSION: Patients with late presentation and those patients requiring higher treatment modalities (e.g., proximal shunts) for achieving detumescence will subsequently have a poor erectile function. These patients should be counseled about the early penile prosthesis placement during initial surgical management.

Laparoscopic Extravesical Lich-Gregoir Ureteroneocystostomy with Psoas Hitch for the Management of Ureterovaginal Fistula in Post-Hysterectomy Patients.

INTRODUCTION: Most commonly ureterovaginal fistula occurs due to surgical injury inflicted to the distal ureter and because of gynaecological procedures. Open surgical repair is a standard procedure and commonly involves ureteroneocystostomy. METHODS: We retrospectively reviewed data of 9 patients, who underwent laparoscopic extravesical Lich-Gregoir ureteroneocystostomy using the psoas hitch procedure for ureterovaginal fistulas following hysterectomy during the period December 2012-August 2014. Transperitoneal laparoscopic ureteroneocystostomy was performed in all cases. RESULTS: The mean operative time was 212 min (range 170-310) and estimated blood loss was 108 ml (range 70-150). Average hospital stay was 5.7 days. Follow-up time was from 6 to 26 months. Postoperative intravenous urography was done after 3 months, which showed patent anastomosis in 8 patients except for 1 patient who had nonvisualization of the ipsilateral renal moiety. Voiding cystogram done at 3 months showed no leakage in all patients. In the postoperative period, 1 patient had recurrent ipsilateral pyelonephritis 2 weeks after surgery, while another patient had febrile UTI. Apart from these no major complications were observed. CONCLUSION: Laparoscopic ureteroneocystostomy with psoas hitch can be performed safely with a success rate compared to that of open surgery but with less morbidity and quick convalescence.

Cavernous hemangioma of the glans penis.

Cavernous hemangioma of the glans penis is a very rare lesion, and only a few cases are reported in the literature. Urologists are in a dilemma to treat such lesion with cosmetic and to obtain good functional outcome. Here, we report a case of cavernous hemangioma of the glans penis in a 22-year-old boy with a successful outcome by intralesional sclerotherapy with 3% sodium tetradecyl sulfate with a review of the literature on the subject.