Percutaneous Nephrolithotomy in a Previously Operated Kidney.

OBJECTIVE: To ascertain the safety and efficacy of percutaneous nephrolithomy in patients with previous open renal surgery. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: The Kidney Centre Postgraduate Training Institute, Karachi from January to December 2018. METHODOLOGY: Patients with previous open renal surgery underwent percutaneous nephrolithomy during study period (Group A). Equal number of percutaneous nephrolithomy patients without previous open surgery taken as controls (Group B). Safety was defined in terms of 'blood loss' as change in hemoglobin (HB) level and 'blood transfusion,' while efficacy was defined in terms of 'stone clearance' and were compared between both the groups. RESULTS: There were a total of 87 patients. Both groups had comparative gender ratio [p = 0.858]. Mean age [p = 0.132] and BMI [p = 0.879] of patients in both groups was not significantly different from each other. Both groups showed no statistically significant difference in terms of values of stone size [p = 0.186], stone laterality [p = 0.437] stone location [p = 0.949], preoperative Hb [p = 0.095], postoperative Hb [p = 0.423] and change in Hb (indicating blood loss, p = 0.398). Puncture levels were significantly different among both groups (supracostal puncture in 18 and 36 patients; infracostal puncture in 63 and 51 patients in groups A and B, respectively, p = 0.006), while operative time [p = 0.787], calyx punctured [p = 0.051], double puncture [p = 0.787], nephrostomy tube [p = 0.288] were statistically not different among groups. Similar number of patients demonstrated residual stones [p = 0.773], along with residual stone sizes [Group A (0.5; 0.5) and Group B (0.65; 0.38)] [p = 0.445]. Intra- and postoperative complications like blood transfusion [p = 0.700] and fever [p = 1.000] along with hospital stay [p = 0.614] were comparable among groups. CONCLUSION: Percutaneous nephrolithomy is safe and effective in previously operated kidneys despite the possibility of calyceal anatomy distortion and scarring. Key Words: Percutaneous nephrolithotomy, Open surgery, Kidney calculi.

Outcome of 980 nm diode laser vaporization for benign prostatic hyperplasia: A prospective study.

Purpose: To evaluate the initial experience and outcome of photo-selective vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH) in Pakistan with the use of a 980 nm diode laser. Materials and Methods: A prospective study was performed from November 2016 to December 2017. A total of 100 patients diagnosed with bladder outlet obstruction secondary to BPH who planned for PVP were enrolled in the study. PVP was carried out with a diode laser at 980 nm (Biolitec Diode 180W laser) in a continuous wave with a 600 nm (twister) fiber. Baseline characteristics and perioperative data were compared. Postoperative outcomes were evaluated by International Prostate Symptom Score (IPSS), post void residual (PVR) and maximum urinary flow rate (Qmax) at 3 and 6 months after surgery. Results: The mean age was 65.82±10.42, mean prostate size was 67.35±16.42, operative time was 55.85±18.01 and total energy was 198.68±49.12 kJ. At 3 months and 6 months, significant improvements were noted (p<0.001) in IPSS 7.04±1.69 (-18.92), Qmax 19.22±4.75 mL/s (+13.09) and and PVR 18.89±5.39 mL (-112.80). Most frequent problems were burning micturition (35%) and terminal dysuria (29%). No significant difference in postoperative hemoglobin was seen in patients who were on anti-platelet drugs. Conclusions: PVP with a diode laser is a safe and effective procedure for the treatment of BPH and is also safe in patients who are on anti-platelet agents.

Predictive Factors for Intraoperative Blood Loss during Percutaneous Nephrolithotomy.

OBJECTIVE: To evaluate the factors that may increase bleeding during Percutaneous nephrolithotomy (PCNL) and correlate them with outcome. STUDY DESIGN: Analytical study. PLACE AND DURATION OF STUDY: The Kidney Centre postgraduate Training Institute, Karachi, Pakistan, from July to December 2016. METHODOLOGY: Consecutive patients who underwent PCNL from July to December 2016 were prospectively enrolled. Drop in hemoglobin was divided into three groups: mild <1 gm/dl, moderate 1-2 gm/dl and major >2 gm/dl. Factors such as age, gender, comorbidities, body mass index (BMI), operative time, creatinine levels, renal cortical thickness, stone size, its characteristics and location, puncture type and site, and need for blood transfusion were assessed by Chi-square/ Fisher exact test and Kruskal Wallis test. Predictive factors were assessed by multinomial logistic-regression analyses. RESULTS: Total 305 patients were enrolled in the study. Median age was 37 (27.5-49.1) years with predominantly males (n=217, 71.8%). Median BMI was 27.3 (24.6-31.4) Kg/m2 and mean stone size was 2.7 (2.1-3.4) cm. Two hundred and ninety-seven (97.7%) stones were radio-opaque. Operative time was 95 (60-127) minutes. There were 50.8% patients who had moderate drop in hemoglobin (1-2 gm/dl). Stone size, BMI and operative time were strongly associated with significant drop in hemoglobin. Complete stone clearance was achieved in 256 (84%) patients. Thirty (9.8%) patients needed blood transfusion. None of the patients required angioembolisation. CONCLUSION: BMI, stone size, and operative time were strongly associated with intraoperative blood loss during PCNL.

Tubeless percutaneous nephrolithotomy: call of the day.

PURPOSE: We challenge the routine placement of nephrostomy tube after percutaneous nephrolithotomy (PCNL) without taking into consideration the size, burden, and multiplicity of the stones; the degree of obstruction of the pelvicaliceal system, or any anatomic variations of the kidney in shape or position. PATIENTS AND METHODS: Between January 2005 to March 2006, 110 patients underwent PCNL, 77% of whom had multiple stones. The mean size of the single stones was 4.3 cm (range 2.8-6.5 cm), and the mean single-stone burden was 7.2 cm2 (range 5.6-14.3 cm2). The mean burden of multiple stones was 11.4 cm2 (range 8-23 cm2). Among the patients, 18 had had previous renal surgery, 12 had renal insufficiency, and 7 had a solitary functioning kidney. One patient each had horseshoe kidney and malrotated kidney. In 106 patients, no nephrostomy drain was placed, only an externalized 5F ureteral catheter for 16 to 20 hours. Two patients had simultaneous bilateral tubeless PCNL. The outcome was evaluated prospectively. The frequency of complications, length of hospital stay, and stone-free status were assessed. RESULTS: A stone-free rate of 80% was achieved using PCNL as monotherapy. The mean postoperative hospital stay was 16 to 20 hours. Three patients required placement of a nephrostomy tube because of significant bleeding and one because of purulent renal discharge. In four patients, a ureteral catheter was replaced by a stent because of significant residual stone burdens. The initial 18 patients underwent ultrasound examination on the first postoperative day, and none demonstrated any extrarenal collection, so routine ultrasound examination was omitted in succeeding patients. One patient required exploration because of a retroperitoneal hematoma. CONCLUSION: Omission of a nephrostomy tube after PCNL while retaining an externalized ureteral catheter for 16 to 20 hours is sufficient and safe irrespective of the stone characteristics. Shape, position, and function of the kidneys are also irrelevant with regard to tubeless PCNL.

Comparison of 24 hours urinary citrate levels in urolithiasis patients and healthy controls.

OBJECTIVE: To identify the difference in urinary citrate excretion between Stone Formers (SF) and Healthy Volunteers (HV) as a metabolic risk factor, that predisposes to urinary stone formation and to compare levels of urinary citrate in (HV) with reference values. METHODS: The 24 hours urinary citrate was evaluated in 40 patients treated for renal citrate and declared stone free, and 40 age matched healthy adults taken as controls. Both the groups had a similar living environment, extrinsic factors, diet and similar genetic descent. RESULTS: There was no significant difference in urinary citrate excretion level among stone formers (mean 262 SD 197) and normal volunteer subjects (mean 269 SD 140). Using the previously defined normal values (200) of urinary citrate in the local population, 55% of stone patients in our study group were hypocitric. While using the same value, 45% of our normal volunteers were also hypocitric. If 320 was taken as normal limit, 70% of the patient's population and 72% of controls were hypocitric. The prevalence of hypocitraturia was similar in the age matched adult groups. CONCLUSION: Certain intrinsic factors in our local subjects may account for the high prevalence of urolithiasis than in western population. Although the urinary citrate excretion of stone patients is similar to normal volunteers, uniformly low urinary citrate excretion may be a feature as a nation and not a predisposing factor for the lithogenesis. This supports the view that there may be more often prominent influences in stone formers possibly of genetic origin.

Bed wetting in school children of Karachi.

OBJECTIVES: To estimate the frequency of primary nocturnal enuresis (PNE) in Pakistani children and to examine the factors associated with it. METHODS: A randomly selected cross-sectional study was conducted in five elementary schools, one in each of five districts of Karachi. The parents of 5000 children age between 3-13 years were asked to complete a questionnaire which included items about the frequency of daytime wetting and nocturnal enuresis, family history, urinary tract infection, parents and child's own concern about this problem and acquisition of treatments. RESULTS: Over all corrected response rate to the questionnaire was 69% (3395). Enuresis was present in 9.1% (308). There were 166 (53.9%) boys and 142 (46%) girls with a median age of 7 years. Only 54% (166) children sought help for their problem of which 26% consulted doctors, 16% visited homeopaths while 11% used hakeems and home remedies. Of the bed wetters, 30% were wet every night, 30% for more than three nights a week and 40% for less than three nights every week. Parents of 68.5% (211) children reported concern for the problem while 69.8% (215) children were also anxious about their enuresis. Among the concerned children group, 22% parents were not concerned about their child's problem. Family history of enuresis was present in 25.6% (79) children. CONCLUSION: The frequency of enuresis among the school going children in Karachi is 9.1% and is similar to that reported in European countries and other Asian countries including Korea and Taiwan. Enuresis causes concern to both parents and children, but only a small percentage of parents seek medical help for this problem.