Laparoscopic donor nephrectomy in unusual venous anatomy - donor and recepient implications.

OBJECTIVES: Laparoscopic donor nephrectomy is now a commonly performed procedure in most of renal transplantation centers. However, the suitability of laparoscopy for donors with abnormal venous anatomy is still a subject of debate. MATERIALS AND METHODS: Between August 2007 and August 2014, 243 laparoscopic donor nephrectomies were performed in our institution. All donors were evaluated with preoperative three-dimensional spiral computed tomography (CT) angiography Thirteen (5.35%) donors had a left renal vein anomaly. A retrospective analysis was performed to collect donor and recipient demographics and perioperative data. RESULTS: Four donors had a type I retroaortic vein, seven had type II retroaortic vein and a circumaortic vein was seen in three donors. The mean operative time was 114±11 minutes and mean warm ischemia time was 202±12 seconds. The mean blood loss was 52.7±18.4mL and no donor required blood transfusion. Mean recipient creatinine at the time of discharge was 1.15±0.18mg/dL, and creatinine at six months and one year follow-up was 1.12±0.13mg/dL and 1.2±0.14mg/dL, respectively. There were no significant differences in operative time, blood loss, warm ischemia time, donor hospital stay or recipient creatinine at 6 months follow-up, following laparoscopic donor nephrectomy in patients with or without left renal vein anomalies. CONCLUSION: Preoperative delineation of venous anatomy using CT angiography is as important as arterial anatomy. Laparoscopic donor nephrectomy is safe and feasible in patients with retroaortic or circumaortic renal vein with good recipient outcome.

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.

A Novel method of ensuring safe and accurate dilatation during percutaneous nephrolithotomy.

OBJECTIVE: To report our technique that helps locate the guidewire into the ureter enabling safe dilatation during PCNL. MATERIALS AND METHODS: Cases in which the guidewire failed to pass into the ureter following successful puncture of the desired calyx were subjected to this technique. A second guidewire was passed through the outer sheath of a 9 Fr. metallic dilator cannula, passed over the first guidewire. The cannula and outer sheath were removed, followed by percutaneous passage of a 6/7.5 Fr ureteroscope between the two guidewires, monitoring its progress through both the endoscopic and fluoroscopic monitors. Once the stone was visualized in the calyx a guidewire was passed through the working channel and maneuvered past the stone into the pelvis and ureter under direct endoscopic vision. This was followed by routine tract dilatation. RESULTS: This technique was employed in 85 out of 675 cases of PCNL carried out at our institute between Jan 2010 to June 2014. The mean time required for our technique, calculated from the point of introduction of the ureteroscope untill the successful passage of the guidewire down into the ureter was 95 seconds. There were no intraoperative or postoperative complications as a result of this technique. Guidewire could be successfully passed into the ureter in 82 out of 85 cases. CONCLUSIONS: Use of the ureteroscope introduced percutaneously through the puncture site in PCNL, is a safe and effective technique that helps in maneuvering the guidewire down into the ureter, which subsequently enables safe dilatation.

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.

Magnetic resonance spectroscopy imaging-directed transrectal ultrasound biopsy increases prostate cancer detection in men with prostate-specific antigen between 4-10 ng/mL and normal digital rectal examination.

OBJECTIVES: To evaluate the ability of magnetic resonance spectroscopic imaging to improve prostate cancer detection rate. METHODS: A retrospective analysis was carried out of 278 men with prostate-specific antigen in the range of 4-10 ng/mL and normal digital rectal examination who underwent transrectal ultrasound-guided prostate biopsy. Outcomes were compared between men who had a standard biopsy versus those who also underwent a prebiopsy magnetic resonance spectroscopic imaging. Men with an abnormal voxel on magnetic resonance spectroscopic imaging had standard transrectal ultrasound biopsies plus biopsies directed to the abnormal voxels. RESULTS: The study group (n = 140) and control group (n = 138) were similar in baseline parameters, such as mean age, prostate size and mean prostate-specific antigen. The overall cancer detection in the magnetic resonance spectroscopic imaging positive group (24.4%) was more than double that of the control group (10.1%). On comparing the magnetic resonance spectroscopic imaging results with the transrectal ultrasound biopsy findings, magnetic resonance spectroscopic imaging had 95.6% sensitivity, 41.9% specificity, a positive predictive value of 24.4%, a negative predictive value of 98% and an accuracy of 51.4%. CONCLUSIONS: Magnetic resonance spectroscopic imaging-directed transrectal ultrasound biopsy increases the cancer detection rate compared with standard transrectal ultrasound biopsy in patients with normal digital rectal examination and elevated prostate-specific antigen in the range of 4-10 ng/mL.

Acute pancreatitis and development of pancreatic pseudo cyst after extra corporeal shock wave lithotripsy to a left renal calculus: A rare case with review of literature.

Extracorporeal shock wave lithotripsy (SWL) is considered the standard of care for the treatment of small upper ureteric and renal calculi. A few centers have extended its use to the treatment of bile duct calculi and pancreatic calculi. The complication rates with SWL are low, resulting in its wide spread acceptance and usage. However, some of the serious complications reported in 1% of patients include acute pancreatitis, perirenal hematoma, urosepsis, venous thrombosis, biliary obstruction, bowel perforation, lung injury, rupture of aortic aneurysm and intracranial hemorrhage. To our knowledge, only six cases of acute pancreatitis or necrotizing pancreatitis following SWL have been documented in the literature. Herein, we report a rare case of acute pancreatitis and formation of a pseudo cyst following SWL for left renal pelvic calculus.

Virilizing lipoadenoma of the adrenal gland in a pre-pubertal girl: A rare case.

We report a case of a 12-year-old girl who presented with the history of hirsutism. On evaluation, she was found to have testosterone secreting adrenal gland tumor. Histopathological examination of the adrenalectomy specimen revealed a lipoadenoma.

Pleomorphic undifferentiated sarcoma of urinary bladder with calcified pulmonary metastasis: A rare entity.

We report the case of a 29-year-old male who presented to us with hematuria, dysuria and bilateral flank pain. On evaluation, the patient was found to have primary pleomorphic undifferentiated sarcoma of bladder with calcified pulmonary metastasis, confirmed with computerized tomography scan and immunohistochemistry.

Fetus in bladder.

This is the first reported case of vesicouterine fistula presenting with a fully formed dead fetus in the urinary bladder.

Primary repair vs Delayed staged repair in infants with primary obstructive megaureters and their long term outcomes - A single centre experience.

BACKGROUND: There is paucity of literature in the management of infants with primary obstructive megaureters undergoing upfront primary repair with an extravesical technique of ureteral re implantation (with or without ureteral tailoring). OBJECTIVE: To compare 2 different approaches in the management of infants with unilateral primary obstructive megaureters. STUDY DESIGN: This was a retrospective analysis of a prospectively maintained data base between 2005 and 2021. Infants <1 year with unilateral primary obstructive megaureter were included. They were divided into 2 groups: those who underwent an upfront extravesical ureteric reimplantation with or without ureteral tailoring during infancy -Primary Repair (PR), and those who initially underwent a low end cutaneous ureterostomy during infancy followed by take down of ureterostomy and intravesical ureteric reimplantation after 1 year of age -Delayed staged repair (DSR). Children presenting with sepsis, in whom a diversion was imperative, were excluded. All children were followed up annually after their definitive repair with a renal ultrasound, diuretic renogram, estimated glomerular filtration rate and assessment of voiding dysfunction if present. The 1st year and 3rd year follow up details were collated and analysed. Failure was defined as persistent obstructive pattern on renogram with worsening differential renal function or presence of high grade reflux with recurrent breakthrough urinary tract infection; both of which necessitated a redo reimplantation following the definitive surgery. RESULTS: There were 18 infants in Primary repair and 16 infants in Delayed Staged Repair. Urinary tract infections was the commonest presenting symptom amongst both groups i.e. > 50%.The post operative complication rate was 11% in Primary repair and 31% in Delayed Staged Repair. One child in each of the groups (2 girls) required redo reimplantation (5.8%). At the end of the 3rd year follow up (from the definitive repair) there was significant reduction in the hydronephrosis, improvement in the differential renal function with no evidence of obstruction and improvement in the estimated glomerular filtration rate amongst all in both groups which was statistically significant i.e. p < 0.05. The success rate was 94.4% in Primary Repair and 93.75% in Delayed Staged Repair. The mean follow up was 9.7 years amongst those undergone Primary Repair and 9 years amongst those undergone Delayed Staged Repair. DISCUSSION AND CONCLUSION: Primary extravesical ureteral reimplantation may be considered as the preferred line of management of unilateral obstructed megaureters during infancy.

Varicocelectomy in adolescents - Does it safeguard future fertility? A single centre experience.

BACKGROUND: There is paucity of literature comparing varicocelectomy to observant management amongst adolescent boys with hormonal and semen abnormalities resulting from high grade unilateral varicoceles and consequent testicular volume loss. Furthermore, it is not known whether surgical correction in such adolescents improves paternity rates in future compared to their non-operated cohort. OBJECTIVE: The primary objective was to compare adolescent boys with unilateral high grade varicocele with associated ipsilateral testicular volume loss who were operated versus those who were not, in relation to their fertility markers (hormonal, semen parameters, and testicular volume) over a 5 year follow up period. The secondary objective was to compare the paternity rates in the respective groups over long term. STUDY DESIGN: This was a single center, retrospective study of a prospectively maintained database conducted from 2010 to 2020, based on a standardized protocol. All adolescent boys >15 years of age (middle and late adolescence), with grade II or III unilateral varicoceles with abnormal fertility markers, who were operated (Group A) and not operated (Group B) were included. The changes in hormonal assay, sonographic assessment, semen analysis at presentation, 1st year and the 5th year follow up amongst both the groups were collated and analysed. Primary paternity rates amongst both the groups was documented by telephonic or email conversations. RESULTS: Of the 182 boys referred for varicocele management, 110 boys (Group A -70 boys and Group B - 40 boys) satisfied our inclusion criteria and were analysed. Mean age at presentation amongst Group A boys was 16.5 years (15-18 years) and Group B boys was 16 years (15-18 years). Grade III varicoceles were more predominant amongst both the groups. There was a significant improvement in all Group A boys (operated) in the fertility markers from the time at presentation to the 5th year follow up (p < 0.001). In Group B, (boys not operated) there was no significant improvement in the above parameters. The testicular catch up growth was 92% at the 5th year follow-up in Group A and 42% in Group B. At long term follow-up, the paternity rate was 80% and 36% in Group A and B respectively. DISCUSSION AND CONCLUSION: In adolescent boys in whom hormonal assay, testicular volumes and semen characteristics are negatively affected by high grade unilateral varicoceles, surgical correction could normalize these values, thereby safeguarding their fertility in the long term.

Application of the "Yang-Monti principle" in children with iatrogenic ureteral injuries.

BACKGROUND: Iatrogenic ureteral injuries in children are rare, due to its retroperitoneal position. The Yang -Monti ileal substitution serves as a good surgical option in such injuries associated with long segment defects of the ureter. OBJECTIVES: To review our experience using the Yang Monti principle of ileal ureter substitution in children with long segment ureteric defects and analyse its intermediate term outcomes. STUDY DESIGN: This was a prospective study, conducted from 2014 to 2019. All children with iatrogenic ureteral injuries with delayed presentations, undergoing the Yang Monti principle of ileal ureter substitution, were included (as illustrated in summary image). These injuries were divided into upper, mid, and distal ureteral injuries and were diagnosed based on a standardized protocol. At follow up, findings of the CT urogram, functional isotope renogram, and renal functions were the key points monitored. The demographic, clinical profile, operative, post-operative complications and follow up data were collated and analyzed. RESULTS: 22 children were diagnosed with iatrogenic ureteral injuries. Of these, 14 children with delayed presentations underwent the Yang Monti principle of ileal ureter substitution. The primary pathology was gangrenous appendicitis (9 cases), calculus cholecystitis (3 cases) and torsion ovary (2 cases). Laparoscopic procedures were the commonest approach for the injury (10). The average age was 11.5 years, with a male predominance. The right ureter was affected in 12 cases. The average time to detection was 7 days. All children underwent an ultrasound guided nephrostomy tube insertion at presentation and the mid ureter (9) was most affected. The mean length of ureteric injury was 3.75 cm. Intra operatively, one ileal segment (2), two ileal segments (11) and three ileal segments (1) were used according to the length of the ureteric defect. Complications were urinary tract infections (2), adhesions (3) and leak (2) which were conservatively managed with no redo surgeries. The median follow up period was 4 years. At follow up CT urogram and isotope diuretic renogram were normal, with preserved renal functions and no metabolic complications in all. DISCUSSION & CONCLUSION: In children associated with iatrogenic ureteral injuries of long lengths, the "Yang Monti ileal substitution" serves as a good and simple option with lesser complications permitting the preservation of the renal function at follow up.

Paediatric Buccal Mucosal Graft Urethroplasty for Non-Hypospadias Urethral Strictures: A Single Centre Experience with Long Term Outcomes.

OBJECTIVE: To review our experience in the management of paediatric urethral strictures with buccal mucosal graft urethroplasty and its long term outcomes. METHODS: This was a retrospective analysis of a prospectively maintained data base between 2009-2019. Circumcised children with long segment urethral strictures (> 1.5 cm) were included. They were characterized as either peno-bulbar (PBS) or isolated bulbar strictures (IBS) based on a standardized protocol. All children underwent single stage dorsal onlay buccal mucosal graft urethroplasty by either the Kulkarni technique (PBS group) or the Barbagli technique (IBS group). All children were followed up at 3 months, then annually thereafter with flow rates at each visit. Success was defined as a flow rate > 10ml/sec with a bell-shaped curve and absence of need for any secondary procedures. RESULTS: 28 children underwent buccal mucosal graft uretheroplasty.16 children were diagnosed with PBS & 12 children with IBS. The median age was 7.5 years (2-17 years) in PBS and 5.5 years (3-10 years) in IBS. Iatrogenic injury was the commonest aetiology ie 71 % (20/28). Mean length of stricture was 4 cm (3-5.5 cm) in PBS and 2.5 cm (2-3.5 cm) in IBS. Median follow up was 96 months (24-120 months) in PBS and 90 months (36-120 months) in IBS. The success rate was 87.5% (14/16) in PBS and 83.3% (10/12) in IBS. CONCLUSION: Single stage dorsal on lay buccal mucosal graft urethroplasty, ie Kulkarni and Barbagli techniques are safe and feasible in children with long segment urethral strictures with good long-term outcomes.

A single centre experience of percutaneous nephrolithotomy in infants and its long-term outcomes.

BACKGROUND: Renal stones in infants requiring Percutaneous nephrolithotomy (PCNL) is rare. There is insufficient literature on the long-term implications of PCNL in growing kidneys of these children. OBJECTIVES: To review our experience of PCNL amongst infants i.e., < 1year of age and to analyse the safety and efficacy of this procedure and assess its long-term renal outcomes. STUDY DESIGN: This was a retrospective analysis of a prospectively maintained data base between 2005 and 2020. All infants with unilateral renal stones >12 mm underwent PCNL. Changes in the serum creatinine, estimated glomerular filtration rate and renal size prior to the PCNL and at the last follow up were monitored. The demographics, clinical profile, operative details, post-operative complications and follow up data were collated and analyzed. RESULTS: 86 children were diagnosed with renal stones of whom, 24 infants met our inclusion criteria and were included in the review. The average age was 9.75 months with fever being the commonest presenting symptom. Five infants were diagnosed with metabolic abnormalities, hypercalciuria being the commonest. Majority of the infants (22) had single stones and the lower calyx was the commonest site (50%). The mean stone burden was 19.5 mm. The stone free rate was 91% during the primary PCNL, which increased to 100% after re-do PCNL. The overall complication rate was 16% which was graded by the modified Clavien Dindo scale for surgical complications. The median follow up period was 144 months and average age at the last follow up was 10.5 years. At the last follow up, a mean serum creatinine of 0.4 mg/dl, mean estimated glomerular filtration rate of 98 ml/min/1.72 m2 and a mean renal size of 8.3 cm was recorded, which was comparable to that of a normal child, thus signifying no deterioration of renal functions and renal growth. Three children showed the presence of cortical scars on an isotope scan at follow up. However, all the 24 operated renal units demonstrated preserved renal functions. DISCUSSION & CONCLUSION: PCNL performed during infancy does not hinder the growth potential of the kidney. Each of the 24 children achieved the target renal size and estimated glomerular filtration rate corresponding to the duration and body size at the end of the follow-up. Thus, PCNL in infants <1 year of age is safe and effective with no adverse effects at long term follow-up.

Laparoscopy training status in India and a review of the current resident skill standards.

CONTEXT: The aim was to identify the current training standard of laparoscopy skills among the urology residents. AIMS: This paper presents the residents' subjective perception of their laparoscopy skills and evidence of an objective assessment of their actual skills. SETTINGS AND DESIGN: An online survey was mailed, and completed by urology residents in training. The residents' perception of laparoscopy training received, exposure to laparoscopy procedures, and training facilities were queried. The assessment was done on the skill levels of the residents presenting at an annual training program. SUBJECTS AND METHODS: 103 residents responded to the online survey and 115 residents were assessed at the training program. STATISTICAL ANALYSIS USED: Discrete data were compared using the t-test to test for significance of the means; P < 0.05 was considered significant. Pearson's correlation coefficient was used to obtain the relationship between variables. RESULTS: An overwhelming 91% rated their laparoscopy skill as just "satisfactory" or worse, and 60% did not have any training facilities in their department. 66% continue to be "assistants only" in conventional laparoscopy surgeries. Assessment of basic laparoscopy skills in the dry lab revealed 92% of residents having poor laparoscopy skills; similar to the subjective opinion in the survey. Only 6% (n = 5) of the residents showed a good or better skill score in the dry lab; similar to the survey. CONCLUSIONS: Based on the survey, a large number of residents have a poor opinion of their own laparoscopy skills, and the training facilities available to them. The data objectively prove the self-assessment of the residents on their laparoscopy skill level.

Simultaneous antegrade and retrograde endoscopic surgery for benign prostatic hyperplasia with vesical calculi - A single-centre experience.

OBJECTIVE: To describe the effectiveness and safety of our novel technique of simultaneous percutaneous cystolithotripsy with transurethral resection of prostate (TURP) for patients with benign prostatic hyperplasia (BPH) complicated with large vesical calculi. PATIENTS AND METHODS: This was a retrospective analysis of 25 patients who underwent simultaneous percutaneous cystolithotripsy with TURP between January 2012 and January 2016. Technique: A 28-F Amplatz sheath was inserted percutaneously into the bladder after sequential dilatation under cystoscopic guidance. Percutaneous cystolithotripsy using a nephroscope and pneumatic lithoclast was then performed simultaneously along with monopolar TURP. Preoperative parameters reviewed included: patient's symptoms, International Prostate Symptom Score, uroflowmetry pattern, prostate volume, and stone burden on ultrasonography of the abdomen and pelvis. Postoperative parameters analysed included: duration of irrigation, time until catheter removal, length of hospital stay, and complications. RESULTS: The mean age of the patients was 67.8 years. The mean prostate size was 62.28 mL and the mean stone burden was 3.18 cm. The mean operating time was 54.2 min. The mean time until catheter removal was 3.2 days. CONCLUSION: Simultaneous percutaneous cystolithotripsy with TURP in patients with BPH with large bladder calculi is safe and feasible.

Evaluation of Jordan's meatoplasty for the treatment of fossa navicularis strictures. A retrospective study.

INTRODUCTION: Fossa navicular strictures can be a challenging problem for reconstructive urologists in which there is a need to achieve good cosmetic results along with a consistent stream. Our aim was to retrospectively evaluate the outcome of Jordan meatoplasty in the management of fossa navicularis strictures. MATERIAL AND METHODS: A total of 25 patients who underwent Jordan meatoplasty for the management of fossa navicularis strictures between 2011 and 2016 were retrospectively reviewed. All patients were evaluated with uroflometry. Preoperative retrograde urethrogram was performed in all patients to exclude proximal urethral strictures. The operative details including operative time were analyzed. All patients were evaluated for urinary pattern changes, irritative voiding symptoms and with uroflometry at the end of three months. Hypospadias objective score evaluation (HOSE) was applied at the end of three months for the evaluation of cosmetic outcome. RESULTS: The mean age of patients was 64 years and the mean operative time was 42 minutes. The mean follow up period was 30 months. The mean post-operative peak urine flow rate at three months after removal of the catheter was 18 ml per second. The meatus was slit shaped in 84%. Only 12% of patients complained of splay of urine at the end of three months. 96% of patients were stricture free, with one patient developing a recurrence at 12 months of follow up which was managed by urethral dilatation. CONCLUSIONS: Jordan meatoplasty is a feasible and easily reproducible technique for the management of distal penile strictures.

Management of recurrent anterior urethral strictures following buccal mucosal graft-urethroplasty: A single center experience.

OBJECTIVE: To describe the safety, feasibility and outcome of redo buccal mucosal graft urethroplasty in patients presenting with recurrent anterior urethral stricture following previous failed BMG urethroplasty. MATERIALS AND METHODS: This was a retrospective chart review of 21 patients with recurrent anterior urethral stricture after buccal mucosal graft urethroplasty, who underwent redo urethroplasty at our institute between January 2008 to January 2014. All patients underwent preoperative evaluation in the form of uroflowmetry, RGU, sonourethrogram and urethroscopy. Among patients with isolated bulbar urethral stricture, who had previously undergone ventral onlay, redo dorsal onlay BMG urethroplasty was done and vice versa (9+8 patients). Three patients, who had previously undergone Kulkarni-Barbagli urethroplasty, underwent dorsal free graft urethroplasty by ventral sagittal urethrotomy approach. One patient who had previously undergone urethroplasty by ASOPA technique underwent 2-stage Bracka repair. Catheter removal was done on 21(st) postoperative day. Follow-up consisted of uroflow, PVR and AUA-SS. Failure was defined as requirement of any post operative procedure. RESULTS: Idiopathic urethral strictures constituted the predominant etiology. Eleven patients presented with stricture recurrence involving the entire grafted area, while the remaining 10 patients had fibrotic ring like strictures at the proximal/distal graft-urethral anastomotic sites. The success rate of redo surgery was 85.7% at a mean follow-up of 41.8 months (range: 1 yr-6 yrs). Among the 18 patients who required no intervention during the follow-up period, the graft survival was longer compared to their initial time to failure. CONCLUSION: Redo buccal mucosal graft urethroplasty is safe and feasible with good intermediate term outcomes.

Laparoscopic extravesical detrusorraphy, a minimally invasive treatment option for vesicoureteral reflux: a single centre experience.

INTRODUCTION: Laparoscopy in pediatric patients offers more benefits than was earlier presumed and these widely reported benefits significantly outweigh any concerns regarding the technical difficulties. Laparoscopic correction of vesicoureteral reflux aims to duplicate the excellent results of open surgery while at the same time reducing perioperative morbidity and analgesic requirements, improving cosmesis and shortening hospital stay. OBJECTIVE: To share our experience of laparoscopic extravesical detrusorraphy, highlight our technical modification of intraoperative minimal "atraumatic" ureteric handling of the ureter, which we hypothesize may decrease ureteral complications, and report our results. STUDY DESIGN: This was a retrospective chart review of 76 toilet-trained children (98 refluxing units), in the age group of 3-16 years, with Grade I-IV reflux, who underwent laparoscopic detrusorraphy from June 2006 to January 2014. A ureteric catheter is inserted into the refluxing ureter and is tied to the Foleys to drain into a common bag. A three port technique is used. During ureteral dissection, a vascular sling in the form of a Rumel loop is used for atraumatic handling of the ureter. A detrusor tunnel is created with hook electrocautery. A stay suture is later passed through the abdominal wall and slings around the dissected ureter, which helps in holding the ureter approximated against the mucosal trough during detrusorraphy. Detrusor fibers are approximated with 5-0 Vicryl. No drain is placed and the Foley and ureteric catheter(s) are removed after 24 h. Intravenous ketorolac is given every 6 h for the first 24 h. Oral paracetamol is used for analgesia after the first 24 h. Adequate bladder emptying is ensured by assessment of post void residual urine before discharge. Renal USG alone is performed 2 weeks post operatively and repeated after 3 months along with a VCUG (voiding cystourethrography). Success was defined as absence of reflux in the follow-up VCUG done at 3 months. RESULTS: Mean operative time was 102 ± 26.5 min for unilateral detrusorraphy and 165 ± 18 min for bilateral extravesical detrusorraphy. The mean duration of hospital stay was 1.5 ± 1.7 days. There was one case of urinary retention that was managed with temporary recatheterization. There were no cases of ureteral ischemia, obstruction, hematuria or bladder spasms. Surgery was successful in 97.9% of the refluxing units (96/98). In two patients with grade IV reflux, there was downgrading to grade II on VCUG done at 3 months' follow-up. The reflux resolved at 8 and 14 months' follow-up, respectively. DISCUSSION: Our technique of atraumatic handling of the ureter, initially with the help of a vascular sling and later with the help of a stay suture passed percutaneously through the abdominal wall, resulted in no ureteric injuries. The postoperative morbidity of this procedure is low because the bladder is not opened, the ureter is not transected, no new UVJ is created and there is no need for placement of a drain. The risk of postoperative bowel adhesions is low as the ureter is dissected out through a narrow peritoneal window, which is again extraperitonealized at the end of the procedure (see figure). The postoperative complications of gross hematuria and bladder spasms, which may be especially encountered in patients undergoing laparoscopic Cohen's, were not seen in our case series. CONCLUSION: Laparoscopic extravesical detrusorraphy provides a minimally invasive treatment option for treatment of unilateral/bilateral grade I-IV vesicoureteral reflux. The postoperative morbidity is low and the success rate is favorable. Our technical modification of a "vascular sling" around the ureter facilitates atraumatic ureteric handling, which may reduce distal ureteral complications like ureteral ischemia and obstruction.