Retroperitoneoscopic nephrolympholysis and ureterolysis for management of intractable filarial chyluria.

PURPOSE: To evaluate the feasibility of retroperitoneoscopic lymphatic disconnection in patients with intractable filarial chyluria with the aim of reducing the morbidity of the surgery. PATIENTS AND METHODS: Two patients presented to us with intractable chyluria. They did not respond to conservative measures and endoscopic sclerotherapy. In view of the severe lipid and protein loss associated with recurrent bouts of chyluria, they merited surgical correction by lymphatic disconnection. Because this operation requires extensive mobilization within the retroperitoneum over a large area, it necessitates a large flank or midline incision. In order to reduce the incision-related morbidity, it was decided to undertake the procedure laparoscopically. The retroperitoneal route was chosen for its obvious advantages. RESULTS: Surgery was carried out uneventfully in both patients, with a mean operating time of 2 hours. The patients stayed in the hospital for an average of 2.5 days. Chyluria resolved in the immediate postoperative period, and they have been asymptomatic over a follow-up of 30 and 18 months. One patient had drainage of lymph for 5 days, which resolved spontaneously. CONCLUSIONS: The objectives of open surgery can be achieved by the minimally invasive approach of retroperitoneoscopy. The new approach significantly reduces the incision-related morbidity without compromising the principles of open surgery. We propose five important steps necessary to avoid recurrence and reduce postoperative morbidity.

Retroperitoneoscopic nephrectomy for benign diseases of the kidney: prospective nonrandomized comparison with open surgical nephrectomy.

PURPOSE: To describe, define, and evaluate the efficacy of retroperitoneoscopic nephrectomy (RPN) for benign diseases of the kidney and to compare it with open surgical nephrectomy (OSN) via a flank approach. PATIENTS AND METHODS: From August 1995 to November 1997, 29 men and 14 women (mean age 33 years) with severely damaged kidneys underwent RPN. Among these, 11 patients had undergone prior surgery, 3 had chronic renal failure, and 8 patients had a percutaneous nephrostomy. The RPN was performed via three or four ports, with the kidneys being removed intact from the retroperitoneal working space. During the same period, 43 patients underwent OSN through a flank approach (extrapleural and extraperitoneal) for nonfunctioning or poorly functioning kidneys. RESULTS: In the RPN group, two patients required conversion to OSN. The operative time and estimated blood loss ranged from 40 to 210 minutes (mean 114 minutes) and 50 to 450 mL (mean 127 mL), respectively. In the OSN group, the corresponding values were 60 to 100 minutes (mean 104 minutes) and 70 to 600 mL (mean 266 mL), respectively. The mean length of hospitalization after RPN was considerably shorter--2 to 7 days (mean 3.4 days)--than after conventional open surgery--4 to 16 days (mean 8.6 days). The incidences of minor and major complications were 21% and 5%, respectively, in the RPN group and 33% and 2% in the OSN group. The postoperative analgesic requirement was significantly less (P < 0.001) in RPN group. The interval to return to normal activity ranged from 7 to 30 days (mean 20.3 days) and 20 to 60 days (mean 32.9 days) in the RPN and OSN group, respectively, with superior performance status, cosmesis, and quality of life observed in the former group. CONCLUSION: Retroperitoneoscopic nephrectomy is as effective as open nephrectomy for benign kidney diseases with less postoperative pain, a shorter hospital stay, earlier recuperation, and excellent cosmesis. This procedure can also be performed in patients who have undergone abdominal operations previously, in those with chronic renal failure, and in those with a percutaneous nephrostomy. The operation has become our first line of approach for benign diseases of the kidney.

Carcinoma penis in a young boy. A case report.

Carcinoma of the penis below the age of fifteen years is a rarity. A 14 year old boy presenting with advanced carcinoma penis with bilateral fungating inguinal lymphadenopathy is the subject of this case report.

Primary obstructive megaureter in adults: need for an aggressive management strategy.

PURPOSE: Primary obstructive megaureter (POM) is an uncommon disease in adults. We reviewed our experience with this disease to determine the clinical profile, management and prognosis of this disease in adults. METHODS: We studied 37 adults with POM who presented from January 1989 to December 1998. Their clinical presentation, renal function, radiologic data, complications, treatment as well as the results and follow-up were studied. RESULTS: The patients' age ranged from 13 to 52 years. Male:female ratio was 27:10. Seven patients had bilateral disease. All patients were symptomatic excepting 2. Complications at presentation were loin pain (26 cases), urinary infection (15 cases), calculus disease (17 cases), azotaemia (5 cases), and obstructive jaundice (1 case). Associated congenital anomalies included contralateral renal agenesis (2 cases), posterior urethral valve (1 case) and exstrophy of bladder (1 case). Thirty-four patients required surgical intervention. Of these, 26 patients underwent ureteroneocystostomy (UNC) with ureteral tailoring in 18 patients; 4 patients were treated endoscopically by ureteric meatotomy and stenting, 2 patients with nonfunctioning kidney by nephroureterectomy, 2 patients in advanced renal failure by percutaneous nephrostomy alone. In 4 out of 5 patients uraemia did not improve despite adequate drainage. CONCLUSION: The majority of adults with POM are symptomatic, have complications and require surgical correction. Complications of stone formation (46%) and renal failure (13.5%) are unusually common in adults. Once renal failure is advanced, intervention appears futile, therefore, it is imperative to treat these patients as soon as possible. Surgical correction by ureteric re-implantation is effective and has low morbidity.

Vivax malaria causing priapism.

We report a 14 year old boy who had priapism induced by vivax malaria. The onset was latent and course was protracted, refractory to anti-malarial and conservative treatment, but satisfactory detumescence was achieved after surgical intervention.

Management of urinary tract calculi by extracorporeal shock wave lithotripsy.

From July 1989 to April 1993, Extracorporeal Shockwave Lithotripsy (ESWL) was performed on 642 patients, of which 21 were from the pediatric age group. All treatments were done on a second generation lithotriptor-Siemens Lithostar, which does not require any modification for positioning of children. Fragmentation was achieved in all the patients (100%). A complete stone free rate was achieved in 17/21 patients (80.9%). Three (14.3%) patients had insignificant residual fragments whereas 1 (4.8%) had a residual fragment approximately 4 mm in size. 5640 shocks were required on an average. We have used low energy shockwaves with good results. General anesthesia was required for lithotripsy in only one child. The average fluoro exposure time was 1.6 minutes. We conclude that ESWL is a safe and effective method for treating urinary tract calculi in children.

[Transient compensatory hypertrophy and limited regeneration of the surgically removed rat ventral prostate].

OBJECTIVES: To confirm whether regeneration of prostate lobe indeed takes place on surgical lobectomy and if so, to what extent. Other issues studied are 1. whether the lobe regenerated is similar morphologically to that developing normally from neonatal origin to adulthood, and 2. the consequences of partial lobectomy on the contralateral lobe and the influence of sex steroid hormones on the regeneration process. METHODS: The effect of surgical removal of one of the ventral prostate lobes on the size of the contralateral lobe has been studied at various time intervals after lobectomy. RESULTS: The surgically extirpated ventral prostate lobe in rats regenerates attaining plateau size at 8-16 weeks post lobectomy. The regenerated lobe, however, remains significantly smaller than the original size. In early phase of post lobectomy (at 2 weeks) the contralateral lobe was significantly hypertrophied. It reverts to normal size on regeneration of the extirpated lobe with time. Orchiectomy carried out at the time of lobectomy caused a drastic reduction in the size of the remaining lobe, which was prevented by exogenous treatment with androgens. In animals receiving treatment with estrogens, the remaining lobe was partially but not fully atrophied. However, estrogens did not support the regeneration of the surgically removed lobe, which requires androgens. CONCLUSIONS: These studies demonstrate that surgical removal of one of the ventral prostate lobe leads to a process of regeneration. However, the regenerated lobe does not attain the normal size.

Day care urology in a hospital based setting.

From January 1, 1991 to December 31, 1992, 3078 operations were performed on day care basis and 1185 operations on in-patient basis. Surgery performed on day care basis included ureteric stone basketing, ureteroenoscopic stone retrieval, JJ stenting, cystolithotripsy, TUR-BT, TUR-P and internal urethrotomy. Failure of complication rate was 0.97%. Most of the complications (26/29) could be detected early and managed by conversion of short admission into a regular one. Only 3 patients (0.1%) were admitted later on through the emergency. There was no mortality. In conclusion, we recommend urologic operative procedures on carefully selected patients on day-care basis to achieve two of the government's primary goals a) the provision of high quality services and b) the reduction of health care costs. Simultaneously a word of caution that it is unique challenge to be handled with care.

Intracorporeal lithotripsy with the Swiss lithoclast.

OBJECTIVE: To evaluate the use of the Swiss lithoclast in the management of urinary calculi. PATIENTS AND METHODS: Between January and November 1993, 60 patients with a total of 61 urinary calculi were treated with the Swiss lithoclast. Forty patients had a ureteric calculus, two had a ureterocele with a calculus, one a steinstrasse, 16 a vesical stone and two a urethral calculus. Eighty per cent of patients were treated on a day-care basis. RESULTS: Fragmentation of the urinary calculi was successful in 59 of the 60 patients. Both patients with a urethral calculus and 15 of 16 with a vesical calculus were stone-free after the procedure. All those with a ureteric calculus were stone-free at 6 weeks. There were no intra-operative or long-term complications directly related to the use of the Swiss lithoclast. CONCLUSION: The results of this study show that the Swiss lithoclast is a simple, safe, reliable and economical method of endoscopic lithotripsy for the treatment of urinary tract calculi. Although the lithoclast's use is limited to rigid or semi-rigid endoscopes there is now a suction facility for the immediate removal of small stone fragments.