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.

Micro-vascular complications of post-transplant diabetes mellitus in renal transplant recipients- an observational study.

INTRODUCTION: The incidence of post-transplant diabetes mellitus (PTDM) ranges from 2.5% to 20% in kidney transplant recipients. Diabetic retinopathy (DR), diabetic kidney disease (DKD), and distal symmetric polyneuropathy (DSPN) are the microvascular complications frequently seen in both type 1 and 2 diabetes mellitus (DM). However, the data regarding these complications in patients with PTDM is lacking. METHOD: A retrospective and prospective observational study of PTDM conducted at a tertiary care hospital from November 2018 to December 2020. 115 kidney transplant recipients who had PTDM of ≥5 years duration were included and analysed. RESULTS: The mean duration of PTDM was 8.8 ± 3.0 years, and the mean of all available HbA1c values was 7.0 ± 0.9%. while none of the patients had evidence of diabetic retinopathy on direct ophthalmoscopy, 37.4% of patients (n = 43) had DSPN and this was associated with the duration of PTDM and age. The mean estimated glomerular filtration rate (eGFR) was 59.24 ± 21.82 ml/min/1.73m2, and patients had a median proteinuria of 620 mg/day (IQR 1290). Out of 115 patients, 20% of them (n = 23) underwent graft kidney biopsy, and 10 biopsies were diagnosed as de-novo DKD. Patients with biopsy proven DKD had a mean PTDM duration of 143.3 ± 52.4 months; a mean HbA1c level of 7.9 ± 1.3%; a mean eGFR of 44.8 ± 21.8 ml/min; and a median proteinuria of 2653 mg (IQR 2758). An additional analysis of all 23 biopsied patients showed that HbA1c level and degree of proteinuria were significantly associated with de-novo DKD. CONCLUSION: PTDM in transplant patients had milder microvascular complications than usually expected in Type 1/2 diabetes in non-transplant patients. DR was not strongly associated with DKD in PTDM patients. Furthermore, de-novo DKD development was associated with poor glycaemic control and increased proteinuria.

Comparison of palonosetron and ondansetron in preventing postoperative nausea and vomiting in renal transplantation recipients: a randomized clinical trial

Abstract Background: End-stage renal diseases patients have a high risk of postoperative nausea and vomiting (PONV), which is multifactorial and need acute attention after renal transplantation for a successful outcome in term of an uneventful postoperative period. The study was done to compare the efficacy of palonosetron and ondansetron in preventing early and late-onset PONV in live donor renal transplantation recipients (LDRT). Methods: The prospective randomized double-blinded study was done on 112 consecutive patients planned for live donor renal transplantation. Patients of both sexes in the age group of 18-60 years were randomly divided into two groups: Group O (Ondansetron) and Group P (Palonosetron) with 56 patients in each group by computer-generated randomization. The study drug was administered intravenously (IV) slowly over 30 seconds, one hour before extubation. Postoperatively, the patients were accessed for PONV at 6, 24, and 72 hours using the Visual Analogue Scale (VAS) nausea score and PONV intensity scale. Results: The incidence of PONV in the study was found to be 30.35%. There was significant difference in incidence of PONV between Group P and Group O at 6 hours (12.5% vs. 32.1%, p = 0.013) and 72 hours (1.8% vs. 33.9%, p < 0.001), but insignificant difference at 24 hours (1.8% vs. 10.7%, p = 0.113). VAS-nausea score was significantly lower in Group P as compared to Group O at a time point of 24 hours (45.54 ± 12.64 vs. 51.96 ± 14.70, p = 0.015) and 72 hours (39.11 ± 10.32 vs. 45.7 ± 15.12, p = 0.015). Conclusion: Palonosetron is clinically superior to ondansetron in preventing early and delayed onset postoperative nausea and vomiting in live-related renal transplant recipients.

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.

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.

Percutaneous nephrostomy in Ureteropelvic junction obstruction with poorly functioning kidney: Is it still pertinent in adults?

OBJECTIVE: To determine the pertinence of percutaneous nephrostomy drainage in adult patients of primary ureteropelvic junction obstruction with poorly functioning kidneys (<20% split renal function). MATERIAL AND METHODS: Clinical records of all patients with primary ureteropelvic junction obstruction with poorly functioning kidneys who underwent percutaneous nephrostomy drainage in our institute between February 2015 and January 2020 were retrospectively reviewed. The patients were divided into 4 groups according to their split renal function obtained from the Tc-99m ethylenedicysteine diuretic renogram. Group I consisted of all patients having split renal function ≤5%, group II with split renal function 6-10%, groupIII with split renal function 11-15%, and finally group IV with split renal function 16-20%. Those patients inwhom split renal function was improved by >10% and had daily percutaneous nephrostomy output >400 mL, underwent pyeloplasty and the rest underwent nephrectomy. RESULTS: Seventy-two patients were studied, out of which 5 were in group I, 20 in groups II and III each, and27 in group IV. The mean age of presentation was 34.4 ± 14 years. The split renal function improvement of>10% was seen in 55 patients (76.4%) after percutaneous nephrostomy drainage (P < .05). Pyeloplasty wasdone in 40 patients (55.6%) and nephrectomy was done in 32 patients (44.4%). CONCLUSION: In conclusion, we recommend the use of a Tc-99m ethylenedicysteine scan for estimation of split renal function during the initial presentation in every patient followed by reconstructive surgery if split renal function is above 15% and nephrectomy if it is below 5%. The trial of percutaneous nephrostomy is pertinent if split renal function is between 6% and 15%.

Safety and efficacy of retrograde intrarenal surgery in primary and residual renal calculi in children.

BACKGROUND: Minimal invasive approach is the current standard of care in the management of pediatric renal calculi. Current guidelines are clear with extra corporal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) for stone size less than and greater than 20 mm respectively. Although retrograde intrarenal surgery (RIRS) is well established in adults but literature on its role, safety and efficacy in children is sparsely available. OBJECTIVE: To share our experience of RIRS and its outcome in a pediatric population in both primary and residual calculi of size less than 20 mm. MATERIALS AND METHODS: We retrospectively analysed data of children who underwent RIRS for either primary or residual renal calculi from January 2017 to January 2021. Children less than 5 years underwent passive ureteric dilatation with stenting preoperatively. A7.5 Fr flexible ureteroscope with an access sheath was used in all cases while performing RIRS. All the patients had a stent left in situ at the end of the procedure. Data including stone burden, number of sittings, operative time, stone-free rate (SFR) and grade of post procedural complications were analysed with appropriate statistical methods. RESULTS: A total of 20 patients were included in this study. The median age at presentation was 9 years ranging from 9 months to 18 years. Eight patients (40%) presented with primary renal calculi and underwent RIRS directly while the rest of the 12 (60%) had residual calculi following other procedures like SWL, PCNL before undergoing RIRS. Seven patients (35%) had congenital renal anomalies. The mean stone size and operating time (OR) was 12.6 ± 3.2 mm 84.5 ± 7.2 min respectively. The post-procedural complications were seen in 4 (20%) patients in the form of Grade-1 modified Clavein classification in 3 and Grade 2 in 1 patient. The 100% stone-free rate was achieved in 80% of the cases after first attempt. DISCUSSION: In the present series, RIRS was effective in both the types of stones (primary and residual) less than 20 mm in size, showing 100% stone free rate with maximum of two attempts. Choosing age based optimised passive ureteric dilation led to injury free access for RIRS. Overall complications remained with in low grades and are comparable to current literature. Limitations of the study include small cohort, retrospective study and the need of three anaesthesia procedures in children under 5 years of age. CONCLUSION: RIRS is safe and effective in children with a renal stone(s) less than 20 mm and it has a high success rate in term of achieving stone free status in both primary and residual calculi.

Evanescing renal allograft cortical necrosis from living donor renal transplantation: A lesson learned over two decades.

BACKGROUND: Renal graft cortical necrosis (GCN) is a catastrophic cause of graft failure. We evaluated the incidence, causes, management, and outcome of GCN across two decades from our center. METHODS: This is a retrospective analysis of transplant patients who had biopsy-proven GCN transplanted between 2000 and 2020. The clinical details, immunological workup, induction, maintenance regimen, causes of cortical necrosis, and the outcomes were compared between the first period 2000-2012, and the second period 2013-2020, when Flow cytometric and Luminex based crossmatch were included in the workup plan. RESULTS: Among 2333 live ABO-compatible renal transplants, 37 (0.015%) patients (36 patients between 2000 and 2012 and 1 between 2013 and 2020) developed GCN (60% had diffuse and 40% patchy GCN) at a median of 8 days after transplantation.Twenty-six (60%) received ATG, 4 received plasmapheresis and ATG (10.8%) as antirejection therapy. The cyclosporine-based regimen was associated with a higher risk of GCN (RR 2.54; 95% CI 1.26 to 5.12, p = 0.009), whereas tacrolimus-based therapy had a lower risk (RR 0.39; 95% CI 0.19 to 0.79, p = 0.009). The introduction of flow cytometry and DSA assay has significantly decreased the incidence of acute rejection and GCN. Only one patient had GCN during the 2013-2020 period because of graft's mucormycosis. Twenty-five (67.56%) patients had no recovery, and 12 (32.43%) had partial recovery of graft function. CONCLUSION: GCN is mainly associated with rejection, and cyclosporin-based maintenance regimen had a higher incidence. The remarkable decrease in GCN after 2012 onwards could be attributed to the use of Flowcytometry, Luminex-based DSA assays, and tacrolimus-based regimens.

A Computed Tomography Angiography (CTA): Based score (SGPGI score) to predict level of difficulty, operative, and postoperative outcomes for right-sided radical nephrectomy.

OBJECTIVE: With the advent of laparoscopic approach for the large (T1b-T3a ± N1) right renal masses, higher rates of complications and conversion to open surgery are being reported. The role of preoperative angioembolization (PAE), which has increased cost and inherent morbidity but may help in select circumstances has also not been clearly defined in the literature. We therefore devised a scoring system (SGPGI score) based on pre-operative Computed Tomography Angiography (CTA) to predict the level of difficulty of radical nephrectomy and enhance its safety and efficacy which could also be used for the judicious use of PAE in selected cases. METHODS: In a prospective observational study on 52 patients with right renal masses from January 2014 to July 2018, we calculated a score based on CTA parameters. The patients were stratified for type and duration of surgery, blood loss, postoperative stay, and Clavien-Dindo grade of postoperative complications. RESULTS: Patients were classified into three groups based on our scoring system. Progressively groups with higher score had higher blood loss, operating time, complications and hospital stay, and were more likely to have undergone conversion to open surgery (Area under curve 0.8625 for a cut off score of 10). Intraclass Correlation Coefficient (ICC) was 0.678-1 for the different components of our score. CONCLUSION: The pre-operative CTA based SGPGI score evaluates right renal masses and is able to predict intra-operative difficulties effectively, leading to enhancement of surgery safety and efficacy. It also helps judiciously use PAE.

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.

A prospective randomized study to define the role of low dose continuous prophylactic antibiotics and anti-adherence agents in altering the microbial colonization related to indwelling double-J stents.

OBJECTIVE: Despite conflicting evidence, it is common practice to use continuous antibiotic prophylaxis (CAP) in patients with indwelling double-J (DJ) stents. Cranberry extracts and d-mannose have been shown to prevent colonization of the urinary tract. We evaluated their role in this setting. METHODS: We conducted a prospective randomized study to evaluate patients with indwelling DJ stents following urological procedures. They were randomized into three groups. Group A (n=46) received CAP (nitrofurantoin 100 mg once daily [OD]). Group B (n=48) received cranberry extract 300 mg and d-mannose 600 mg twice daily (BD). Group C (n=40) received no prophylaxis. The stents were removed between 15 days and 45 days after surgery. Three groups were compared in terms of colonization of stent and urine, stent related symptoms and febrile urinary tract infections (UTIs) during the period of indwelling stent and until 1 week after removal. RESULTS: In Group A, 9 (19.5%) patients had significant bacterial growth on the stents. This was 8 (16.7%) in the Group B and 5 (12.5%) in Group C (p-value: 0.743). However, the culture positivity rate of urine specimens showed a significant difference (p-value: 0.023) with Group B showing least colonization of urine compared to groups A and C. There was no statistically significant difference in the frequency of stent related symptoms (p-value: 0.242) or febrile UTIs (p-value: 0.399) among the groups. CONCLUSION: Prophylactic agents have no role in altering bacterial growth on temporary indwelling DJ stent, stent related symptoms or febrile UTIs. Cranberry extract may reduce the colonization of urinary tract, but its clinical significance needs further evaluation.

The Adequacy of Pelvic Lymphadenectomy During Radical Cystectomy for Carcinoma Urinary Bladder: A Narrative Review of Literature.

An adequate pelvic lymph node dissection (PLND) is an essential part of radical cystectomy for muscle invasive bladder cancer. However, the definition of what constitutes an adequate PLND is often shrouded in controversy. Various authors have defined different anatomic templates of PLND based on levels of pelvic lymph nodes. Some have suggested other surrogate markers of the adequacy of PLND, namely lymph node count and lymph node density. While individual studies have shown the efficacy and reliability of some of the above markers, none of them have been recommended forthright due to the absence of robust prospective data. The use of non-standardized nomenclature while referring to the above variables has made this matter more complex. Most of older data seems to favor use of extended template of PLND over the standard template. On the other hand, one recent randomized controlled trial (RCT) did not show any benefit of one template over the other in terms of survival benefit, but the study design allowed for a large margin of bias. Therefore, we conducted a systematic search of literature using EMBASE, Medline, and PubMed using PRISMA-P checklist for articles in English Language published over last 20 years. Out of 132 relevant articles, 47 articles were included in the final review. We have reviewed existing literature and guidelines and have attempted to provide a few suggestions toward a uniform nomenclature for the various anatomical descriptions and the extent of PLND done while doing a radical cystectomy. The results of another large RCT (SWOG S1011) are awaited and until we have a definitive evidence, we should adhere to these suggestions as much as possible and deal with each patient on a case to case basis.

Role of ureterocalicostomy in management of giant hydronephrosis in children in contemporary practice: Indications, outcomes and challenges.

INTRODUCTION: Given the rarity of giant hydronephrosis (GH), ideal surgical approach, assessment of drainage after surgery, expected improvement in renal function and morphological changes in the kidney on follow up have not been studied extensively. The aim of this study was to investigate the role of ureterocalicostomy (UC) in unilateral GH with respect to its current indications, outcomes and the challenges associated with it. MATERIALS AND METHODS: We retrospectively analysed data of 25 children (up to the age of 18 years) who underwent UC between January 2008 and January 2019 using open, laparoscopic or robotic-assisted approach. Preoperative workup included ultrasonography for pelvic anteroposterior diameter (APD) and cortical thickness (CT), and diuretic scan for split renal function (SRF) and drainage. Patients were followed with ultrasonography and diuretic renal scan at 3 months, after further 6 month and then annually. RESULTS: The median age was 7 years and median follow-up was 22 months. Eight children underwent UC as salvage procedure while 17 children underwent UC as an upfront procedure. APD declined significantly (p < 0.001) and CT improved significantly (p = 0.009) after surgery. The drainage as well as SRF did not change significantly after surgery. Four children developed flank pain after stent removal; one required a redo-ureterocalicostomy for anastomotic stricture while another required balloon dilatation of the anastomosis. Two children responded to prolonged stenting for 2 months. DISCUSSION: Ultrasonography (APD, CT), Diuretic renal scan (SRF and drainage pattern) are used to monitor HDN. APD is particularly important in GH because the diuretic renogram invariably shows an obstructive drainage owing to the large volume of the pelvicalyceal system. Similar to previous studies in literature, we too reported a decline in APD. CT improved in our study, however, the drainage pattern as well as SRF did not change significantly (Figure). Diuretic scan in isolation was not sufficient to predict failure. A combination of ultrasonographic and diuretic scan parameters were useful for follow up and for detection of failure. The success rate in our study was 92%. Chief limitations of our study were retrospective nature and lack of comparison with pyeloplasty. Moreover, some cases were performed with minimal invasive techniques, so the study group was heterogenous. CONCLUSIONS: UC offers excellent outcome in children with GH due to primary as well as secondary UPJO. Isolated ultrasonographic or diuretic renogram parameters are not sufficient to predict failure and a combination of them should be used for follow up after UC.

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.

Crossed unfused renal ectopia with pelviureteric junction obstruction associated with nephrolithiasis: a rare troublesome triad managed by robotic surgery.

We report a rare case of non-fused renal ectopia with pelviureteric junction obstruction and multiple pelvic and renal calculi thereby discussing vascular anatomy of the non-fused ectopic kidney along with robot assisted surgical management of this rare clinical entity which amounts for good preoperative workup for best surgical and clinical outcome.

Presentation, treatment and outcomes of pediatric anterior urethral strictures: 28 years' experience from a referral center.

BACKGROUND: Pediatric urethral strictures are an uncommon entity, with the anterior urethra being the most common affected location, similar to adults. The, literature on outcomes in these strictures is limited, especially in the non-traumatic group, as most of the studies have included hypospadias related "neourethral" strictures and posterior strictures, thereby making interpretation difficult. It is for these reasons we decided to search our database to identify the different surgical procedures used and analyze the outcomes of interventions in these children and adolescents with anterior urethral strictures. OBJECTIVE: To report the treatment strategies and outcomes in a series of 119 pediatric anterior urethral strictures, identified in a 28-year period in a high-volume tertiary center. MATERIALS AND METHODS: A retrospective case-note review of all cases of pediatric anterior urethral strictures was done. Data on the clinical presentation including age at presentation, characteristics of strictures identified, primary intervention and additional secondary procedures and outcomes were collected. RESULTS: We identified 119 boys with anterior urethral strictures with commonest location being the bulbar urethra (60.5%). Sixty patients (50.4%) in this cohort underwent minimally invasive intervention in the form of dilatation or direct visual internal urethrotomy (DVIU) with the rest undergoing open intervention. The primary success rate was 87.1% (101/116) at a median follow-up of 29 (IQR 21-38) months. Idiopathic urethral stricture and iatrogenic strictures had better success rate of 92.5% and 82.1% than traumatic strictures (78.9%) and it was lowest for those traumatic strictures that were treated with DVIU (66.7%). Multifocal strictures had comparatively poorer outcomes (62.5%) compared with penile or bulbar strictures, with worst outcomes (44.4%) in those treated with substitution urethroplasty. Length >1 cm, multifocality and treatment with substitution urethroplasty were significantly associated with recurrence. Three boys with strictures associated with anorectal malformations were a particularly difficult group and needed multiple intervention and had poor outcomes. CONCLUSION: Based on our study, we recommend a minimally invasive approach for short segment, bulbar strictures, especially of idiopathic etiology. For other locations and longer strictures, we recommend urethroplasty. Caution must be exercised to avoid underestimation of the actual pathology of the stricture. Caretakers of children with complete bulbar level blockage associated with anorectal malformations undergoing urethroplasty should be explained about the need for multiple interventions and possibility of poor voiding outcomes.

Permanent perineal urethrostomy for anterior urethral strictures: A critical appraisal of long-term outcomes and erectile function.

OBJECTIVE: In complex strictures, especially in elderly patients, perineal urethrostomy (PU) provide excellent voiding function. This study aimed at evaluating the long-term voiding and erectile function of PU as a permanent procedure for such strictures. MATERIAL AND METHODS: We retrospectively evaluated 146 patients who underwent permanent PU at our institution from January 2000 to December 2018. All patients had complex urethral strictures. Patients with posterior urethral involvement were excluded. Patients were followed up at 3 months and then yearly. Failure was defined as the need for any additional procedures. They were also evaluated with the International Index of Erectile Function (IIEF-5) questionnaire. Fisher's exact test and χ2 test were used for statistical analysis. RESULTS: The median age at the time of surgery was 58±7.3 years. The mean stricture length was 6.5±2.1 cm. All the patients had a history of previous surgery, and the average number of procedures per patient was 2.4. The median follow-up period was 26 months. The most common early and late postoperative complications were bleeding and stenosis of the urethrostomy, respectively. A total of 129 (88.3%) patients had a successful surgery. The number of patients with no erectile dysfunction increased from 55.4% to 67.8% after PU. The mean IIEF-5 score improved from 20.07 to 21.31 after PU, but this did not achieve statistical significance (p=0.3558). CONCLUSION: Permanent PU is an acceptable option for complex long-segment anterior urethral strictures, especially in elderly patients, with an excellent long-term outcome. A majority of patients also maintain a satisfactory erectile function.

"When ablation goes wrong"- urethral strictures after ablation of posterior urethral valves-characteristics, management and outcomes".

BACKGROUND: Post-ablation urethral strictures are a rare but devastating complication following transurethral ablation of posterior urethral valve which can be more difficult to treat than the valve itself. Though with the miniaturization of scopes the incidence of these strictures has decreased, sadly they still continue to occur. Hence, literature on these strictures is also limited due to the rarity of occurrence. OBJECTIVE: To analyze the management strategies and outcomes of post-valve-ablation urethral strictures managed in a tertiary care center. MATERIALS AND METHODS: A retrospective review of all boys with the diagnosis of urethral strictures who had undergone management in our center from January 2000 to July 2017, with a minimum follow-up data for 12 months following interventions was done and among them the subset who developed strictures following valve ablation were identified. We also included those patients who had been referred for management of strictures following ablation elsewhere and had all their preoperative and operative details recorded. Out of a total of 199 boys who had undergone management of stricture during this time period, 13 boys with stricture of urethra following valve ablation were identified and studied. The history, presentation, timeline of events leading to stricture formation, possible predisposing factors, characteristics of strictures, mode of management and outcomes were recorded. RESULTS: Among the 13 boys, 5 had developed strictures following in-house fulguration while 8 developed strictures following ablation elsewhere. The median age at diagnosis in these patients was 8 years (range, 3-18). The length of stricture varied from very short in the proximal bulbar to long penobulbar stricture. Median length of strictures was 10 mm (range: 3-35). Of the 9 patients who underwent primary endoscopic intervention, 8 had successful outcomes (88.7%) while one patient ultimately required open urethroplasty. Of the 4 patients who had open intervention, except the patient who underwent meatoplasty, the rest needed multiple surgical and endoscopic interventions. Median follow up period was 20 months (range: 12-68). CONCLUSION: Urethral Stricture disease continues to be a rare but significant complication of valve ablation. Post ablation stricture can happen in any part of the urethra. Our data suggests that if a DVIU or dilatation is to be implemented for the treatment of a stricture after ablation, it may be most suitable for short, proximal strictures. Proper technique of valve ablation by a dedicated pediatric urologist using a proper sized resectoscope with proper isolation of electrode from the rest of urethral wall is crucial to prevent these strictures.

Efficacy and Safety of Supracostal Access for Mini Percutaneous Nephrolithotomy in Pediatric Patients.

OBJECTIVE: To evaluate the efficacy and safety of supracostal percutaneous nephrolithotomy (PCNL) through the 11th intercostal space and compare it with subcostal PCNL in children with renal calculi. MATERIALS AND METHODS: Children with renal calculi who underwent PCNL between January 2010 and December 2017 were divided into 2 groups: supracostal PCNL (group 1) and subcostal PCNL (group 2). Stone location, stone burden, location of the access points, operative time, postoperative visual pain score, success rate, hospital stay, and complications according to the modified Clavien classification were compared. Comparison of medians was done using Mann Whitney U test and the means were compared using t test. RESULTS: Group 1 had 50 patients while group 2 had 60 patients. The stone-free rate was 84.0% and 85.0% in groups 1 and 2, respectively after 1 session of PCNL (P = .885). After auxiliary procedures, it increased to 96.0% and 96.6%, respectively (P = .852). The mean fall in hematocrit was 0.9% in group 1 and 1.5% in group 2 (P = .11) whereas the median pain score was 4 in group 1 and 3 in group 2 (P = .37). In all, 54 complications were recorded the commonest among which were grade I (81.5%). Twenty-nine complications were observed in group 1 while 25 complications were observed in group 2 (P = .088). One patient developed nephropleural fistula while another patient developed hydropneumothorax. Both belonged to group 1. CONCLUSION: Supracostal access for PCNL is an effective and safe alternative to subcostal access for children with renal calculi in terms of stone-free rate and complications.