Recurrent extramedullary plasmacytomas without multiple myeloma: A case report with review of the literature.

BACKGROUND: Extramedullary plasmacytoma (EMP) is an uncommon presentation and usually occurs in conjunction with multiple myeloma (MM). An EMP without developing MM at any point is an extremely rare presentation, and only seven such cases have been reported in the literature to date. PRESENTATION OF CASE: We present a case of EMP, who presented with multiple recurrent lesions in rare sites like nasal cavity, testis and skin without the involvement of bone marrow at any point of disease course. He was treated with multiagent chemotherapy (DT-PACE) and continues to be in remission at 29 months post-chemotherapy, which is the longest amongst all the cases reported so far. DISCUSSION AND CONCLUSIONS: There are no clearly defined guidelines to treat EMP. Our case had a clinical presentation at very unusual sites and was treated with DT-PACE regimen as against the previous seven reported cases and had the most prolonged period of remission.

Correlation of Transabdominal Ultrasonography and Cystoscopy in Follow-up of Patients with Non-muscle Invasive Bladder Cancer.

Cystoscopy (CS) is considered to be the gold standard in the follow-up of non-muscle invasive bladder cancer. However, CS is invasive, time-consuming, and expensive. On the other hand, modern sensitive transducers have improved the imaging of urinary tract rendering transabdominal ultrasonography (US) more effective in visualizing intraluminal filling defects in the bladder than it was in the past. Twenty-five follow-up patients of low-risk bladder cancer meeting the inclusion and exclusion criteria were included in study. Ultrasonography of the bladder was performed by a single senior radiologist, and subsequently, these patients were subjected to flexible cystoscopy under local anesthesia. Pain score was calculated for each of the cystoscopies done. Findings of transabdominal ultrasound of the bladder were correlated and compared with those of cystoscopy. Subjects with US and/or CS findings suggestive of recurrence underwent transurethral resection of bladder tumor (TURBT) under general anesthesia and confirmation of the bladder carcinoma was achieved by the histopathological examination. Mean patient age was 60.56 years with range of 29 to 77 years. The sensitivity of modern ultrasonographic techniques was found to be 84.61% with specificity of 91.7% taking flexible cystoscopy as the gold standard for detection of recurrence. The accuracy of US was 88% with positive predictive value of 91.7% and negative predictive value of 84.61%. Technological evolution has improved the accuracy of ultrasonography in diagnosis of bladder carcinoma. It represents a valuable surveillance tool in selected sub group of low risk non-muscle invasive bladder cancer patients.

Is early removal of prophylactic ureteric stents beneficial in live donor renal transplantation?

Prophylactic ureteric stenting has been shown to reduce ureteric leaks and collecting system obstruction following renal transplantation and is in widespread use. However, the optimal time for removal of ureteric stents after renal transplantation remains unclear. Aim of this study was to compare the result of early versus late removal of ureteric stents after kidney transplantation of the laparoscopically retrieved live related donor grafts. Eligible patients were live donor kidney transplant recipients with normal urinary tracts. All recipients underwent extravesical Lich-Gregoire ureteroneocystostomy over 4F/160 cm polyurethane double J stents by a uniform technique. They were randomized on seventh postoperative day for early removal of stents on postoperative day 7 (Group I), or for late removal on postoperative day 28 (Group II). The incidence of urinary tract infections, asymptomatic bacteriuria, and urological complications were compared. Between 2007 and 2009, 130 kidney transplants were performed at one centre of which 100 were enrolled for the study, and 50 each were randomized into the two groups. Donor and recipient age, sex, native renal disease, immunosupression, number of rejection episodes, and antirejection therapy were similar in the two groups. The occurrence of symptomatic urinary tract infection during the follow-up period of 6 months was significantly less in the early stent removal group [5 out of 50 (10%) in Group I, vs 50 out of 15 (30%) in Group II, P=0.02]. Asymptomatic bacteriuria was documented in 2 out of 50 (4%) in Group I and 4 out of 50 (8%) in Group II (P=0.3). There was no statistically significant difference in the rate of ureteric leak, ureteric obstruction, or hematuria in the two groups (P=1.0). We conclude that, in kidney transplant recipients of laparoscopically retrieved live donor grafts, early stent removal at the end of first week reduces the incidence of urinary tract infection without increasing the rate of urine leak or ureteric obstruction.

Pneumococcusuria: From bench to bedside.

The present study highlights six cases of pneumococcusuria during the time period of May 2008 to May 2010. All the patients had a co-existing predisposing factor with the isolation of Streptococcus pneumoniae in urine. Five of the six patients having signs and symptoms of urinary tract infections (UTI) were treated and cured of the same. It becomes essential to consider pneumococcal UTI in the presence of clinical signs and symptoms associated with urinary tract abnormalities like hydronephrosis and renal stones. S. pneumoniae may be regarded as an emerging pathogen in UTI. Precise microbiological diagnosis must correlate with the clinical signs and symptoms for the administration of appropriate antibiotic therapy.

Laparoscopic assisted dismembered pyeloplasty in children: intermediate results.

To study the results of an innovative minimally invasive technique of performing dismembered pyeloplasty in children. Using 5 mm camera and 3 mm working ports, the ureteropelvic junction (UPJ) is mobilized by a transperitoneal laparoscopic technique. The UPJ is brought out through a tiny flank incision and a standard dismembered pyeloplasty is performed over a double J stent. Between October 2003 and January 2005, 13 children underwent laparoscopic assisted dismembered pyeloplasty. Indications, operative duration, hospital stay, preoperative and postoperative isotope renogram parameters were analyzed. The children were in the age range of 3 months to 6 years-three were right sided and ten were left sided. Only three were symptomatic while the remaining ten were detected to have UPJ obstruction during evaluation for antenatally detected hydronephrosis. Mean operative duration was 104.2 min (range 80-150 min) with no significant difference in the two patients with crossing vessels. Incision was smaller than 2 cms in all and the average postoperative hospital stay was 3.2 days (range 2-5 days). Follow-up ranging from 28 to 44 months showed reduction in hydronephrosis and improvement in renal function of all the operated units. Isotope renogram in only one patient showed equivocal slopes and prolonged half clearance times though no further surgical intervention was required. This technique has results comparable to that of open pyeloplasty and hence, maybe considered a good option for surgeons making the transition to laparoscopic pyeloplasty.

Supracostal access for percutaneous nephrolithotomy: less morbid, more effective.

OBJECTIVES: The aim of this research was to study the success and morbidity of supracostal access for percutaneous nephrolithotomy (PCNL), as it is often avoided for fear of complications. MATERIALS AND METHODS: Between July 2000 and May 2007, 565 patients underwent PCNL, of whom 110 had a supracostal access. All procedures were performed in a single sitting under general anesthesia. Data were analyzed prospectively for indications, stone clearance rates, and preoperative and postoperative complications. RESULTS: Indications for supracostal access included large pelvic stones in 39 patients, partial or complete staghorn stones in 32, calyceal stones with major stone bulk above the level of 12th rib in 35, and upper ureteric stones in four. Patients' ages ranged between 13 and 71 years (mean 44.2 years). Fifty-six cases were left sided and 54 right sided, whereas 103 (93.6%) were radiopaque stones. All tracts were in the 11th intercostal space, though one had an additional tract in the tenth space. Single-tract access was used in 101 cases (91.8%), but nine (8.2%) required a second tract. Overall stone clearance rate with PCNL monotherapy was 86.4%, and this increased to 97.3% with secondary procedures. Overall complication rate was 11.8% and included hydrothorax/hemothorax in ten, perinephric collection in one, infection/sepsis in two, and excessive bleeding in two. Postoperative hospital stay ranged from 2 to 15 days. CONCLUSIONS: The supracostal approach gives high stone clearance rates with acceptable morbidity rates and should be attempted in selected cases. Complications when present may be managed easily with conservative measures.

Laparoscopic right donor nephrectomy: is there a right way?

BACKGROUND AND PURPOSE: There is a continuing reluctance among transplant surgeons to procure a right-kidney allograft laparoscopically. We describe our experience with right laparoscopic donor nephrectomy (RLDN) by three techniques. PATIENTS AND METHODS: We retrospectively analyzed all seven RLDNs performed at our center from January 2002 to June 2005. The technique used in a particular case depended on the anatomy of the renal vasculature and included transperitoneal (N = 1), retroperitoneoscopic (N = 4), and retroperitoneoscopy-assisted approaches without the use of hand port or other assist devices (N = 2). No stapling or manual-assist devices were used in the last four cases for division of the renal vessels. RESULTS: The mean blood loss, operating time, hospital stay, and serum creatinine concentration on day 7 were 94.3 +/- 46.9 mL (SD), 212.8 +/- 66 minutes, 4.9 +/- 1.9 days, and 1.1 +/- 0.2 mg/dL, respectively. The overall warm ischemia time was 217 +/- 116 seconds. Our preferred technique currently is to go for a total retroperitoneoscopic approach to the right kidney initially. If the renal vein appears short, we make a small subcostal incision to retrieve the kidney openly at this stage (retroperitoneoscopy-assisted approach) with minimal risks to the donor and recipient. CONCLUSIONS: Retroperitoneoscopic RLDN performed without hand-assist or stapling devices is safe and cost-effective and yields kidneys with excellent function. Rather than have a fixed approach to RLDN, we suggest a choice depending on the length of the renal vessels observed during surgery.

Initial experience with laparoscopic donor nephrectomies.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) is being adopted rapidly by transplant centres around the world as it offers less postoperative pain, quicker convalescence, and better cosmetic result when compared with the open approach. There may, however, be a steep learning curve with this technique. METHOD: A retrospective review was performed to evaluate the donor morbidity and graft outcome of 21 consecutive LDN performed at one centre between May 2002 and August 2003. RESULTS: Eighteen LDN were performed on the left and three on the right side. All left and one right LDN were done transperitoneally while the remaining two right side kidneys were removed by a retroperitoneal approach. The mean (+/-SD) operating time and warm ischemic time were, respectively, 236 minutes (+/- 46) and 4 minutes (+/- 1). The mean time for resuming oral intake was 23 hours (SD +/- 22.7). The median length of hospital stay was 5 days (range 3 to 18). One patient was reoperated for bleeding and required four units of packed cell transfusion. One recipient displayed delayed graft function requiring dialysis for 14 days. There were no graft losses. The mean creatinine of the recipients at the time of discharge was 1.15 mg/dL (+/- 0.21). CONCLUSIONS: There is undoubtedly a learning curve with LDN. Nevertheless, with prior skills in similar procedures such as laparoscopic radical nephrectomies, it is feasible to diminish the learning curve and morbidity of LDN to yield results consistent with those in the published literature.

Terminal hand-assist for laparoscopic donor nephrectomy.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) has become widely popular in developed countries but not so in developing countries. One explanation for this maybe the difficulty in getting access devices due to the prohibitive cost. We report our method of terminal hand-assisted LDN in which successful donor nephrectomy is feasible without expensive access devices. METHOD: The patient is placed in the corresponding classic renal surgery position. Three ports are placed for left-sided and four for right-sided LDN. After complete mobilization of the kidney laparoscopically, the assistant's right hand is introduced for left-sided LDN through a 7-cm left lower quadrant transverse muscle-splitting incision. For right-sided LDN, the surgeon's right hand is inserted through a corresponding ipsilateral incision (for right-handed surgeons). A simple method to prevent the leakage of pneumoperitoneum is described. The hand inside the abdomen aids in the final steps and completes the extraction of the kidney swiftly. Manual mopping, lavage, and hemostasis are also possible. RESULTS: Five cases of LDN at our centre were done in this fashion, four on the left side and one on the right. The mean kidney retrieval time after clamping the renal artery was 3:18 +/- 0:46 minutes (range 2:30 to 4:30). Postoperative stay was 4 to 5 days. Recipient serum creatinine normalized within 3 to 4 days. CONCLUSIONS: Short duration terminal hand-assist for LDN without any special access device is possible without the fear of excessive gas leakage. It is helpful to reduce prolonged warm ischemia and to relieve the surgeon's apprehension, at least in the initial learning phase of LDN.

Right-sided laparaoscopic donor nephrectomy is feasible: experience with three cases.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) is more difficult on the right than the left and is typically not recommended for the right kidney. MATERIALS AND METHODS: Between November 2002 and May 2003, three patients underwent right-sided donor nephrectomy: one transperitoneally and two retroperitoneoscopically. All procedures were performed in the right kidney position. Three ports were placed for retroperitoneoscopic approach and four for transperitoneal, including one to retract the liver. Renal arteries were clipped thrice and divided, and renal veins divided using an endo-GIA30 stapler. Kidneys were retrieved in all cases by extending the lower port incision by 7 to 8 cm. The records of donors and recipients, including early graft outcomes were reviewed. RESULTS: Kidney retrieval time and total warm ischemic time were 3:30 minutes and 5 minutes, respectively, for transperitoneal LDN and 3:40 to 4:10 minutes and 5 to 7 minutes, respectively, for retroperitoneal LDN. The operating times were 176, 224, and 160 minutes, respectively. The first donor (transperitoneal) was discharged on the fourth postoperative day, and the other two (retroperitoneal) on the third day. The serum creatinine of all recipients normalized within 72 hours, with normal isotope renal scans on the fifth postoperative day. CONCLUSIONS: Right-sided LDN is feasible and safe without adversely affecting graft quality. The retroperitoneal approach is technically easier, gives a longer length of renal artery, and has a quicker convalescence.

Laparoscopic simultaneous bilateral pretransplant nephrectomy for uncontrolled hypertension.

Severe hypertension resistant to multiple antihypertensive drugs represents an indication for bilateral pretransplant renal ablation by surgery or angioembolization. Besides causing severe pain and renal postinfarction syndrome, angioembolization may be ineffective. We present our experience with simultaneous bilateral laparoscopic pretransplant nephrectomies in patients with end-stage renal disease and severe uncontrollable hypertension. Among the three patients considered for bilateral pretransplant laparoscopic nephrectomy between September 2002 and August 2003, the procedure was successfully performed in two patients. Left nephrectomy was performed transperitoneally and right nephrectomy retroperitoneoscopically. In one of the three patients, a prior attempt at angioembolization had produced a dense perirenal reaction, rendering laparoscopic surgery impossible. Total operating time for bilateral laparoscopic nephrectomies was 260 and 280 minutes. Within 1 month following the nephrectomies, all patients became normotensive with minimal or no antihypertensive medications. We conclude that simultaneous bilateral laparoscopic nephrectomy is feasible and less morbid in end-stage renal disease patients. Prior angioembolisation can make laparoscopic surgery difficult or impossible.

Surgical and radiological management of renovascular hypertension in a developing country.

PURPOSE: We determined the long-term outcome of radiological and surgical intervention in young patients with renovascular hypertension. MATERIALS AND METHODS: Between 1989 and 2001, 85 patients with a mean age +/- SD of 21 +/- 10.3 years, including 59 with Takayasu's arteritis (TA) and 26 with fibromuscular dysplasia (FMD), underwent radiological (percutaneous transluminal angioplasty) or surgical treatment for renovascular hypertension due to renal artery stenosis. The technical success, complications and clinical response of each treatment were compared. RESULTS: Of the patients 29 with TA and 20 with FMD underwent a total of 56 balloon angioplasties. Technical success was achieved in 94.58 renal units with a clinical response in 41 patients (83.9%). However, the re-stenosis rate was 24.13% in TA and 10% in FMD cases. A total of 41 surgical procedures were performed in the 28 and 7 patients with TA and FMD, respectively, including aortorenal bypass with vein in 12, and with a polytetrafluoroethylene graft in 4, lienorenal bypass in 4, iliorenal bypass in 2, gastroduodenal bypass in 1, autotransplantation in 1, nephrectomy in 14 and partial nephrectomy in 2. The clinical response rate to renal revascularization procedures was 94.4%, whereas it was only 50.0% for nephrectomy/partial nephrectomy during a median followup of 42 months (range 9 to 96). CONCLUSIONS: Percutaneous transluminal angioplasty and renal revascularization provide comparable long-term results in the management of renal artery stenosis due to TA and FMD. Although it is technically complex, surgery for TA is safe and effective. However, the rate of re-stenosis following angioplasty for TA is higher compared with FMD.

Renal & prostatic disorders in the elderly.

The population of aged people is increasing in number all over the world along with the problems associated with senescence. The functional and morphological changes that occur with ageing are accompanied by an increased risk of certain conditions like drug-induced nephrotoxicity and acute tubular necrosis. Elderly patients of end-stage renal disease can undergo renal replacement therapy with acceptably good results. If free from any medical and other illnesses, elderly persons can be considered for kidney donation without any increased risk for surgery or anaesthesia. However, such kidneys are functionally not as good as kidneys from young individuals. Prostatic diseases like prostatic hyperplasia and cancer are more a concern of the aged than the younger population. Besides, there is an apprehension about the increased risk of anaesthesia due to the frequent presence of other co-existent illnesses in the senile population. Less morbid therapeutic methods are available to deal with prostatic disorders but one should not hesitate to undertake major open or endoscopic surgeries in such patients, should it be necessary.