Outcomes and predictors of clinical T1 renal mass (cT1) upstaged to pathological T3a (pT3a) after partial nephrectomy: A single-center experience.

OBJECTIVES: Clinical T1 (cT1) renal mass treated surgically has a good prognosis, but there is an upstaging risk that potentially threatens oncological outcomes after partial nephrectomy (PN). We aim to analyze and study the incidence, predictors, perioperative morbidity, and oncological outcomes of pT3a upstaging. METHODOLOGY: A retrospective study of 313 patients who underwent PN for cT1 renal mass at a single center from a single tertiary referral center between 2000 and 2021 was done. Demographic, perioperative, pathological, and outcome variables were reviewed. We compared these parameters between upstaged and non-upstaged groups. Multivariate logistic regression analysis was used to study preoperative variables associated with upstaging. RESULTS: Nineteen patients were upstaged to pT3a. Making an incidence of 6.1%. Upstaged tumors were bigger (5.02 cm vs. 4.08 cm, p = 0.004), had higher clinical stage T1b (84.2 vs. 40.5%, p < 0.001), had more tumors which were central location (21 vs. 3.4%, p < 0.001), had more endophytic and mesophytic tumors (15.8 vs. 5.8% and 52.6 vs. 9.5%, p < 0.001), and had higher R.E.N.A.L Nephrometry score (8.05 vs. 6, p < 0.001). Upstaged tumors had more operative times (227 vs. 203 min, p = 0.01), more postoperative complications (68.4 vs. 13.1%, p < 0.001), more major complications of Clavien Dindo Grade 3 and above (15.8 vs. 4.4%, p < 0.001). Age (OR 1.035, p = 0.034), Radiological tumor dimension (OR 1.578, p = 0.003), Radiological or Clinical stage (T1b) (9.19, p = 0.008), Higher Nephrometry score (Intermediate and High) (OR 6.184, p = 0.004) were preoperative predictors of upstaging. Oncological outcomes were comparable. CONCLUSION: Tumor upstaging was uncommon with more perioperative morbidity. Higher age, larger tumor size, higher tumor stage, and higher nephrometry scores were preoperative predictors of upstaging.

Initial experience of comparison between two slimmest single-use flexible ureteroscopes: Indoscope Sleek (Bioradmedisys™) Versus Uscope PU3033A (Pusen™): A single-center prospective study.

PURPOSE: A single-use digital flexible ureteroscope (fURS) has become a cost-effective alternative option to reusable fURS. The requirement of large-diameter access sheath for passage of 9.5 Fr single-use fURS has not always achieved in the first attempt in all cases leading to stage stone clearance. Recently, two slimmest single-use digital disposable fURSs have been introduced by Bioradmedisys™ and Pusen™ to mitigate the accessibility problem, without or with small size access sheath. Primary objective was to compare in vivo performance and surgical outcomes with two single-use fURS: 7.5Fr Indoscope (Bioradmedisys™, Pune, India) and 7.5Fr Uscope PU3033A (Pusen, Zhuhai, China). METHODS: 60 patients undergoing Retrograde Intrarenal Surgery (RIRS) with < 2 cm renal stones were prospectively randomized into: Group A (30 patients) for Indoscope and Group B (30 patients) for Uscope PU3033A. Pre-operative, intra-operative, and post-operative parameters were evaluated. In vivo visibility and maneuverability were rated on 5-point Likert scale by the operating surgeon. At one-month stone clearance was assessed with ultrasound and X-ray KUB. Data were analyzed using SPSS 23.0. RESULTS: Patient demographics and stone characteristics were comparable in both groups. Indoscope had significantly higher visibility (p < 0.05) than Uscope; however, the maneuverability scores were comparable between both the groups (p > 0.05). 28 patients in group A and 26 patients in group B achieved complete stone clearance (p = 0.38). Scope failure was observed in 1 case of group B (p = 0.31). CONCLUSION: We conclude that 7.5Fr Indoscope has better vision than 7.5Fr Uscope and the rest of in vivo performances were comparable with similar outcomes and complications among both scopes.

A multicentric non-randomized prospective observational study on the clinical efficiency of thulium fibre laser in large volume stones (> 1000 mm3).

PURPOSE: Our objective was to analyse the clinical efficiency of TFL in large volume stones during retrograde intrarenal surgery. MATERIALS AND METHODS: Patients with large volume renal stones (> 1000 mm3) operated at two different centres, from May 2020 to April 2021, were enrolled in this study. Retrograde intrarenal surgery was performed using 60W Superpulse thulium fibre laser™ (IPG Photonics, Russia). Demographic data, stone parameters, laser time, and total operating time were recorded, and laser efficacy (J/mm3) and ablation speed (mm3/s) were calculated. NCCT KUB was done at 3 months postoperatively to calculate stone-free rate. RESULTS: A total of 76 patients were included and analysed in the study. Mean stone volume was 1753.12 ± 1245.81 (1169.27-2193.25) mm3, mean stone density was 1104.46 ± 313.09 (875.00-1317.00) HU, mean laser time was 537.79 ± 689.89 (21.00-1080.00) sec, mean operating time was 43.38 ± 12.96 (35.00-51.25) min, mean laser efficacy was 20.30 ± 15.5 (8.88-25.57) J/mm3, and mean ablation speed was 1.32 ± 0.7 (0.82-1.64) mm3/sec. A strong positive correlation was found between the stone volume and ablation speed (r = 0.659, p = 0.000), and a moderate negative correlation was found between the stone volume and laser efficacy (J/mm3) (r = - 0.392, p = 0.000). With increasing volume of the stone, J/mm3 decreased significantly and ablation speed increased significantly (p < 0.001). Complications occurred in 21.05% (16/76) patients, most of which were Clavien grades 1-2. Overall SFR is 96.05%. CONCLUSION: Laser efficiency increases at higher stone volumes (> 1000 mm3), as less energy is required to ablate every mm3 of stone.

A prospective comparative study of mini-PCNL using Trilogy™ or thulium fibre laser with suction.

INTRODUCTION: There has been recent introduction of novel lithotripters and high-power lasers for stone disintegration. With miniaturization of PCNL, there is need of effective disintegration and faster stone-clearance. This study aimed to evaluate efficiency of Trilogy™ and Thulium fibre laser (TFL) in mini-percutaneous nephrolithotomy (mini-PCNL). METHODS: This is prospective study comparing efficiency and outcomes of Trilogy™ and TFL in mini-PCNL between January 2019 and February 2020. Primary objective was to compare stone fragmentation rates, with secondary objectives beings stone-free rates and complications. RESULTS: There were 60 mini-PCNL with suction using either Trilogy™ or TFL energy source. Mean stone size and density were 27.60 ± 10.17 mm, 22.04 ± 9.69 mm (p = 0.05) and 1172.9 ± 313.5HU, 1308.9 ± 333.9HU (p = 0.10) for Trilogy™ and TFL, respectively. Using 3D doctor imaging software from CT images, mean stone volumes were 3718.9 ± 3038.7mm3 for Trilogy™ and 3425.9 ± 3096.1mm3 for TFL(p = 0.77). Using probe-activation time or lasing time, stone-fragmentation rate was 5.98 ± 4.25mm3/sec for Trilogy™ and 3.95 ± 1.00mm3/sec for TFL(p = 0.015). Treatment time (puncture to complete clearance) was 32.48 ± 15.39 min for Trilogy™ and 28.63 ± 18.56 min for TFL(p = 0.38). Haemoglobin drop was 1.19 ± 0.76gm/dl for Trilogy™ and 0.99 ± 0.74gm/dl for TFL (p = 0.30). Trilogy™ arm had 96.6% complete clearance and TFL had 76.6% in TFL at 48 h. One patient in Trilogy™ arm required auxiliary RIRS for residual stone. Both arms had complete stone clearance at 1 month follow-up. Trilogy™ arm had 3 Clavien-Dindo grade-II complications while TFL had 2 Clavien-Dindo grade-II complications (UTI requiring antibiotics). There was no blood transfusion in either of arm. CONCLUSION: Trilogy™ had significantly better stone fragmentation rate than TFL in managing renal stones. However, stone-free rates and complications were comparable for Trilogy™ and TFL.

Super-mini percutaneous nephrolithotomy (SMP) vs retrograde intrarenal surgery (RIRS) in the management of renal calculi ≤ 2 cm: a propensity matched study.

OBJECTIVE: To compare the effectiveness and safety of Super-Mini PCNL (SMP) and Retrograde Intrarenal Surgery (RIRS) in the management of renal calculi ≤ 2 cm. PATIENTS AND METHODS: A prospective, inter-institutional, observational study of patients presenting with renal calculi ≤ 2 cm. Patients underwent either SMP (Group 1) or RIRS (Group 2) and were performed by 2 experienced high-volume surgeons. RESULTS: Between September 2018 and April 2019, 593 patients underwent PCNL and 239 patients had RIRS in two tertiary centers. Among them, 149 patients were included for the final analysis after propensity-score matching out of which 75 patients underwent SMP in one center and 74 patients underwent RIRS in the other. The stone-free rate (SFR) was statistically significantly higher in Group 1 on POD-1 (98.66% vs. 89.19%; p = 0.015), and was still higher in Group 1 on POD-30 (98.66% vs. 93.24%, p = 0.092) SFR on both POD-1 and POD-30 for lower pole calculi was higher in Group 1 (100 vs. 82.61%, p = 0.047 and 100 vs 92.61% p = 0.171). The mean (SD) operative time was significantly shorter in Group 1 at 36.43 min (14.07) vs 51.15 (17.95) mins (p < 0.0001). The mean hemoglobin drop was significantly less in Group 1 (0.31 vs 0.53 gm%; p = 0.020). There were more Clavien-Dindo complications in Group 2 (p = 0.021). The mean VAS pain score was significantly less in Group 2 at 6 and 12 h postoperatively (2.52 vs 3.67, 1.85 vs 2.40, respectively: p < 0.0001), whereas the mean VAS pain score was significantly less in Group 1 at 24 h postoperatively (0.31 vs 1.01, p < 0.0001). The mean hospital stay was significantly shorter in Group 1 (28.37 vs 45.70 h; p < 0.0001). CONCLUSION: SMP has significantly lower operative times, complication rates, shorter hospital stay, with higher stone-free rates compared to RIRS. SMP is associated with more early post-operative pain though.

Laparoscopic ureteric reimplantation versus robotic-assisted laparoscopic ureteric reimplantation for lower ureter pathology: Single-institutional comparative study.

OBJECTIVE: To compare and analyze the results of laparoscopic ureteric reimplantation and robotic-assisted ureteric reimplantation at our tertiary institute. MATERIALS AND METHODS: We retrospectively reviewed data of adult patients who underwent laparoscopic ureteric reimplantation and robotic-assisted ureteric reimplantation between January 2000 and December 2020. Data were analyzed for 19 patients in the laparoscopic group and 47 patients in the robotic group. The data were compared in both the groups. RESULTS: The most common presentation was flank pain (67.89%) followed by recurrent UTI (21.05%) in both the groups. The baseline characteristics and demographic data including age, gender, laterality, Charlson comorbidity index, and BMI were comparable in both the groups. The time range from previous surgeries to presentation varied from 7 days to 5 years. There is statistically significant difference between the operative time in the laparoscopic (224.23 ± 76.61 min) and robotic groups (187.06 ± 52.81 min) (p = 0.027). There is statistically significant difference between the hospital stay also between the two groups (9.07 ± 2.75 vs. 6 ± 1.65 days p-0.001). There were no differences in the complication rate and postoperative outcomes in both the groups. Mean length of follow-up was 28 ± 25.5 (2-108) months and 20.57 ± 19.91 (2-96) months in both the groups, respectively. The success rates in terms of symptomatic improvement, decrease in hydronephrosis, and improved drainage in the laparoscopic and robotic groups were 94.73% and 95.45%, respectively, which were statistically not significant. CONCLUSIONS: Robotic ureteric reimplantation and laparoscopic ureteric reimplantation are comparable in clinical outcomes. Robotic-assisted laparoscopic ureteric reimplantation is feasible, safe, and faster with excellent outcomes, decreased hospital stay, and minimal complications.

Superselective angioembolization in posttraumatic pseudoaneurysm of corpora cavernosa presenting as acute urinary retention.

Pseudoaneurysm of corpora cavernosa is rare and its presentation as acute urinary retention has not been reported in the literature so far. We report a 47-year-old gentleman who presented with acute urinary retention. Doppler ultrasound revealed pseudoaneurysm of corpora cavernosa at bulbar urethra region with 2 feeder vessels with turbulent flow inside. Selective internal pudendal artery angiogram was done and two feeder arteries from bilateral pudendal arteries were confirmed. Trans perineal thrombin & fibrinogen instillation and selective coil embolization of left internal pudendal artery were done, leading to complete obliteration of pseudoaneurysm and alleviation of patient's symptoms.

Outcome of post-COVID-19 fungal pyelonephritis: A single Indian tertiary center experience.

Introduction: COVID-19 pandemic is associated with secondary opportunistic fungal infections. These have an aggressive course with a high mortality rate. We present our experience of seven cases of post-COVID-19 fungal pyelonephritis. Methods: An observational study over a period of 8 months of May to December 2021 was carried out at our tertiary care hospital, including all patients with features of fungal pyelonephritis in post-COVID-19 setting. The patient demographics, details of previous COVID-19 infection, details of present admission and management were collected. The endpoints were either discharge from the hospital or death. Results: Seven patients were included. Mean age of presentation was 42 years (range: 20-63 years, standard deviation ± 14.2). Male-to-female ratio was 6:1. One patient was diabetic. Two patients were asymptomatic, one had mild infection, and four patients had severe COVID-19 infection as per National Institute of Health criteria. In the present admission, all patients had symptomatic pyelonephritis with laboratory parameters showing elevated D dimer, C reactive protein, and total leukocyte counts. In all seven patients, ultrasound of kidney ureter bladder region showed bulky kidney, color Doppler showed main renal arterial thrombosis in two patients, segmental arterial thrombosis in another patient. Computed tomography scan was suggestive of changes of pyelonephritis in all patients with multiple renal hypodense areas. All patients required nephrectomy with biopsy suggestive of changes of necrotizing fungal inflammation. Three patients expired. Conclusion: Management of post-COVID-19 fungal pyelonephritis should be aggressive and suspicious laboratory and imaging findings should be treated by early nephrectomy.

A clinical experience of thulium fibre laser in miniperc to dust with suction: a new horizon.

PURPOSE: To report safety and efficacy of mini-PCNL with suction attached to sheath combined with high-power Thulium Fibre laser (TFL). The secondary aim was to evaluate optimal laser settings for maximum stone dusting. MATERIALS AND METHODS: Prospective, single arm study was conducted from June 2019-December 2019 using miniPCNL with suction and TFL in 54 patients with renal stones < 3 cm. Stone fragments for each laser setting were independently retrieved and segregated according to size(< 1 mm,1-3 mm, > 3 mm) and weighed. Xray/CT scan imaging was performed in all patients within 48 h and 30 days to assess stone clearance. Optimal laser settings were evaluated for maximum dusting. RESULTS: Mean stone size was 18.32 ± 6.37 mm, volume was 2337.75 ± 1996.84mm3 and stone density was 1300.55 ± 435.32 HU. Total operative time was 39.85 ± 20.52 min, laser time was 10.08 ± 7.41 min and stone fragmentation rate was 5.02 ± 3.93 mm3/s. The procedure was completely tubeless in 37.04%, nephrostomy tube in 37.04% and DJ stent placed in 25.92%. Postoperatively, three patients had urinary infection (Clavien 2). Complete stone clearance at 48 h was achieved in 35 (64.8%) cases. 19 patients (35.2%) who had residual fragments at 48 h, had 100% clearance at one month on CT/Xray KUB. CONCLUSIONS: MiniPCNL using a nephrostomy sheath with suction along with high power Thulium Fibre Laser is safe and effective modality for lithotripsy. An initial laser setting of 0.2 J and 125-200 Hz was optimal for maximum dusting and simultaneous aspiration. Randomized comparative studies with other energy sources are being considered.

Initial experience with slimmest single-use flexible ureteroscope Uscope PU3033A (PUSEN™) in retrograde intrarenal surgery and its comparison with Uscope PU3022a: a single-center prospective study.

PURPOSE: Single-use disposable digital flexible ureterorenoscope has become an attractive option to reusable scope with many advantages. Currently available single-use digital fURS have outer shaft diameter above 9 Fr which requires large access sheath insertion and sometimes double J stent placement. Recently, 7.5 Fr single-use digital fURS is introduced in market by Pusen. Objective of this study is to compare two Pusen single-use scopes in the clinical setting: 7.5 Fr Uscope PU3033A and 9.5 Fr Uscope PU3022A. METHODS: 30 patients, having renal stones < 2 cm, planned for RIRS were prospectively randomized to two groups: group 1 had 15 patients in which 7.5 Fr Uscope PU3033A and group 2 had 15 patients in which 9.5 Fr Uscope PU3022A was used. The various pre-operative, intra-operative, and post-operative parameters at 1 month along with complications were evaluated for both the scopes by a single surgical team. RESULTS: Pre-operative parameters including stone characteristics were comparable in both the groups. Three patients in group 2 needed ureteric dilatation prior to 11/13 access sheath insertion, while 10/12 Fr access sheath was placed in all patients in group 1 without manipulation (p = 0.06). Intra-operative vision was comparable in both scopes with an empty working channel and with laser. Hazy vision while lasing in two and one patient in group 1 and group 2, respectively (p = 0.54). In group 1, one had fever and UTI, while in group 2, one had fever post-operatively. CONCLUSION: 7.5 Fr Uscope PU3033A could be introduced with smaller access sheath. The vision, deflection, maneuverability is comparable to 9.5 Fr Uscope PU3022a.

Size Distribution of Fragments by High-power Holmium Laser Lithotripsy in MiniPCNL with Suction.

PURPOSE OF REVIEW: Data are lacking on distribution of size of fragments created with the laser lithotripsy, stone density, and composition. Dust (< 1 mm) and small fragments (1-3 mm) may be too small to be efficiently removed with forceps compared to larger fragments (> 3 mm). We aim to report the size distribution of fragments formed during holmium laser lithotripsy. RECENT FINDINGS: One hundred ten patients with renal calculi < 3 cm underwent miniPCNL using ClearPetra sheath (Well Lead Medical Co., China) with controllable irrigation and suction system that minimizes fragment dispersion and maximizes fragment aspiration. Moses holmium laser (Lumenis INC, Israel) was used with predefined laser energy settings for lithotripsy. Proportion of fragment size < 1 mm was 46.36 ± 16.68%, 1-3 mm was 28.18 ± 10.01%, and > 3 mm was 25.19 ± 16.18% for the entire cohort. Complete stone clearance at 48 h was achieved in 77.3% cases. The remaining 22.7% patients had complete clearance at 1-month follow-up CT. In all the stone density, volume, and composition groups, majority of fragments created were either < 1 mm or 1-3 mm. Only 25% fragments were > 3 mm that would get aspirated out through the sheath with suction or could be retrieved with forceps. The combination of a high-power holmium laser and suction would help in complete stone clearance with effective aspiration of smaller stone fragments and dust simultaneously during lasing.

Comparison of STONE score, Guy's stone score and Clinical Research Office of the Endourological Society (CROES) score as predictive tools for percutaneous nephrolithotomy outcome: a prospective study.

OBJECTIVE: To evaluate which among the three scoring systems used to predict stone-free status (SFS) after percutaneous nephrolithotomy (PCNL), namely Guy's stone score (GSS), STONE nephrolithometry score and Clinical Research Office of the Endourological Society (CROES) nephrolithometry nomogram, is the most accurate predictor of SFS. METHOD AND MATERIALS: We prospectively included all patients who underwent PCNL (tract size >24 F) at our hospital between July 2017 and January 2019. All demographic and peri-operative data were tabulated including calculation of GSS, STONE score and CROES nomogram score using preoperative computed tomography. Comparison of the 'stone-free' group and 'residual-stone' group was carried out using standard statistical methods. RESULTS: A total of 252 patients were enrolled. The mean GSS, STONE score and CROES score in the stone-free group was 1.60, 6.98 and 212.27, respectively, and in the residual stone group group it was 2.93, 8.98 and 129.89, respectively (P < 0.001 in each). Receiver-operating characteristic (ROC) curves showed that all three scoring systems had similar predictive accuracy for post-PCNL SFS, with STONE score having the highest area under the ROC curve value (0.852). GSS was significantly associated with operating time, estimated blood loss (EBL) and length of hospital stay (LOS; P < 0.001 in each). STONE score and CROES score were both significantly associated with EBL (P = 0.029 and 0.001, respectively). CONCLUSION: All three scoring systems are equally predictive of post-PCNL SFS. EBL is significantly associated with all three scoring systems, while GSS is also associated with operating time and LOS.

Robotic-assisted kidney transplant: a single center experience with median follow-up of 2.8 years.

PURPOSE: The main aim of the paper is to report a single-centre experience with RAKT, focusing on surgical, perioperative and functional outcomes at a median follow-up of 2.8 years. METHODS: Data of 26 RAKT patients was prospectively collected from December 2014 to February 2019 with follow-up of up to 55 months. All donors were done laparoscopically. We followed Vattikuti-Medanta technique with modification of using pfannenstiel incision instead of Gelpoint and patient positioned in steep Trendelenburg position (30°) with leg split position. Hypothermia was maintained using a "modified graft hypothermia jacket". The engrafted kidney is oriented with the vessels being tagged with Prolene sutures. RESULTS: The mean BMI was 26.1 ± 4.7. The mean warm, cold and total ischemia times were 4.8 ± 1.1, 113.8 ± 20.9 and 118.7 ± 21.2 min, respectively. Mean rewarming time was 62.5 ± 10 min. The mean post-operative day (POD) 1, 3, 7, 30, 6 months, 1 year and most recent creatinine was 3.4, 2.4, 1.8, 1.4,1.2, 1.2 and 1.69 mg/dl. There was no case of delayed graft dysfunction (DGF) with graft survival of 1.8-55 months. The mean GFR at POD 1, 1 month and 1 year was 24, 53.16 and 64.6. We had two intraoperative complications-one topsy turvy graft placement with anastomosis of donor ureter to native ureter and other had to be converted to open technique after anastomosis to control graft surface bleeding. Three postoperative complications-one patient has graft pyelonephritis which was managed conservatively with antibiotics. Two patients had lymphocele. One patient was managed with just aspiration while the other required laparoscopic de-roofing of the lymphocele. The mean hospital stay was 13.5 ± 3 days. CONCLUSIONS: RAKT is feasible and safe only if performed by surgeons with appropriate background in robotic surgery and kidney transplantation after proper surgical training at experienced centres in the mid-term follow-up. Further studies need to confirm the long-term safety of RAKT.

EMS Lithoclast Trilogy™: an effective single-probe dual-energy lithotripter for mini and standard PCNL.

PURPOSE: Several energy sources are available to clear stones during PCNL. Required improvements are faster stone clearance, optimized suction and ease of use while maintaining high patient safety standard. EMS LithoClast® Trilogy, is the first device combining electromagnetic impactor with ultrasonic energy and suction, all-in-one probe. Animal studies and in vitro phantom stone studies have proven safety and efficacy of this device. We aim to study safety and clinical efficacy of Trilogy in our patients. METHODS: 31 patients with renal stones were included. Amplatz sheath sizes/Trilogy probe size was 22-28 Fr/10.2 Fr for standard PNL (n = 20) and 15 Fr./5.7 Fr for mini PNL access (n = 11). Analysis was done with respect to demography, stone characteristics, operation duration (total time and lithotripter activation time), post op Hb drop, clearance rate and adverse events. Stone area/volume was calculated based on CT using 3D doctor. Efficacy was determined by stone volume clearance rate (mm3/min). RESULTS: Male:female ratio was 6:5 and 16:4 for mini (MPNL)/standard PNL (SPNL). Stone densities were 1229 ± 206 vs. 1168 ± 344 HU (MPNL vs. SPNL). Mean stone volumes were 3776.1 ± 2132 mm3 for MPNL and 7096 ± 6441 for SPNL. Mean stone volume clearance ratios were 370.5 ± 171 mm3/min and 590.7 ± 250mm3/min for MPNL and SPNL, respectively. Hb drop was 1.24 ± 0.64 g/dL (MPNL) and 1.23 ± 0.89gm/dL (SPNL). Total procedure time/lithotripter activation time was 53.4 ± 23.8/14.7 ± 12.4 min for MPNL and 65.2 ± 23.5/12.0 ± 8.9 for SPNL. Immediate post-operative/1 month stone clearance rates were 93%/96% with one clinically insignificant residual fragment (< 3 mm) and no necessity for auxiliary procedures. No device failure occured and three Clavien grade I and one grade II complications were observed. CONCLUSION: Swiss LithoClast® Trilogy provides fast stone clearance in standard/mini-PCNL procedures. Ease of use, high tissue safety and optimized suction that avoids fragment blockings are other key features.

Changing trends in the endourological management of urolithiasis in anomalous kidneys.

OBJECTIVES: To present our single-centre experience of urolithiasis management in anomalous kidneys, highlighting the need for an algorithm-based approach in deciding the appropriate treatment method for each type. PATIENTS AND METHODS: We retrospectively reviewed the data of all the patients who presented to our renal unit with urolithiasis in an anomalous kidney between January 1990 and July 2014. The peri-operative characteristics of all the patients, along with management approach, were studied. RESULTS: Percutaneous nephrolithotomy (PCNL) was the most common surgical technique used, followed by flexible ureterorenoscopy (URS). Pain was the most common presentation in these patients. The overall stone clearance rate associated with PCNL and flexible URS was 85.8% in cases of anomalous kidneys in this series. The stone clearance rates in ectopic kidneys, horseshoe kidneys, malrotated kidneys and autosomal dominant polycystic kidneys associated with PCNL and flexible URS were similar: 86%, 88%, 76% and 83%, respectively, and 81.2%, 80%, 92% and 100%, respectively . Based on our results, we developed a stone management algorithm. CONCLUSION: The management of renal calculi in patients with renal anomalies may vary based on the stone size, location, density, pelvicalyceal system anatomy and drainage. An algorithm-based approach could help surgeons decide the appropriate treatment in this population.

Analysis of factors affecting radiation exposure during percutaneous nephrolithotomy procedures.

OBJECTIVES: To measure and analyse various factors affecting radiation exposure (RE) to surgeons during percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: A total of 212 patients who underwent PCNL were analysed. Informed consent was obtained from all enrolled patients. Ultrasonography/fluoroscopy guided punctures were done. The tract was dilatated and sheath placement done after which the procedure was completed in a routine fashion. A JJ or ureteric catheter or percutaneous nephrostomy (PCN) tube was placed as per the merit of the case. A digitalised mobile surgical C-arm image-intensifier system was used in all cases. RE was determined using a pen dosimeter worn outside the lead apron of the surgeon at the level of the chest for uniformity and was recorded on a per case basis at the end of the procedure. Data were recorded for analysis with respect to relevant parameters. Multivariate regression analysis was used to identify various parameters which affect RE (mSv). RESULTS: The parameters analysed included: age, number and size of stones, body mass index (BMI) of patients, Hounsfield unit of stone (HU), degree of hydronephrosis, number of tracts, mode of access to pelvicalyceal system (PCS), sheath size (F), operative time (min), placement of a JJ or ureteric catheter or PCN tube, and kV used for exposure. There was a significant statistical relationship between stone volume (P < 0.001), number of tracts (P < 0.001), mode of access to PCS (P = 0.001), and sheath size (P = 0.002), with RE. The HU had a negative relationship, with a decrease in HU causing increased RE (P = 0.002). BMI, number of stones, degree of hydronephrosis, operative time and placement of a JJ or ureteric catheter or PCN tube did not have any correlation with RE in our study. CONCLUSION: The mean (SD) RE per procedure was 0.21 (0.11) mSv. Increasing size and low HU of stone, increasing number of tracts, fluoroscopic access to PCS, increasing sheath size and kV were found to increase RE. Although the exposure levels are within safety limits, serial monitoring and constant vigilance are mandatory to inform surgeons.

Vascular injuries during laparoscopic donor nephrectomy and proposed risk reduction strategies.

INTRODUCTION: Laparoscopic donor nephrectomy (LDN) has become the standard of care and popular among most of the transplant centres across the globe. Objective of this video is to report different vascular injuries, their management during LDNs and propose risk reduction strategies. PATIENT AND METHODS: This was a retrospective analysis of all the LDNs performed between January 2011 and March 2016. All donor nephrectomies were performed laparoscopically by transperitoneal route, under ideal operative conditions by expert laparoscopic surgeons and by novice surgeons. RESULTS: 858 LDNs (left, n = 797; right, n = 61) were performed during the study period with 5 cases of vascular injuries. Mean (SD) donor age was 45.5 (± 10.76) years and the operative time was 165 (± 44.4) min. Of these five cases, two had renal vein injury, while the three others had renal artery, inferior vena cava and aortic injury (one each). Four injuries occurred during left LDN and only one during a right LDN. Vascular injuries were managed using the Rescue stitch or metallic clips as indicated. Risk reduction strategy was developed to avoid vascular injuries during LDN, which include - meticulous attention to port placement, addition of fourth port, complete dissection of upper pole and pedicle before clipping, and judicious use of ultrasonic diathermy. CONCLUSIONS: Careful evaluation of computed tomography angiography just before surgery will act like a global positioning system (GPS) for the operating surgeon. Rescue stitch is a saviour. Not to panic and being well versed with the risk reduction strategies of laparoscopy and rescue measures is of paramount importance.

Laparoscopic and robotic specimen retrieval system (Modified Nadiad Bag): Validation and cost-effectiveness study model.

AIM: To construct and validate a cost-effective indigenously made retrieval system (Modified Nadiad bag) in minimal access urology. METHOD: The components of the modified Nadiad bag are a polyethylene roll, fishnet thread, and a 5 Fr ureteral catheter. The bag is indigenously made in our institute and used for organ retrieval after proper sterilization. The video recordings of entrapments and retrievals done over the past few months were reviewed. The procedures under review in which the bag was used were: Robot Assisted Radical Prostatectomy (50 cases), laparoscopic radical nephrectomy (50 cases), laparoscopic simple nephrectomy (50 cases) and laparoscopic adrenalectomy (18 cases). We also compared the retrieval time with experts and novices. RESULTS: The retrieval times, the organ size (largest dimension) and specimen weight were records for each case. Multivariate analysis of the data was done and we extrapolated the retrieval time with organ size, specimen weight and expertise of the surgeon. There was no significant difference among expert surgeons and novice surgeons with regards to retrieval times (p value = 0.29), with regards to organ size (p value = 0.83) and with regards to specimen weight (p value = 0.99). CONCLUSION: Our design of retrieval system offers a cost-effective option which is easy to make, without the risk of tumor seeding and without the need for separate access sheath. It's a retrieval system which has proved its efficacy in laparoscopic as well as robotic procedures with no bearing on the expertise of the surgeon involved.

Are we ready for urological subspecialty-based practice in India? The resident's perspective.

INTRODUCTION: In the current era, every broad specialty has diversified into many subspecialties including urology, which is one of the most dynamic fields. The concept of early sub-specialization relies on excelling in a niche area of interest. While this concept is appealing to the most, no formal evaluation of our residency programs has ever been conducted with regard to their adequacy in terms of equipping residents to make informed sub-specialization choices. We performed a survey amongst urological residents, in an attempt to gather information on some unanswered questions related to our residency training programs and the concept of sub-specialization. METHODS: Using the Delphi principles, we conducted a survey consisting of 46 questions, amongst the Indian Urological residents (n = 85), to assess the overall exposure to various subspecialties during their residency program, and the inclination of residents towards them. RESULTS: Residents get a fair exposure to endourology, uro-oncology, female urology and reconstructive urology during their residency. However, the same did not hold true for pediatric urology, andrology and laparoscopic/robotic surgery. 90% of the residents expressed an inclination towards academic practice, while 76.5% were interested in sub-specialization. 60% of the residents felt that they had obtained adequate exposure during residency to make a decision in this regard. Less than 20% were inclined towards female urology, andrology or pediatric urology as a career option. CONCLUSION: There is a growing interest and inclination amongst Indian Urological residents to attain expertise in sub-specialised fields. However, our current residency programs need consolidated efforts to ensure an adequate exposure to all the aspects of Urology, especially in the subspecialties of pediatric urology, andrology and minimally invasive urology. Training should be optimized to a level, which enables the residents to take a well informed decision regarding their choice of subspecialised career path.

Aquablation therapy for symptomatic benign prostatic hyperplasia: a single-centre experience in 47 patients.

OBJECTIVE: To report procedure process improvements and confirm the preserved safety and short-term effectiveness of a second-generation Aquablation device for the treatment of lower urinary tract symptoms (LUTS) attributable to benign prostatic hyperplasia (BPH) in 47 consecutive patients at a single institution. PATIENTS AND METHODS: Aquablation was performed in 47 patients with symptomatic BPH at a single institution. Baseline, peri-operative and 3-month urinary function data were collected. RESULTS: The mean (range) patient age was 66 (50-79) years, and transrectal ultrasonography-measured prostate volume was 48 (20-118) mL. A median lobe was present in 25 patients (53%) and eight patients had catheter-dependent urinary retention. The mean (range) total procedure time was 35 (13-128) min and the tissue resection time was 4 (1-10) min. Five Clavien-Dindo grade I/II and five Clavien-Dindo grade III complications were recorded in eight patients. The mean (range) hospital stay was 3.1 (1-8) days and the mean (range) duration of urethral catheterization was 1.9 (1-11) days. The mean International Prostate Symptom Score (IPSS) decreased from 24.4 at baseline to 5 at 3 months; IPSS quality-of-life score decreased from 4.5 to 0.3 points; peak urinary flow rate increased from 7.1 to 16.5 mL/s and post-void residual urine volume decreased from 119 to 43 mL (all P < 0.01). CONCLUSIONS: This study confirmed procedure process improvements resulting from system enhancements, with preservation of safety and effectiveness during use of a second-generation device for the treatment of LUTS attibutable to BPH in the largest single-institution study conducted to date.