Percutaneous nephrolithotomy in children.

INTRODUCTION: The high success rates of percutaneous nephrolithotomy (PCNL) in the clearance of large renal calculi has made it a primary mode of surgical management in adults. Similarly, in children too PCNL has been gaining ground and the indications for the same are on the rise. We retrospectively evaluated the safety and efficacy of this technique, in children below 18 years of age. MATERIALS AND METHODS: We retrospectively reviewed the inpatient, outpatient records, imaging films of all children with renal stones undergoing PCNL at our hospital. RESULTS: During the study period, 123 children underwent 129 PCNL at our centre for renal calculi. The mean age was 11.06 years and 87 (70.73%) of the children were males. The size of the stones varied from 15 to 37 mms in the longest diameter. A complete staghorn was noted in six (4.65%) and a partial staghorn in nine (6.97%) children. Supine PCNL was performed in 21 (16.2%) children and remaining 102 (83.7%) children underwent PCNL in prone position. The mean drop in haemoglobin was 1.24 gm%. Stone clearance was achieved in 122 (94.5%) children. Post-operatively four (3.1%) children needed blood transfusions due to excessive bleeding. CONCLUSIONS: Refinements in percutaneous access techniques, miniaturization of instruments, and technologic advances in energy sources for lithotripsy have led to improvement of outcomes and have lowered the morbidity rates in children following PCNL. It is a safe and effective means of clearing large volumes of renal calculi with minimal morbidity.

Neoadjuvant Chemotherapy Followed by Cystectomy: a Single-Center Experience.

Nearly 50% of patients with muscle-invasive bladder cancer treated with cystectomy alone will progress to metastatic disease. Surgery alone is not a sufficient therapy in a large number of patients with invasive bladder cancer. Systemic therapy with cisplatin-based chemotherapy has been shown to provide response rates in several bladder cancer studies. There have been multiple randomized controlled studies undertaken to define further the effectiveness of neoadjuvant cisplatin-based chemotherapy in advance of cystectomy. In this study, we have retrospectively reviewed our series of patients who underwent neoadjuvant chemotherapy followed by radical cystectomy for muscle-invasive disease. Between Jan 2005 and Dec 2019, 72 patients underwent radical cystectomy following neoadjuvant chemotherapy over a 15-year period. The data was retrospectively collected and analyzed. The median age was 59.84 ± 8.967 years (range, 43 to 74), and the ratio of male to female patients was 5:1. Of the 72 patients, 14 (19.44%) completed all the three cycles, 52 (72.22%) completed at least two cycles, and the remaining 6 (8.33%) completed only one cycle of neoadjuvant chemotherapy. A total of 36 (50%) patients died during the follow-up period. The mean and median survival of the patients was 84.85 ± 4.25 months and 91.0 ± 5.83 months respectively. Neoadjuvant MVAC should be offered to patients with locally advanced bladder cancer and who are candidates for radical cystectomy. It is safe and effective in patients with adequate renal function. The patients need to be carefully monitored for chemotherapy-induced toxic effects, and appropriate intervention is necessary in the event of severe adverse effects.

Adrenal cysts: Our laparoscopic experience.

INTRODUCTION: Cystic lesions of the adrenals are rare with an incidence of 0.06% in autopsies, and the most frequently found are either the endothelial cysts or the pseudocysts. We report our series of patients presenting with adrenal cysts. MATERIALS AND METHODS: The case records of patients presenting with adrenal cysts were reviewed and analyzed. Age, gender, presenting symptoms, physical examination findings, laboratory investigations and imaging records were all noted and analysed. RESULTS: During the 10-year study period, 14 patients, with a mean age of 41.36 ± 5.57 years, were diagnosed to have adrenal cysts. Laparoscopic excision of cysts was performed in three and laparoscopic adrenalectomy in the remaining eleven. CONCLUSIONS: Adrenal cysts are rare, and intervention is indicated whenever they are large (>5 cm), symptomatic, functional, and potentially malignant. Laparoscopic management of these cysts in the form of either decortication/excision is safe, effective, minimally invasive, with minimal blood loss and shorter duration of hospitalization.

Severe renal injuries in children following blunt abdominal trauma: selective management and outcome.

INTRODUCTION: Blunt trauma accounts for the majority of pediatric renal injuries. Most injuries are often minor and can be managed without surgical intervention. We have retrospectively reviewed our series of children with severe (grade IV/V) renal injuries, their management and outcome. MATERIALS AND METHODS: Medical records of children less than 18 years with renal injuries were reviewed. The cause of injury, time following injury, management and outcome in these children were recorded. The outcome data were analyzed. RESULTS: During the period between January 1996 and December 2008, 43 children with grade IV/V renal injuries were admitted with blunt abdominal trauma. Ten of these 43 children underwent exploration and 33 initially managed non-operatively. Two of these 33 children on non-operative management needed nephrectomy for vascular injury and delayed haemorrhage. CONCLUSIONS: Most children with grade IV/V renal injury following blunt trauma can be managed non-operatively. Management can be properly planned and executed based on clinical features, CT imaging and staging of renal injuries. Surgical intervention is needed for associated abdominal organ injuries and renal vascular injuries.

Laparoscopic hemi/partial nephrectomy in children with ureteral duplication anomalies.

INTRODUCTION: Recent advances in laparoscopic surgery as well as increasing experience with these techniques have led to the selection of laparoscopic surgery for hemi/partial nephroureterectomy in children with a non/poorly functioning moiety in a duplex kidney. There is very little data on the long term follow-up of such children. We report our experience of laparoscopic hemi-nephroureterectomy in children with duplex moiety. MATERIALS AND METHODS: We retrospectively reviewed the case records of children undergoing laparoscopic partial/hemi nephroureterectomy. Demographic data, age, weight, diagnosis, type of operation, operative time, concomitant and subsequent procedures, blood loss, use of drains, analgesic requirement, length of hospitalization and complications were recorded. RESULTS: 29 children (21 girls and 8 boys) underwent laparoscopic hemi/partial nephrectomy. The median operative time was 94 min (range 68-146 min). The mean blood loss was 25 ml and no children required perioperative blood transfusion. CONCLUSIONS: Laparoscopic hemi/partial nephrectomy in children is safe, associated with decreased morbidity and shorter hospitalization. Long term follow-up is necessary to study long term outcomes.

Modified Koyanagi's procedure for proximal hypospadias: our experience.

Koyanagi described an elegant technique for one-stage proximal hypospadias repair. It is particularly suited for the most severe forms of hypospadias. A modified Koyanagi technique was used to repair the hypospadias in 14 children, aged 3-9 years. One child developed breakdown of the suture line, three other children developed small urethrocutaneous fistula needing closure and one child had post-operative meatal stenosis. Despite the high rate of complications, modified Koyanagi's procedure is a good procedure of choice for severe/proximal hypospadias.

Postpercutaneous Nephrolithotomy Ureteropelvic Junction Obstruction.

Percutaneous endoscopic renal surgery such as percutaneous nephrolithotomy (PCNL) is a safe and effective treatment for patients with large and/or complex renal calculi. However, a unique set of complications can occur with this surgical approach that may involve the targeted kidney and surrounding structures. Renal collecting system obstruction after PCNL is rare, but may result from ureteral avulsion, stricture formation, transient mucosal edema, blood clot, or infundibular stenosis. Impaction of stone and trauma during PCNL could induce stricture formation and obstruction. Use of proper percutaneous and endoscopic techniques and instruments will help to reduce the chances of developing such strictures and obstruction.

Percutaneous Nephrolithotomy in an Elderly Female with Severe Kyphoscoliosis: Modified Prone Position.

Percutaneous nephrolithotomy (PCNL) is one of the important options in the management of large (>2 cms) and complex renal calculi. Traditionally the prone position has been used to access the pelvicaliceal system as well as to remove renal calculi. Several modifications to this position have been suggested and reported by several urologists. We performed PCNL in an elderly female with a severe kyphoscoliosis by modifying the classical prone position.

Retained Double J Stent with Huge Renal and Bladder Calculi Extracted by Percutaneous Nephrolithotomy and Percutaneous Cystolitholapaxy in a Single Encounter.

We report a case of retained Double J ureteral stent with huge, multiple calculi at both ends in a 10-year-old female child. The renal and bladder calculi were managed by percutaneous nephrolithotomy and percutaneous cystolitholapaxy in a single sitting.

Type 2 diabetes mellitus and renal stones.

BACKGROUND: The incidence of urinary stone disease has shown a steep rise in recent decades along with marked modifications in dietary habits and life- style. There has been an increased prevalence of urinary stone disease in patients with diabetes. We took up this study to determine the association of diabetes mellitus with kidney stones in patients undergoing surgical treatment. MATERIALS AND METHODS: Patients presenting with renal stones for surgical management formed the study group. Body mass index (BMI) was calculated by noting the weight and height of the patient. The extracted stone/stone fragments were analyzed to determine the chemical composition. Urinary pH was similarly noted in all. RESULTS: The mean BMI among the diabetics was 26.35 ± 5.20 (range 17.75-35.60), whereas the mean BMI among the non-diabetics was 23.41 ± 2.85 (range 17.71-31.62) (P < 0.0004). The incidence of uric acid calculi in the diabetics was significantly high (P < 0.03). The mean urinary pH among the diabetics was 5.61 ± 0.36 and among the non-diabetics was 6.87 ± 0.32, which was significantly lower (P < 0.000044). CONCLUSIONS: There is a strong association between type 2 diabetes and uric acid stone formation. There is also a strong association between diabetes mellitus, BMI, and also with lower urinary pH.

Yang-Monti's Catheterizable Stoma in Children.

BACKGROUND: In 1981, Mitrofanoff described a procedure to create a continent urinary stoma for clean intermittent catheterization. Since then several procedures have been described including Yang-Monti ileovesicostomy for effective catheterization. OBJECTIVES: We report on our experience from the use of Monti's procedure in children at our center. PATIENTS AND METHODS: Children < 18 years of age undergoing urinary diversion/reconstruction with Yang-Monti's procedure for congenital conditions or neuropathic bladder formed the study group. All these children, post-operatively were taught clean intermittent catheterization (CIC) and put on a regime using a 14/16 Fr catheter every 3 hours. The children were followed regularly at 3, 6, 12, 18 and 24months post-operatively, with special attention paid to any problems with catheterization and incontinence. RESULTS: During the period from Jan 2000 to Dec 2011, at our center, 19 children less than eighteen years of age underwent urinary diversion with Yang-Monti's catheterizable stoma. The indications for urinary diversion was neuropathic bladder in eight, exstrophy bladder in seven , valve bladder syndrome in three and persistent urethral stricture in one. None of the children found CIC difficult during the post-operative period and there was no hindrance to the passage of the catheter. CONCLUSIONS: Although the appendix remains the tissue of choice for creation of catherterizable stoma, the Yang-Monti ileovesicostomy is effective, convenient conduit for children. Long-term complications are minimal and children find this comfortable to do CIC.

Genital reconstruction in exstrophy patients.

INTRODUCTION: Surgery for bladder exstrophy has been evolving over the last four to five decades. Because survival has become almost universal, the focus has changed in the exstrophy-epispadias complex to improving quality of life. The most prevalent problem in the long-term function of exstrophy patients is the sexual activity of the adolescent and adult males. The penis in exstrophy patients appears short because of marked congenital deficiency of anterior corporal tissue. Many patients approach for genital reconstruction to improve cosmesis as well as to correct chordee. We report our series of male patients seeking genital reconstruction following exstrophy repair in the past. MATERIALS AND METHODS: Fourteen adolescent/adult male patients attended urology services during the period January 2000-December 2009 seeking genital reconstruction following exstrophy repair in the past. RESULTS: Three patients underwent epispadias repair, four patients had chordee correction with cosmetic excision of skin tags and seven patients underwent chordee correction with penile lengthening. All patients reported satisfaction in the answered questionnaire. Patients undergoing penile lengthening by partial corporal dissection achieved a mean increase in length of 1.614 ± 0.279 cm dorsally and 1.543 ± 0.230 cm ventrally. The satisfactory rate assessed by the Short Form-36 (SF-36) showed that irrespective of the different genital reconstructive procedures done, the patients were satisfied with cosmetic and functional outcome. CONCLUSIONS: Surgical procedures have transformed the management in these patients with bladder exstrophy. Bladders can be safely placed within the pelvis, with most patients achieving urinary continence and cosmetically acceptable external genitalia. Genital reconstruction in the form of correction of chordee, excision of ugly skin tags and lengthening of penis can be performed to give the patients a satisfactory cosmetic and functional system.

Flexible ureteroscopy for upper ureteral calculi in children.

INTRODUCTION: Ureteroscopy is one of the therapeutic options in the management of urinary stone disease in children. Previous literature has described ureteroscopy primarily in mid to distal ureteral calculi. We report our experience with flexible ureteroscopy in the management of upper ureteral calculi. PATIENTS AND METHODS: All children with upper ureteral stones were included prospectively in the study. Stone burden was measured in millimeters. Presentation, operative access, intraoperative complications, stone-free rates, and postoperative complications were evaluated. RESULTS: A total of 80 children (69 boys and 11 girls) underwent 88 ureteroscopic procedures. In 72 (90%) children, complete stone clearance was achieved after a single ureteroscopic session. In 6 (7.5%) others, complete stone clearance was achieved after the second ureteroscopic session. CONCLUSIONS: Complete stone clearance after single ureteroscopy is possible if the calculi are single, small (<10 mm), and below the level of the pelviureteral junction.

Laparoscopic adrenalectomy for adrenal masses in children.

OBJECTIVE: The laparoscopic approach to the adrenal gland was first reported in 1992. Since then numerous studies have been published, comprising of adults. Experience with the laparoscopic technique for adrenal disease in children and adolescents has been limited. We have reviewed our experience with laparoscopic adrenal surgery in children. PATIENTS AND METHODS: All children with pathologic adrenal masses undergoing laparoscopic adrenal surgery were included. The primary study outcome measures included operative time, conversion to open surgery, complications, duration of hospital stay and outcome of surgery. RESULTS: Eighteen children underwent laparoscopic adrenalectomy during the period January 2003-July 2009. The mean operating time was 95 min, mean blood loss was 30 ml and the average postoperative hospital stay was 50h. There were no conversions to open surgery and no major intra- or postoperative complications noted. CONCLUSIONS: Laparoscopic adrenalectomy is a safe and feasible procedure with good results. It can be used to safely treat suspected benign and malignant adrenal masses in children with minimal morbidity and a shorter hospital stay.

Solitary urethrocutaneous fistula managed by the PATIO repair.

OBJECTIVE: A novel technique has been described for repairing penile urethrocutaneous fistula: the PATIO ('preserve the tract and turn it inside out') repair. We report our experience with this technique in managing solitary urethrocutaneous fistula following primary hypospadias repair. METHODS: Children with fistulae underwent the PATIO technique of repair. The inclusion criterion was solitary fistula of <4mm widest diameter. RESULTS: Ten children underwent the procedure. The mean operating time was 22 min. In four of these children a healthy vascularized tunica vaginalis flap was interposed between the urethra and skin. No recurrence of fistula was noted. CONCLUSION: The PATIO repair is simple and easy to perform, with low morbidity, and is reliable in treating solitary urethrocutaneous fistula <4mm in size.

Staged buccal mucosa urethroplasty in reoperative hypospadias.

INTRODUCTION: Repeated attempts at surgical repair of serious complications involving either the partial or complete breakdown of the hypospadias repair are less likely to succeed because the penis is densely scarred, or significantly shortened, and the skin over the penis is immobile and hypovascular. Buccal mucosa (BM) has become the preferred material for reconstruction, whenever a child with skin-deficient hypospadias needs reoperation. We report the results of our surgical experience with staged reoperation using BM, in the repair of hypospadias in children with complications after multiple failed repairs. MATERIALS AND METHODS: Children needing reoperation for hypospadias underwent a staged repair using buccal mucosa. The complications were noted. RESULTS: Twenty-one children aged 3 - 16 years underwent this staged repair during the period May 2000 - April 2010. Two of these 21 children had a failed first stage. One child developed a urethro-cutaneous fistula following the second stage, which was corrected in an additional stage. CONCLUSIONS: The use of the buccal mucosa graft for urethral reconstruction in a child with hypospadias, needing a reoperation, is a successful method, with a low incidence of complications.