Is it the End for Urologic Pelvic Laparoscopic Surgery?

AIM: To scrutinize the rapid development of robotic versus traditional laparoscopic technique in pelvic urologic surgery. INTRODUCTION: In the last few decades, advances in research and development have led to tremendous progress in medical diagnostics and treatment of disease. Minimally invasive surgery has moved from experimental to becoming the dominant form of surgical management across the surgical specialties. Laparoscopy is nowadays used widely in abdominal surgery, from simple diagnostic laparoscopy to complex colorectal and gynecologic cancer procedures. METHODS: A literature search of electronic databases (PubMed, Medscape, Embase) using the key words: "pelvic laparoscopy, urologic oncology, robotic surgery, minimally invasive access" was performed for all relevant articles in the English language. Data were extrapolated from the abstracts alone to avoid subjective bias in drawing conclusions. RESULTS: Telemedicine and telesurgery, the diagnostic and operative process is conducted from a distance. The surgeon uses computer-assisted surgery away from the bedside via a robotic system and performs the surgical task at hand. In pelvic urological cancer surgery the use of robotic technique expands to female and reconstructive procedures as well. The leap forward is so massive, that traditional laparoscopic surgery is starting to be considered less, with a growing number of organizations being now more interested in developing a robotic service. Minimally invasive surgical techniques aim to improve surgical outcome in conjunction with delivery of high-quality patient care. Quality studies demonstrating superiority and cost effectiveness are lacking, however. CONCLUSIONS: Although tremendous accomplishments took place over a few years, there is still a lot of ground to be covered in standardizing the learning process and evaluating the outcome from the application of new technologies in the field of robotic pelvic surgery.

Impact of type 2 diabetes mellitus on quality of life in people with diabetespresenting to a specialist diabetes clinic.

BACKGROUND/AIM: Quality of life is an important health-related factor that has an impact on all health interventions. The aim of the study was to assess psychosocial outcomes in people with diabetes. MATERIALS AND METHODS: A total of 142 people with type 2 diabetes were recruited from a specialist diabetes center. The validated Urdu version of the WHO-5 Well-Being Index was administered for easy understanding of the quality of life of the regional population. RESULTS: The 142 adult participants with diabetes were recruited from a specialist diabetes clinic. The rate of likely depression (WHO-5 score of <28) was 16.9%. Neuropathy was found to have a negative impact on the quality of life in people with diabetes (P < 0.001). CONCLUSION: People with complications of diabetes like neuropathy may experience worsening quality of life. It is advised to incorporate the WHO-5 into annual patient reviews as a measure of emotional well-being to drive changes that improve outcomes for people with diabetes.

Forming a stone in pelviureteric junction obstruction: cause or effect?

ABSTRACT Objectives To investigate a possible causal relationship for stone formation in pelviureteric junction obstruction and to outline management options. Materials and Methods A literature search and evidence synthesis was conducted via electronic databases in the English language using the key words pelviureteric junction obstruction; urolithiasis; hyperoxaluria; laparoscopic pyeloplasty; flexible nephroscopy; percutaneous nephrolithotomy, alone or in combination. Relevant articles were analysed to extract conclusions. Results Concomitant pelviureteric junction obstruction (PUJO) and renal lithiasis has been reported only scarcely in the literature. Although PUJO has been extensively studied throughout the years, the presence of calculi in such a patient has not received equal attention and there is still doubt surrounding the pathophysiology and global management. Conclusions Metabolic risk factors appear to play an important role, enough to justify metabolic evaluation in these patients. Urinary stasis and infection are well known factors predisposing to lithiasis and contribute to some extent. The choice for treatment is not always straightforward. Management should be tailored according to degree of obstruction, renal function, patient symptoms and stone size. Simultaneous treatment is feasible with the aid of minimally invasive operative techniques and laparoscopy in particular.

Forming a stone in pelviureteric junction obstruction: Cause or effect?

OBJECTIVES: To investigate a possible causal relationship for stone formation in pelviureteric junction obstruction and to outline management options. MATERIALS AND METHODS: A literature search and evidence synthesis was conducted via electronic databases in the English language using the key words pelviureteric junction obstruction; urolithiasis; hyperoxaluria; laparoscopic pyeloplasty; flexible nephroscopy; percutaneous nephrolithotomy, alone or in combination. Relevant articles were analysed to extract conclusions. RESULTS: Concomitant pelviureteric junction obstruction (PUJO) and renal lithiasis has been reported only scarcely in the literature. Although PUJO has been extensively studied throughout the years, the presence of calculi in such a patient has not received equal attention and there is still doubt surrounding the pathophysiology and global management. CONCLUSIONS: Metabolic risk factors appear to play an important role, enough to justify metabolic evaluation in these patients. Urinary stasis and infection are well known factors predisposing to lithiasis and contribute to some extent. The choice for treatment is not always straightforward. Management should be tailored according to degree of obstruction, renal function, patient symptoms and stone size. Simultaneous treatment is feasible with the aid of minimally invasive operative techniques and laparoscopy in particular.

Pattern of physical activity among persons with type 2 diabetes with special consideration to daily routine.

OBJECTIVE: Physical activity is essential in maintaining a healthy lifestyle. Physical activity can improve general health, quality of life and diabetes management. The aim and objective of the study was to assess the physical activity trends in daily routine of people with type 2 diabetes. METHODS: Two hundred persons with diabetes from four different clinical settings were included to access the trends of physical activity using a customized questionnaire EPIC-2. Pattern of physical activity was assessed across a set of domains including sleep time, hours of TV watch, preferred mode of transport for specific distance and household activities. Data was analyzed using SPSS 21. RESULTS: Out of 200 persons with diabetes, 104(52%) were male and 96 (48%) were female. Out of the total sample of patients, 85 (81.7%) Male and 80 (83.3%) female patients preferred walk to cover a distance of less than one mile. There was a significant difference in selection of mode of transport for all other specified distance, esp. in female patients with both age groups. There was insignificant difference for physical activity pattern related to household activities in young and elderly male subjects. The mean sleeping time for younger male subjects on weekend was 464.31± 88.88 minutes/day and for elder it was 418.65± 102.66 minutes/day while for young female subjects was 476.25± 113.74 minutes/day and in female elderly subjects it was 420.62± 120.62 minutes/day respectively. CONCLUSION: In type 2 diabetics we observed a low level of physical activity which may be detrimental for the control of diabetes mellitus.

Fulminant hepatic failure (FHF) due to acute hepatitis C.

Acute hepatitis C (HCV) infection has been identified as an important cause of fulminant hepatic failure (FHF), characterized by rapid deterioration of liver function from massive hepatic necrosis leading to encephalopathy and multi-organ failure. We admitted a female patient at Shalamar Hospital with jaundice, fever, encephalopathy and coagulopathy of short duration with no history of any comorbidity. Her hepatitis viral screen revealed positive anti HCV. Her viral loads were also high. A diagnosis of FHF due to acute HCV infection was made. Patient was treated conservatively and improved gradually. In summary, acute HCV can cause FHF and should be ruled out in patients with FHF of unknown cause in an endemic country for HCV like Pakistan.

Charcot osteoarthropathy in type 2 diabetes persons presenting to specialist diabetes clinic at a tertiary care hospital.

BACKGROUND: Charcot osteoarthropathy or charcot foot is a rare, chronic, non-communicable condition of bones and joints which may results into severe deformity and more prone to develop ulcers possibly leading to amputation. The purpose of this study was to determine the prevalence of Charcot osteoarthropathy and its association with age, BMI, gender, duration of diabetes, HBA1c and peripheral neuropathy. METHODS: A total of 1931 subjects with type 2 diabetes having mean age 50.72 ± 10.66 years presenting in a specialist diabetes clinic at shalamar hospital, Lahore, Pakistan were enrolled. The diagnosis of Charcot osteoarthropathy was made by examination of both dorsal and plantar surfaces of foot for swelling, erythema, increase in temperature and any musculoskeletal deformity which was later confirmed by radiographs. Assessment of neuropathy was carried out by checking the sense of pressure, joint position and vibration. BMI (Body Mass Index), fasting blood glucose (FBG) and HbA1C were determined. RESULTS: In all subjects including male 704 (36.45 %) and female 1227 (63.55 %), 0.4 % subjects had charcot deformity, while 0.2 %, 0.15 % and 0.05 % subjects having right, left and bilateral deformity respectively. Bilaterally symmetrical neuropathy was diagnosed in 25.4 % in subjects. There was a significant association (p < 0.05) of deformity with duration of diabetes, HbA1C and neuropathy, however no significant association (p > 0.05) was found with age, BMI, weight, height and gender. CONCLUSION: There is a need to have a special care of persons with diabetes regarding blood glucose control and development of peripheral neuropathy. Early identification and management of risk factors may prevent the occurrence of charcot deformity. Patients must be educated about the foot care.

Calcification of the vas deferens and seminal vesicles: a review.

INTRODUCTION: Calcification of the vas deferens and seminal vesicles is a rare condition of unknown incidence. It has been described in association with diabetes, hyperparathyroidism and genitourinary tuberculosis, amongst other conditions. Little is known about the clinical significance and management of this condition. We review the literature in an effort to find answers about an entity that is frequently appreciated as an incidental finding. MATERIALS AND METHODS: An electronic database search was performed (Medline) using the key words: vas deferens; seminal vesicles; calcification, alone or in combination. Articles were selected according to relevance and quality of evidence. RESULTS: The search included published manuscripts between 1960 and 2012. A total of 17 relevant publications were identified. The majority were written in the English language and mostly consisted of case presentations and reports of radiologic findings. CONCLUSION: Calcification of the vas deferens and seminal vesicles is a rare condition. However, it may be implicated in male factor infertility and symptoms from the urogenital tract. Treatment should be directed towards the underlying cause on an individual basis. It is unknown whether control of the primary process has any effects on the histopathological appearance of the ducts and/or their improvement of function.

Would You Want to Be the Patient? "Live Surgical Broadcast" or "As-Live Unedited Surgical Broadcast".

OBJECTIVE: To evaluate patient safety, educational value, and ethical issues surrounding "Live surgical broadcast" (LSB) and "As-live surgical broadcast" (ALB) using data obtained from urologic delegates attending two recent endourology meetings in the United Kingdom. SUBJECTS AND METHODS: Two hundred twelve delegates at the UK section meeting of the Société Internationale d'Urologie (SIU) were invited to complete an online survey using SurveyMonkey(®) to compare their previous perceptions of LSB and ALB, and to compare their current experience of ALB to previous experience of LSB. One hundred three delegates at the British Association of Urological Surgeons (BAUS) Endourology meeting used live voting keypads to compare their experience of LSB and ALB simultaneously, as well as comparing their current experience of ALB to previous experience of LSB. Responses were recorded using a Likert scale. RESULTS: One hundred sixty-five responses were analyzed from the meetings. Most delegates were in specialist practice as a consultant or trainee (89.1%). LSB had been witnessed more than ALB (87.1% vs 66.6%, p=0.049). Based on previous experiences, the educational value of both formats was felt similar, but delegates felt there were significant patient safety benefits with ALB over LSB. Delegates were significantly less likely to recommend a friend or family, or volunteer themselves to be a patient in an LSB setting. On-the-day comparison of LSB and ALB shows a similar educational value to both formats, but with significantly less concern for the surgeon and patient's outcome with ALB. CONCLUSION: ALB offers similar educational opportunities to delegates when compared with LSB, while appearing to offer significant welfare benefits to both surgeon and patient. Further studies are required to objectively quantify these subjective observations.

Laparoscopic varicocelectomy in the management of chronic scrotal pain.

BACKGROUND AND OBJECTIVES: To evaluate the usefulness of laparoscopic varicocelectomy in the management of chronic scrotal pain. METHODS: Between 2009 and 2011, 48 patients in total were treated with laparoscopic varicocelectomy for dull scrotal pain that worsened with physical activity and was attributed to varicoceles. All patients were followed up at 3 and 6 months and biannually thereafter with a physical examination, visual analog scale score, and ultrasonographic scan in selected cases. RESULTS: The mean age was 38.2 years (range, 23-54 years). The mean follow-up period was 19.6 months (range, 6-26 months). Bilateral varicoceles were present in 7 patients (14.6%), and a unilateral varicocele was present in 41 (85.4%). The varicocele was grade 3 in 27 patients (56.3%), grade 2 in 20 (41.6%), and grade 1 in 1 (2.1%). The mean preoperative visual analog scale score was 4.8 on a scale from 0 to 10. The mean postoperative visual analog scale score at 3 months was 0.8. After the procedure, 42 patients (87.5%) had a significant improvement in the visual analog scale score (P<.001); 5 (10.4%) had symptom improvement, although it was not statistically significant; and 1 (2.1%) remained unchanged. During follow-up, we observed 5 recurrences (10.4%) whereas de novo hydrocele formation was identified in 4 individuals (8.3%). CONCLUSION: Laparoscopic varicocelectomy is efficient in the treatment of symptomatic varicoceles with a low complication rate. However, careful patient selection is necessary because it appears that individuals presenting with sharp, radiating testicular pain and/or a low-grade varicocele are less likely to benefit from this procedure.

Hyoscine N-butylbromide (Buscopan®) in the treatment of acute ureteral colic: what is the evidence?

OBJECTIVE: To investigate the evidence for the use of hyoscine N-butylbromide (HBB) in the treatment of acute renal colic. METHODS: A literature search was performed using the keywords 'hyoscine N-butylbromide', 'ureteral colic', 'spasmolytic', 'anticholinergic' and 'analgesia'. The articles were given the appropriate level of evidence according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence guidelines. RESULTS: The analgesic effect of HBB as monotherapy is inferior to that of opioids and/or non-steroidal anti-inflammatory drugs (NSAIDs). It does provide an analgesic and antispasmodic effect, but not as long-lasting as NSAIDs. HBB does not serve as an adjunct to opioids. Furthermore, it does not facilitate passage of ureteral stones and has no effect on expulsion rate. CONCLUSIONS: HBB is often used where urinary tract smooth muscle spasm is thought to be part of the pathophysiological process. According to the evidence, administration of HBB follows non-peer-reviewed protocols which are based on empiric recommendations. Its role is still unclear, as it appears to have no advantage when used as monotherapy over established forms of analgesia. There appears to be a time-dependent relation to pain reduction following parenteral administration, but this needs to be confirmed by more prospective randomized cohorts.

Thromboprophylaxis and bleeding diathesis in minimally invasive stone surgery.

With populations ageing and active treatment of urinary stones increasingly in demand, more patients with stones are presenting with an underlying bleeding disorder or need for regular thromboprophylaxis, by means of antiplatelet and other medication. A practical guide to thromboprophylaxis in the treatment of urinary tract lithiasis has not yet been established. Patients can be stratified according to levels of risk of arterial and venous thromboembolism, which influence the requirements for antiplatelet and anticoagulant medications, respectively. Patients should also be stratified according to their risk of bleeding. Consideration of the combined risks of bleeding and thromboembolism should determine the perioperative thromboprophylactic strategy. The choice of shockwave lithotripsy, percutaneous nephrolithotomy or ureteroscopy with laser lithotripsy for treatment of lithiasis should be determined with regard to these risks. Although ureteroscopy is the preferred method in high-risk patients, shockwave lithotripsy and percutaneous nephrolithotomy can be chosen when indicated, if appropriate guidelines are strictly followed.

The use of a thermoexpandable metal alloy stent in the minimally invasive management of retroperitoneal fibrosis: a single center experience from the United kingdom.

PURPOSE: To review our experience with and the effectiveness of the ureteral Memokath 051 metallic stent for the minimally invasive management of retroperitoneal fibrosis (RPF). PATIENTS AND METHODS: We retrospectively reviewed the records of patients with RPF who were treated between April 2008 and February 2013. Success was defined as improvement of renal function and lack of complications after stent placement. Follow-up was at 6 weeks, 3 months, 6 months, and annually thereafter. RESULTS: A total of 14 patients were identified. The study included eight female and six male patients. Mean age was 60.2 years±8.4 standard deviation (SD). The majority of patients had idiopathic RPF (n=12, 85.7%). Stent placement was performed in 23 renal units in 14 patients, 9 (64.3%) of whom had bilateral disease. Ten (71.4%) patients had previously received medical treatment, while three (21.4%) presented with recurrent disease postureterolysis. The mean length of follow-up was 22.5 months (range 3-56 mos). Mean stricture length was 7.6 cm±6.2 SD on the right and 7.7 cm±5.1 SD (P=0.925) on the left. Patients tolerated the stents well with minimal discomfort. Ureteral obstruction was managed successfully in 78.6% of patients (n=11/14). All patients had improvement of renal function. CONCLUSIONS: To our knowledge, this is the first study using metal stents in patients with RPF. Retrograde placement of the ureteral Memokath 051 metal stent can be considered as a promising alternative for initial or salvage postureterolysis minimally invasive management of ureteral obstruction in RPF.

How to conduct a successful workshop: The trainees' perspective.

OBJECTIVES: To define the success of a medical workshop from the trainees' perspective, where a medical workshop is a scientific event with the aim of presenting updated knowledge and to teach medical skills to the participants. In surgical specialties, it contributes to the development and maintenance of surgical skills. METHODS: Medline was searched for the previous 4 months to identify articles with combinations of the keywords 'workshops', 'training', 'simulators', and 'virtual reality'. Further articles were obtained by manually searching the reference lists of identified papers. We also obtained information and critical aspects of view from other trainees. RESULTS: Based on 30 articles from the Medline search, and mostly from the trainees' perspective, we present the basic characteristics of a successful workshop. The objective of the workshop, appropriate faculty members and presenters, highly motivated participants, the use of simulators and evaluation sheets, the venue and the registration fees all have a major role in the success of a workshop. CONCLUSIONS: A successful workshop is that from which trainees have grasped most of the knowledge and skills imparted to them, with a positive progression reflected on their learning curve. Workshops are a current necessity and all efforts should be made to achieve the desired result from the trainees' perspective.

Current status of minimally invasive endoscopic management of ureteric strictures.

Endourological techniques are used more often nowadays in the treatment of ureteric strictures of various etiologies. Advances in technology have provided new tools to the armamentarium of the endoscopic urological surgeon. Numerous studies exist that investigate the efficiency and safety of each of the therapeutic modalities available. In this review, we attempt to demonstrate the available and contemporary evidence supporting each minimally invasive modality in the management of ureteric strictures.

A self-expanding thermolabile nitinol stent as a minimally invasive treatment alternative for ureteral strictures in renal transplant patients.

BACKGROUND AND PURPOSE: Ureteral obstruction in renal transplant allografts secondary to strictures can pose a challenging problem. Its incidence is reported between 0.5% and 4.7%. Usually, open surgical repair is performed. We present a series of patients in whom a metal Memokath™ 051 stent has been used as a minimally invasive treatment alternative. METHODS: We analyzed our data on the use of thermo-expandable metallic Memokath 051 stents for ureteral strictures in renal transplant patients. RESULTS: Between 2003 and 2010, eight male kidney recipients with a mean age of 49 years and obstructed ureters after kidney transplantation were treated with ureteral Memokath insertion. In six patients, the obstruction was at the level of the anastomosis, and in two, at the pelviureteral junction. After a mean follow-up of 4 years, half of the stents are in situ providing a good graft function. The average indwelling time is 4 years. Spontaneous resolution of the stricture without the need for further stent insertion was seen in three patients after a mean indwelling time of 7.3 months. There was one treatment failure in a patient with an obstructed, dilated, and convoluted ureter that was unable to withhold the stent in situ. No perioperative complications were recorded in this series. The overall success rate was 87%. CONCLUSION: Ureteral stent placement with the Memokath 051 is a safe minimally invasive treatment alternative for ureteral strictures in renal transplant recipients.