Mini-versus standard percutaneous nephrolithotomy in pediatric population: A randomized controlled trial.

INTRODUCTION: Mini PCNL has gained popularity in adult patients due to reduction in the complication rate with comparable stone free rate. There is paucity of level 1 evidence regarding the benefit of mini PCNL in the pediatric group. OBJECTIVE: We performed a randomised study to compare mini PCNL (mPCNL) with standard PCNL (sPCNL) for the management of renal calculi in patients less than 18 years of age in terms of safety, efficacy, and stone-free rate (SFR). MATERIALS AND METHODS: A randomised controlled trial was performed on 50 children who underwent PCNL from June 2015 to March 2021, who were divided into two groups. Group I had 25 patients managed with mPCNL (sheath size 16.5 Fr) and Group II had 25 patients who underwent sPCNL (sheath size 26 Fr). Primary outcomes including stone free rates (SFR) and hemoglobin drop and secondary outcomes like operative time, complications, pain score, need of analgesia, incidence of nephrostomy site leak, hospital stay in days were compared between the two groups. RESULTS: The mean age of patients in groups I and II was 9.4 ± 2.6 and 10.4 ± 2.26 years, respectively (p = 0.15). The mean stone sizes in both groups I and II were 18.6 ± 2.56 and 20.2 ± 3.58 mm, respectively (p > 0.05). The stone free rate for group I was 88% and for group II, 92% (p = 0.64). The average drop in hemoglobin was higher in group II compared to group I (1.1 ± 0.31 g/dl and 1.7 ± 0.23 g/dl respectively; p < 0.0001), however the mean blood transfusion rate was not significantly different in both groups. The operating time was shorter in group II compared to group I (p-value - 0.0030). The pain scores were lesser for the group I. Grade I complications were higher in group II as compared to group I (p-0.047); however, grade II complications were comparable in both groups. The mean hospital stay was not significantly different in both groups. DISCUSSION: This study confirms the role of mini PCNL in pediatric patients with renal stones. The stone clearance rate of mini PCNL is equivalent to standard PCNL, with lesser blood loss and postoperative complications, however with longer operative time during mPCNL. The small number of the participants in both arms is a limitation of this study and may also reflect fewer children with urolithiasis being treated surgically even in a tertiary care referral centre. CONCLUSIONS: Mini-PCNL offers equivalent stone free outcome with lower complications rate compared to the standard PCNL for all types of renal stones.

Comparing T2-T3 staging of penile cancer according to the American Joint Committee on cancer 8th edition with two modified staging systems in predicting survival outcome: A single-center experience.

Introduction: Penile cancer is a rare malignancy of the genitourinary tract. We aimed to validate the recent changes in the T2 and T3 stages of penile cancer in the American Joint Committee on Cancer (AJCC) 8th edition and to compare its predictive ability with two other modified staging systems for survival outcomes. Methods: This is a retrospective study of patients diagnosed with penile cancer from June 2015 to March 2020. The AJCC 8th edition and two other newly proposed systems by Li et al. and Sali et al. were used for staging the tumor. All variables were categorized and correlated with lymph node (LN) metastases and overall survival (OS). Results: Fifty-four patients were eligible for this study. The mean age was 58 years (range 46-72 years). The tumor stage (P = 0.016), clinical LN stage (P = 0.001), the involvement of the spongiosa (P = 0.015) and the cavernosa (P = 0.002), lymphovascular invasion (LVI) (P = 0.000), and PNI (P = 0.021) were found to be the significant predictors of LN metastases. When the 5 year OS was compared between the T2 and T3 stages of the AJCC 8th edition, Li staging and the Sali staging systems, it was 91% and 50.1% (P = 0.001), 97.5% and 10.3% (P = 0.000), 94.4% and 14.7% (P = 0.000), respectively. The presence of LVI (P = 0.001) was the most significant independent predictor of OS. Conclusions: The recent changes in the AJCC 8th edition pertaining to the T2-T3 stage are relevant, although the other two newly proposed staging systems were more precise in predicting the survival outcomes.

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

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

Experience with management of renal cell carcinoma with inferior vena cava/right atrial tumor thrombus.

INTRODUCTION: We aimed to present our experience in managing renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus. METHODS: Records of all patients aged 18 years and older, with a diagnosis of primary renal masses with IVC thrombus, presenting to our institute from January 2012 to August 2020 were retrospectively reviewed. Patients with tumor thrombus limited only to renal vein were excluded from the analysis. Their hospital course and outcomes were recorded and evaluated for predictors of survival. RESULTS: During the study period, we treated 61 patients with a renal mass and concurrent IVC thrombus and 56 of these underwent surgery. 7 of them had level III and 6 had level IV thrombus. A total of six patients received neoadjuvant tyrosine kinase inhibitor (TKI) therapy and all of them showed a decrease in size and level of tumor thrombus and cardiopulmonary bypass was safely avoided. Fourteen patients had distant metastasis and underwent cytoreductive surgery and of these 12 patients received TKI therapy after surgery with a mean survival of 26.8 months. The overall survival at 2 and 5 years of nonmetastatic group was 81.1% and 47.5% respectively and in metastatic group was 35.1% and 0%, respectively. Poor performance status, distant metastasis, higher T stage, higher thrombus levels, and positive surgical margins were all predictors of decreased survival. CONCLUSIONS: Complete surgical resection in both nonmetastatic and metastatic RCC with IVC thrombus has long-term survival benefits. Neoadjuvant TKI therapy, with adequate preoperative planning, helps in decreasing the size of the thrombus and in safely avoiding bypass in level III and IV IVC thrombi.

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

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