Thoracic Complications in Supracostal Percutaneous Nephrolithotomy.

BACKGROUND: Due to the risk of pleural injury leading to thoracic complications, many urologist still hesitate to perform supracostal puncture during percutaneous nephrolithotomy. Our aim of this study was to evaluate the thoracic complications in supracostal access percutaneous nephrolithotomy. METHODS: This is a retrospective analysis of 101 patients who were treated with supracostal access percutaneous nephrolithotomy at our institute from September 2013 and December 2019. Indications for supracostal punctures were staghorn 28(27.7%), middle calyceal stones 10(9.9%), pelvic stones 29(28.7%), complex inferior calyceal stones 26(25.7%), upper calyceal stone 10(9.9%)and upper ureteric stone17(16.8%).The intercostal space between the 11th and 12th ribs was used in all the cases. RESULTS: Among the 101 patients who undergone percutaneous nephrolithotomy by supracostal access, three patients (2.97%) had pleural injury. Among them one patient developed hydrothorax and needed chest tube insertion and remaining two patients had minimal pneumo thorax with blunting of costo-phrenic angle, which was managed conservatively. The lung parenchymal or other viscera injury was not observed in our study. Most punctures were, a single supracostal superior calyceal access 18(17.8%) and middle posterior calyceal access 88(82.2%), except for staghorn and multiple complex lower calyceal calculi needed multiple tracts 23(22.8%). Complete clearance was observed in 77(76.2%) patients. CONCLUSIONS: The supracostal puncture was a safe and effective approach with high stone clearance rate and acceptable morbidity in selected cases of staghorn, upper ureteral, and upper calyceal calculi. It should be adapted whenever needed and should not be avoided due to fear of chest complications.

Urethral Strictures and its Management at Tertiary Hospital of Nepal.

BACKGROUND: Urethral stricture can occur from urethral meatus to bladder neck. Treatment of urethral stricture include dilatation, endoscopic incision and anastomotic urethroplasty. The aim of this study is to report our experience in the management of different types of urethral strictures. METHODS: We retrospectively reviewed the chart of all the patients of urethral stricture who received treatment at Kathmandu model hospital between January 2015 and October 2019. Different types of urethral stricture along with various modalities of treatment given were recorded. RESULTS: Fifty patients were included in this study, all were males. Mean age was 49 (16-82) years. Bulbar urethra was the most common site in 54% of cases and bulbomembranous least common, only 10% of cases. Depending on sites and size of stricture, different types of surgery performed were meatoplasty, dviu and anastomotic urethroplasty. CONCLUSIONS: Urethral stricture is a troublesome disease and can occur anywhere from meatus to the bladder neck. Different surgical techniques are present and the treatment should be individualized, depending on location and length of the stricture.

Semi-rigid Ureteroscopy for the Management of Ureteric Calculi: Our Experience and Complication Encountered.

BACKGROUND: Semi-rigid ureteroscopy lithotripsy have become standard of treatment for ureteral calculi. The aim of this study isto review outcome of Semi-rigidureteroscopy lithotripsy and to report the complications encountered. METHODS: After approval from institutional committee of Public Health Concern Trust Nepal,we retrospectively reviewed the chart of all patients of ureteral stone who underwent ureteroscopy and pneumatic lithotripsy at Kathmandu Model Hospital between January 2013 and September 2017. Patient characteristics, stone size, success rate and complications were assessed. Intraoperative complications were graded using modified Satava classification system and the postoperative complications graded according to modified Clavien classification system. The success rate was based on stone free status after primary semi-rigid ureteroscopy lithotripsy, without the need of any other secondary procedures. RESULTS: Total 232 patients underwent semi-rigidureteroscopy lithotripsy. Mean age was 46 (16-76) years, with 128 males and 104 females. Size of the stone ranges from 5-18mm. The success rate of primary semi-rigidureteroscopy lithotripsy was in218 (93.9%) cases.Most intraoperative complications were modified Satava grade I (41.7%) andII(3.87%).Four(1.7%) patient had grade III complication, requiring conversion to open surgery. Ureteral avulsion was seen in 1(0.43%) patient, requiring ureteral reimplantation.The postoperative complication were modified Clavien grade I(10.7%), grade II(5.17%), grade III (4.6%) and grade IV(0.43%). Double J stents were inserted in all the patients postoperatively.The mean hospital stay was 2.2(1-14)days. CONCLUSIONS: Semi-rigid ureteroscopy lithotripsy for the management of ureteral stones is efficacious and have a lesser major complications.

Initial Experience of Retroperitoneoscopic Surgery in Benign Renal Diseases.

BACKGROUND: To review our early experience to determine the feasibility, efficacy and clinical outcomes of retroperitoneoscopic surgery in benign renal diseases. METHODS: This is a prospective observational study carried out between December 2014 to March 2018. Among 14 patients enrolled in the study, 9 cases of nonfunctioning kidney underwent retroperitoneoscopic simple nephrectony, 4 cases of benign renal cortical cysts underwent decortication of cysts and one case of pelviureteric junction obstruction underwent Anderson Hynes pyeloplasty. RESULTS: Retroperitoneoscopic nephrectomy, renal cyst decortication and A-H pyeloplasty were performed in 13 patients successfully. The procedure in one patient of RP nephrectomy converted to open surgery due to dense perinephric and hilar adhesions. Which resulted to failure to progress. The mean operative time of RP nephrectomy, decortications and pyeloplasty were 206.4 (150-248), 67.5 (60-80) and 275 minutes, average blood loss was 96.7 (50-120), 27.5 (20-30) and 70 ml, and the mean hospital stay were 3.5 (3-4), 2 (2-2) and 4 days respectively. The perioperative period was uneventful. CONCLUSIONS: Retroperitoneoscopic surgery is feasible and safe in benign renal diseases. Because of reduced post operative pain and less chances of bowel injury, retroperitoneoscopic surgery is gaining more popularity.

Managing Ureterovaginal Fistulas following Obstetric and Gynecological Surgeries.

BACKGROUND: Iatrogenic ureteric injuries leading to fistula are rare but devastating complications of obstetric and gynecological surgeries. The aim of the study was to review the demography of ureterovaginal fistula (UVF) and its surgical outcome in Kathmandu Model Hospital. METHODS: This is a review of 15 patients of ureterovaginal fistula who were referred to department of Obstetrics and Gynaecology of Kathmandu Model Hospital from Feb 2014 to Sept 2017. We reviewed the demography, causes and surgical outcome of ureterovaginal fistula (UVF). Ten patients who had complete blind end at the distal ureter, underwent Lich-Gregoir extravesical ureteroneocystostomy. In other five patients, guide wire was successfully negotiated beyond the fistula site, however retrograde double J stenting could be done in only four patients. RESULTS: All the patients had distal ureteric injury close to vesicoureteric junction leading to ureterovaginal fistula. Among them, majority were due to post-hysterectomy in 60% (n=9) followed by obstetrical procedures in 40% (n=6). Fourteen patients (93%) had successful closure of the fistula with complete preservation of renal function. Retrograde double J stenting was possible in patients who were referred earlier within two weeks of the onset of injury. CONCLUSIONS: Iatrogenic injury to the distal ureter during surgery was the leading cause for the ureterovaginal fistula. Endoscopic management with ureteric stents was still possible if the patients were referred earlier following primary surgery.