Challenges of Retrograde Ureteroscopic Procedures in Overweight Patients.

BACKGROUND: Obesity and urolithiasis are both prevalent conditions that have an impact on the healthcare system. The ureteric diameter and accessibility play a crucial role in the management of urolithiasis in both overweight and normal weight patients. Studies have shown that obesity can lead to changes in ureter diameter where excessive body fat can exert pressure on the kidneys, causing them to enlarge in size and this enlargement can result in a compression of the adjacent structures, including the ureter. The aim of this study is to assess the incidence of intraoperative challenges faced during retrograde ureteroscopic procedures in overweight patients with ureteric and renal calculi. METHODS: We retrospectively reviewed patients who underwent retrograde ureteroscopic surgery (RURS) for urolithiasis from 1st January 2021 until 30th August 2023. The outcome and any complications were documented and compared with the patient's Body Mass Index (BMI). All patients who undergo RURS in our facility have to have a Non-Contrast CT scan prior to surgery. Procedural success was determined by the ability to obtain access to the stone site intraoperatively and stone-free status in kidney, ureter, and bladder (KUB) X-ray post-operatively. Post-operative complications were recorded up to two weeks post-operatively and classified according to the Calvein Dindo Classification. RESULTS: Our total sample size was 146 patients out of which 75 were overweight and 71 were normal weight patients. In 34 (45%) of overweight patients' access to the ureter was restricted due to a narrow ureteric orifice with ureteroscopy not successful; on the contrary 13 (18%) of normal weight patients faced this same issue. This was statistically significant with a p-value of .004. The stone clearance rates were 91% and 95% in overweight and normal weight patients respectively, which is higher in normal weight patients however this difference was not found to be a statistically significant finding (p-value .028). Overweight patients had 12% Grade I and 8% Grade II complications whereas normal weight patients had 11% Grade I complications and 1.4% Grade II with no higher-grade complications. CONCLUSION: Retrograde ureteroscopic procedures are a safe treatment modality for patients with urolithiasis in both overweight and normal weight populations. They are shown to have similar success rates between both populations once ureteric access is obtained. However, access failure rates are shown to be slightly higher in overweight patients. Hence, further preoperative patient counselling and technical considerations should be undertaken.

Laparoscopy-Assisted Percutaneous Nephrolithotripsy (PCNL) in Ectopic Pelvic Kidney.

An ectopic kidney is a rare developmental anomaly in which the kidney can be pelvic, iliac, abdominal, and thoracic, and affected patients are more prone to conditions such as reflux, pelvic ureteric junction (PUJ) obstruction, hydronephrosis, nephrolithiasis, and even renal failure than patients with normally structured kidneys. In this case, we present a 43-year-old male who is a known case of ectopic left pelvic kidney and presented with chronic lower abdominal pain. Upon imaging, it was revealed that he had a staghorn stone for which he underwent laparoscopy-assisted percutaneous nephrolithotripsy (PCNL). Postoperatively, the patient underwent a quick recovery and was discharged on postoperative day 3 without any perioperative complications. Hence given our experience with this case and the similar experiences of urologists over time, the use of laparoscopy-assisted PCNL appears to create a safe way of entering the abdomen and locating the ectopic kidney as well as provide visual guidance in puncture and dilatation all the while protecting the adjacent structures from harm. This demonstrates that laparoscopy-assisted PCNL is a feasible safe and minimally invasive procedure for patients with ectopic kidneys presenting with large stones.

Ultrasound heterogeneity as an indicator of testicular salvage in testicular torsion: A single center experience.

OBJECTIVE: Testicular torsion is a common urological emergency, mainly in the younger population. Our aim is to evaluate the efficacy and value of testicular echogenicity in predicting testicular viability. METHODS: Patients who were older than 13 years of age and were discharged with the diagnosis of testicular torsion were reviewed. Data obtained included demographic data, history, physical examination results, ultrasound findings including size, color Doppler flow, and echotexture, torsion degrees, and surgical procedure. In addition, the histopathological findings of patients who underwent orchiectomy were reviewed. RESULTS: A total of 71 cases were diagnosed with testicular torsion between January 2016 to December 2018. The mean age at presentation was 20.4±7.0 years. The average time from the onset of pain until the presentation was 36.0±55.1 h. Out of the 71 ultrasound scans reviewed, 45.1% showed homogenous echotexture and 54.9% showed heterogeneous echotexture of the affected testis. On scrotal exploration, the mean degree of torsion was 475.7±301.8 degrees; 66.2% of the patients had a viable testis; and bilateral orchidopexy was done. The remaining 33.8% had a non-viable testis. Homogenous echotexture was after an average of 13.5 h of scrotal pain, while heterogeneous echotexture presented after 53.7 h of scrotal pain. There was a statistically significant difference between the time of presentation and echotexture changes on scrotal ultrasonography (p<0.01). The relationship between echotexture changes and testicular viability was statistically significant as well (p<0.001). CONCLUSION: A long time since the onset of pain coupled with heterogeneous changes in testicular parenchyma is a good indicator of non-viability. However, we still advocate for surgical exploration as the gold standard in diagnosis and management.

Percutaneous nephrolithotomy of a staghorn calculus in a patient with renal angiomyolipoma.

Renal angiomyolipoma (AML) is the most common benign renal tumor and is prevalent in around 0.2%-0.6% of the population. Its main associated risk is bleeding. It is uncommon that AML presents simultaneously with a staghorn calculus requiring percutaneous nephrolithotomy (PCNL) for stone resolution with only two previously reported cases. In this case, we present a 41-year-old female patient who presented with a 2-year complaint of left flank pain and hematuria. Following investigation, the patient had a large staghorn calculus in the left kidney and an incidental finding of a large AML in the ipsilateral kidney. A single puncture was made under ultrasound guidance, to avoid any form of injury to the AML, and complete stone clearance was achieved through a single tract only. Although the concurrence of AML with a renal calculus requiring PCNL presents a clinical challenge, using ultrasound guidance for stone clearance is a safe and successful means of management with minimal exposure to radiation.

Direct comparison of the different conventional laparoscopic positions with the ethos surgical platform in a laparoscopic pelvic surgery simulation setting.

OBJECTIVE: Laparoscopic surgery can be harmful to surgeons requiring a prolonged learning curve due to significant ergonomic drawbacks. Based on preliminary clinical experience, we present an experimental evaluation of the second-generation ETHOS™ operating chair by comparing it with two different operating positions of conventional laparoscopic pelvic surgery. MATERIALS AND METHODS: The ETHOS operation platform consists of a seat like a saddle and five more parts that can be adjusted individually to support the surgeon's trunk and extremities. This operation platform was tested in 30 trainees who performed three standard suturing exercises in a pelvitrainer, approximating a linear and a U-shaped incision, made on the skin of a chicken leg, and completing an urethrovesical anastomosis, on a pig bladder specimen model, using interrupted sutures. The trainees performed each exercise in standing laterally to pelvitrainer (torero position) vs standing behind pelvi-trainer and sitting on ETHOS. The mean values, from all times and for each exercise and position, were documented, and the participants filled out a validated questionnaire focusing on ergonomic issues. RESULTS: There were no significant differences among the different training modalities, in step 1 and step 2. However, in step 3, which mimics the urethrovesical anastomosis, the mean times were statistically significant significantly less by using ETHOS (p<0.0001). The mean times of training in step 3 were 41.2 minutes in the behind the camera position, 49 minutes in torero position, and 39.7 minutes by using ETHOS. The position that was maintained, during the exercises, was mainly responsible for the improvement noted in the ergonomic scores. CONCLUSIONS: The new operating platform (ETHOS chair) can significantly improve ergonomics in laparoscopy particularly concerning difficult steps like intracorporeal suturing. This may also improve the urethrovesical anastomosis times in a clinical setting.

Penile prosthesis implantation for treatment of postpriapism erectile dysfunction.

INTRODUCTION: Our aim was to evaluate the procedure and outcome of penile prosthesis surgery in the treatment of men with postpriapism erectile dysfunction. MATERIALS AND METHODS: During the period between 1997 and 2004, a total of 17 patients with postpriapism erectile dysfunction underwent penile prosthesis implantation at our institution. Prosthesis implantation was done electively 6 to 18 months after priapism, when the patients presented with erectile dysfunction. Of the prosthesis implanted, 11 were malleable, 4 were 2-piece, and 2 were 3-piece prostheses (AMS, Minnetonka, Minnesota, USA). RESULTS: All the 17 patients were successfully implanted with penile prosthesis. Intra-operatively, corporeal dilation was difficult due to extensive corporeal fibrosis, which led to urethral injury in 2 patients. There were no major postoperative complications. The median hospital stay was 5 days. The follow-up period ranged from 2 to 9 years (median, 6 years). All the patients were satisfied with the prosthesis. CONCLUSION: Penile prosthesis implantation is the modality of treatment for patients with postpriapism erectile dysfunction at our institution. It has a high patient satisfaction rate. Although procedure-related complications are common due to corporeal fibrosis, they were mostly minor ones and did not affect the outcome of the procedure.