Understanding ureteroscopy complications according to modified Clavien classification system.

OBJECTIVE: To determine the complications of ureteric stone treatment with semi-rigid uretero-renoscopy in accordance with the modified Clavien classification system. METHODS: The descriptive, prospective study was conducted at the Department of Urology, Sindh Institute of Urology and Transplantation, Karachi, from June 30, 2020, to December 29, 2021, and comprised patients of either gender aged 18-70 years having ureteric stones. All patients were subjected to ureterorenoscopy using a semi-rigid ureteroscope under general anaesthesia. The patients were followed up for 2 months. All complications were noted and graded in line with the Modified Clavien Complication System. Ultrasound and X-ray were used to determine the stone-free rate. Data was analysed using SPSS 23. RESULTS: Of the 414 patients, 304(73.4%) were males and 110(26.5%) were females. The overall mean age was 40.22±13.10 years. There were 106(25.6%) proximal, 134(32.3%) middle, and 174(42%) distal ureteric stones. Stent placement was done in 56(13.5%) cases. There were 260(62.8%) patients with no complication, 90(21.7%) with grade I complications, 34(8.2%) with grade II complications, 10(2.4%) with grade IIIa, 8(1.9%) with grade IIIb, and 12 (2.9%) with grade IVa complications. CONCLUSIONS: Uretero-renoscopy was found to be a safe procedure, as it had minimal associated complications with optimal stone clearance and great dexterity. The Modified Clavien classification system was found to be an easy way to classify surgical complications of uretero-renoscopy.

Da Vinci Robotic Surgical System: Early Experience from Pakistan.

OBJECTIVE: To determine the outcomes of robotic surgeries using the Da Vinci robotic surgical system (DVSS) at Pakistan's largest urological tertiary healthcare system. STUDY DESIGN: Descriptive study. Place and Duration of the Study: Department of Minimally Invasive and Robotic Surgery, Division of Urology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan, from March 2017 to December 2021. METHODOLOGY: Hospital records of patients who underwent robotic urological surgeries were assessed for their outcomes in terms of blood loss, mortality, system malfunction, and conversion to open surgery. Descriptive statistics were determined. RESULTS: A total of 550 procedures were performed. The mean age recorded was 39.58±16.83 years. The mean blood loss recorded was 255.611±353.57 ml; there were 3 cases of malfunction. Forty cases were converted to open surgery, and the mortality rate was 1.1%. CONCLUSION: Minimally invasive surgical techniques have high precision, fewer complications, and lower morbidity rates. Using DVSS for surgical interventions is both effective and safe. KEY WORDS: Minimally invasive surgery, Da Vinci robotic surgical system, Robotic surgery.

Comparison of Outcomes of Extracorporeal Shockwave Lithotripsy with Ureteroscopic Lasertripsy for Management of Proximal Ureteral Stones.

OBJECTIVE: To compare the outcomes of extracorporeal shockwave lithotripsy with ureterorenoscopy and lasertripsy for managing upper ureteral stones of size 10mm to 15mm. STUDY DESIGN: Observational, cross-sectional study. Place and Duration of the Study: Department of Urology, Sindh Institute of Urology and Transplantation (SIUT), from December 2020 to December 2021. METHODOLOGY: A total of 168 patients with the diagnosis of proximal ureteric stone of size 1-1.5 cm were enrolled for this study. Patients were divided into two groups by simple random method. Group 1 patients underwent ureteroscopic lithotripsy (URS) and lasertripsy while Group 2 patients were subjected to extracorporeal shockwave lithotripsy (ESWL). Patients' demography, operative time, duration of hospitalisation, complication rate and stone-free rates, were recorded for both groups. Frequency and percentages were calculated for categorical variables and mean and standard deviation were calculated for continuous variables. For comparison of continuous variables, one-way ANOVA was applied, and Chi-square test was applied to compare the categorical variables. The p-value ≤0.05 was taken as significant. RESULTS: The mean age was of 39.55 ± 14.06 years, with the majority falling within the age group of 26 to 40 years. There were more males (116, 69%) than females (52, 31%). Most of the patients did not have a history of diabetes or hypertension. Sixty-two patients had previous history of stones. The average duration of ureteric stone disease was 3.18 ± 3.14 months. The mean size of the ureteric stone was 10.82 ± 3.19mm. The procedure duration was significantly shorter for URS, as compared to ESWL (33.81 ± 15.42 minutes vs. 45.00 ± 0.00 minutes, p=<0.01. The overall stone clearance rate was significantly higher after URS (83.3%) as compared to ESWL (64.2%, p=0.05). CONCLUSION: URS was a superior treatment option as compared to ESWL. However, the selection of the most appropriate procedure should be based on a tailored approach considering the patient's preference and the size of the stones. KEY WORDS: Extracorporeal shockwave lithotripsy (ESWL), Ureteroscopic lithotripsy (URS), Modified clavien classification system (MCCS), Ureteric stone.

Percutaneous Nephrolithotomy in Anomalous Kidney.

OBJECTIVE: To assess the stone-free rate (SFR) subsequent to percutaneous nephrolithotomy (PCNL) in patients with anatomically anomalous kidneys. STUDY DESIGN: Cross-sectional study. Place and Duration of the Study: Department of Urology, Sindh Institute of Urology and Transplantation Karachi, from 23 July 2020 till 30 October 2021. METHODOLOGY: Sixty-five patients of renal stone disease with abnormal kidneys, aged 18-60 years of both genders were enrolled in this cross-sectional study. Demographic information like age, gender, stone size, duration of disease, and type of abnormality were noted. After PCNL, stone-free status was determined after 2 weeks of the procedure by performing ultrasound KUB. RESULTS: A total of 65 patients were included in this study with mean age of 36.37 ± 12.86 years [Range: 18-60]. There were 76.9% of males and 23.1% of females. Regarding anatomical malformation, 46.2% were malrotated kidneys, 16.9% were horseshoe kidneys, 16.9% were partial Duplex system, 9.2% had bifid pelvis. Median duration of the disease was 12 (IQR=10). Forty-one patients (63.1%) had single and 24 (36.9%) had multiple number of stones with average size of 3.26 ± 1.14 cm. SFR after PCNL in patients with abnormal kidneys was 70.77% (46/65) while 29.23% (19/65) were observed with residual fragments. Out of 19 cases with residual fragments, 10 (53.2%) had stone size <1 cm and 9 (47.4%) had stone of 1 to 3 cm. Sixteen out of 19 patients with residual stones were treated with ESWL (most required: one session), and re-do PCNL was performed in three cases. CONCLUSION: PCNL is an effective and safe operation in anatomically anomalous kidneys. For satisfactory outcomes, it requires extreme care and exceptional surgical skill. KEY WORDS: Malrotated kidney, Duplex system, Kidney anomaly, Horseshoe kidney, PCNL, Extracorporeal shockwave lithotripsy (ESWL).

Squamous Cell Carcinoma of the Kidney: A Large Case Series.

OBJECTIVES: We present our experience with and data about a very rare neoplasm of the kidney, squamous cell carcinoma (SCC). METHODS: A total of 14 patients with a diagnosis of SCC were identified on the basis of a retrospective analysis of medical records of patients who underwent surgery for renal cancers between 2015 and 2021 at the Sindh Institute of Urology and Transplantation. IBM SPSS v25 was used to record and analyze data. RESULTS: Most patients found to have SCC of the kidney were male (71.4%). The mean (SD) patient age was 56 (13.7) years. Flank pain was the most common presenting symptom (n = 11; 78.6%) followed by fever (n = 6; 42.9%). Only 4 (28.5%) of the 14 patients had a preoperatively established diagnosis of SCC; the remaining 10 (71.4%) had an incidental finding of SCC on their histopathology specimen. The mean (SD) overall survival was 5 (4.5) months. CONCLUSIONS: SCC of the kidney is a rare upper urinary tract neoplasm reported in the literature. The gradual onset of vague symptoms, lack of pathognomonic signs, and inconclusive radiological features make the disease unsuspected in most cases, therefore delaying diagnosis and treatment. It usually presents at an advanced stage, and the prognosis is often poor. A high index of suspicion is warranted in patients with chronic kidney stone disease.

Mixed epithelial and stromal tumour of the kidney masquerading as hydatid cyst: a rare case report from the developing world.

Mixed epithelial and stromal tumour (MEST) is a rare entity with an incidence of 0.2% among renal cancers. It has strong predilection towards females with a 1:6 male to female ratio, the tumour is cystic with some solid component with biphasic proliferation of stromal and epithelial cells. The case of a 37-years-old female is presented with right lumbar pain since 3 months. The family history was unremarkable. The routine workup revealed mild neutrophilia and borderline Echinococcus antibody titres. Ultrasound revealed a complex cystic lesion with a solid component in the right kidney. CT scan with contrast confirmed a multiloculated mixed density lesion with daughter cysts arising from the middle lobe of the right kidney. Initial diagnosis of renal hydatid cyst was established and she underwent partial nephrectomy with excision of the cystic mass. Surprisingly the histopathology revealed mixed epithelial and stromal tumour.