Single ileal segment in a cat-tail configuration for bilateral ureteric strictures.

INTRODUCTION: Management of bilateral long length ureteric strictures is difficult with few options for reconstruction. In this report, we describe our experience with the use of a single, 15- 20 cm ileal segment for reconstruction of bilateral long length (involving more than 2/3rd ureter) ureteric strictures. PATIENTS AND METHODS: A retrospective analysis of 5 cases operated between 2015 and 2020for bilateral long length ureteric strictures, using a single segment ileal interposition in a cat tail configuration was performed. We evaluated renal function, surgical success, incidence of urinary tract infection and complications of the procedure. Surgical success was defined as an asymptomatic patient with no hydronephrosis and/or prompt drainage of the kidney on radiological investigations. RESULTS: The average age of presentation was 42.8 ± 7.4 years (33-53) years). All the cases were secondary to a gynaecological intervention. The mean creatinine prior to surgery was 0.81 ± 0.36 mg % (range 0.5 -1.4 mg%). Mean duration of follow-up was 28.6 ± 20.6 months (Range 10 - 56 months). Mean hospital stay was 14.4 ± 3.36 days (range 12-20 days). Two patients developed ileus and one patient developed deep venous thrombosis in the post-operative period. One patient developed pyelonephritis within one month of surgery. There was no deterioration of renal function with the mean serum creatinine at last follow-up being 0.9 ± 0.36 mg% (range 0.6 - 1.5 mg%). CONCLUSION: The use of an ileal segment in cat-tail configuration for bilateral simultaneous ileal replacement is a feasible and safe option. The medium-term result states that it is effective in the preservation of renal function and provides a good conduit for drainage.

ROLE OF MICROPERC IN MINIMAL INVASIVE EXTRACTION OF Renal STONES IN CHILDREN.

BACKGROUND: Microperc using all-seeing needle is associated with reduced tract-related morbidity. AIM & OBJECTIVES: The purpose of this study was to examine the effectiveness and safety of microperc in children. PATIENTS & METHODS: From July 2010 to August 2014, a total of 17 children with renal stones underwent microperc at Muljibhai Patel Urological Hospital, Nadiad, India. Renal access was achieved through 4.85-Fr (16 gauge) all-seeing needle (PolyDiagnost, Pfaffenhofen, Germany). and fragmentation with 200 µm holmium:YAG laser fiber. The patient's demographic data, clinical features, operating time, hemoglobin drop, stone clearance, complications (Clavien-Dindo), and length of hospital stay were prospectively studied. RESULTS: A total of 17 patients with a median age of 9 years were studied. The stone size ranged from 5.3mm to 24.9mm. The median operative time was 40 minutes. The median decrease in haemoglobin was 1.2 mg/dl. The stone-free rate at first postoperative day and at the first month after the procedure were 82.4% and 88.2% respectively. The mean hospital stay was 56.4 hours. None of the patients required blood transfusion. An overall success rate of 94.1% was achieved at median follow-up of 4 months. Comparing small size stones (< 1cm) and moderate size stone (1-3cm); the immediate clearance rates were 100% and 75% respectively (p=0.331). There was no statistically significant difference in the operating time (40 vs 43mins; p=0.592), haemoglobin drop (0.85 vs 1.25 g/dl; p=0.595) and the length of hospital stay. One patient in each group had conversion to miniperc to remove residual stone fragment. There was one minor intra-operative pelvic perforation (Clavien II). There were two postoperative complications in patients with moderate stone; one of the patients had right lower lobar pneumonia and the other had colic pain and both cases were managed conservatively (Clavien I). CONCLUSION: This study has demonstrated that microperc is a safe and effective procedure in the extraction of small to medium size renal stones in children.

Renal deterioration index: preoperative prognostic model for renal functional outcome after treatment of bilateral obstructive urolithiasis in patients with chronic kidney disease.

BACKGROUND AND PURPOSE: Patients who present with varying severity of obstructive urolithiasis behave differently after the treatment. Some patients recover with improved renal function while others progress to renal failure. Our objective was to objectively quantify which patients would progress to renal failure after treatment for obstructive urolithiasis. PATIENTS AND METHODS: A prospective analysis of 167 patients with renal failure from bilateral obstructive urolithiasis who were treated and subsequently followed for at least 1 year was performed. Failure was defined as glomerular filtration rate (GFR) values less than 15 mL/min at 1 year follow-up. All patients had preoperative placement of a percutaneous nephrostomy tube for at least 5 days before treatment with either ureteroscopy or percutaneous nephrolithotomy. Multiple logistic regression analysis of affecting parameters was performed. A renal deterioration index (RDI) was constructed based on scores assigned to varying severity of multivariate significant factors and the receiver operating characteristic (ROC) curve was analyzed. RESULTS: There were 48(28.7%) patients who progressed to CKD stage V at 1-year follow-up. Combined cortical width (≤ 0.001), proteinuria (0.01), positive urine culture (0.004), and nadir preoperative GFR postbilateral percutaneous nephrostomy (0.016) were statistically significant factors affecting renal deterioration on multivariate analysis. RDI has a high ROC curve (AUC=0.90) for predicting renal functional outcome. Combining these parameters in a prediction table yielded a RDI score ≥ 12 being associated with high odds risk (odds ratio=11.2) of treatment failure. CONCLUSION: RDI ≥ 12 is associated with renal deterioration after appropriate treatment of bilateral obstructive urolithiasis.

Management of urolithiasis in live-related kidney donors.

OBJECTIVE: To analyze our experience in management of urolithiasis in renal donors. MATERIALS AND METHODS: The stones were treated either pretransplant or posttransplant. The Amsterdam forum criteria for acceptance of living donors were used for donor selection. The donors underwent the following procedures: pretransplant extracorporeal shock wave lithotripsy (ESWL) (n=5), pretransplant retrograde intrarenal surgery (RIRS) (n=1), ex-vivo ureteroscopy (ex-vivo URS) (n=1), and ex-vivo pyelolithotomy (ex-vivo Pyl) (n=2); intraoperative Double-J stent; and observation (n=3). Data were analyzed for technical feasibility, intraoperative and postoperative complications, and stone clearance. RESULTS: The male and female ratio was 4:8 and average age was 52.3 years (38-71). In the pretransplant ESWL group, average of 740 shocks (600-1500) was given; the power was not ramped up beyond 12 kV. Ex-vivo URS was performed on bench with 6F pediatric cystoscope, while in the ex-vivo Pyl, a 12F nephroscope was introduced via a pyelotomy and stones were retrieved intact with a dormia basket. A postoperative ultrasound at one month revealed complete clearance of stones in all except one donor. At a mean follow-up of 36 months (10-58), there was no stone recurrence in donor or recipient. CONCLUSIONS: This report shows the feasibility and safety of ex-vivo URS and ex-vivo Pyl in living donors, in select cases with subcentimeter calculi, an option of conservative management with Double-J stent is safe. ESWL/RIRS can be performed safely in the pretransplant setting. Proper donor selection and follow-up are crucial to success. We propose a treatment selection algorithm for management of these donors.

Spontaneous subcapsular renal hematoma: A case report and review of literature.

Spontaneous subcapsular renal hematoma is not a common entity. We report a 38-year-old lady presenting with sudden onset right flank pain with uncontrolled hypertension and she was found to have subcapsular collection in the right kidney on ultrasonography. Finding was confirmed on computed tomography. Except hypertension, no particular cause for the condition could be found. Symptoms and size of the collection decreased on conservative treatment. They completely disappeared on ultrasonography at 6 months follow-up. She was asymptomatic at 18 months follow-up.

Donor gonadal vein reconstruction for extension of the transected renal vessels in living renal transplantation.

INTRODUCTION: Donor gonadal vein is a readily available vascular reconstruction material for vascular reconstruction, for difficult situations, in living related renal transplantation. Vein extension with the gonadal vein has been described as a simple and safe method to elongate renal vein especially in right living donor kidneys. We applied the donor gonadal vein for lacerated accessory renal artery and renal vein reconstruction. MATERIALS AND METHODS: The donor gonadal vein was used to reconstruct the lacerated accessory renal artery in one patient. The donor gonadal vein was isolated, used as an interposition graft to bridge the gap between transected accessory renal artery and external iliac artery of the recipient. In another patient, gonadal vein was used to reconstruct short right renal vein, which got damaged during retrieval. RESULTS: This technique resulted in a tension-free anastomosis. There were no procedure related complications. The ischemia time remained within acceptable limits and grafts showed excellent outcomes. CONCLUSIONS: The use of gonadal vein for renal vascular reconstruction seems to be an acceptable option during living related renal transplantation, lest the need arise, with no increased graft morbidity.

Face and content validity of transurethral resection of prostate on Uro Trainer: is the simulation training useful?

BACKGROUND: Uro Trainer (UT; Karl Storz GmbH, Tuttlingen, Germany), a virtual reality simulator for transurethral resection of prostate (TURP), has been infrequently validated. To ascertain the utility of such a trainer, we performed a basic face and content validity study. MATERIALS AND METHODS: Ten experts and nine novices (done more than 50 and less than 3 TURPs, respectively) performed a TURP on UT and rated simulator usefulness (seven items), realism (five items), and overall score (one item) on a Likert's 10-point scale. Scores of < 6.0, 6.0 to 8.0, and > 8.0 on the Likert scale 1 to 10 were considered not, slightly, and highly acceptable, respectively. RESULTS: Novices rated UT as more helpful than experts in the following aspects of face and content validity: usefulness general (p = 0.0001, statistically significant), hand-eye coordination (p = 0.04, statistically significant), material knowledge and skills (p = 0.02, statistically significant), spatial skills (p = 0.003, statistically significant), cystoscopy (p = 0.002, statistically significant), TURP (0.002, statistically significant), visual aspects (p = 0.003, statistically significant), and overall score (p = 0.007, statistically significant). One item of usefulness (coagulation) and three items of realism (tissue feel, depth feel, and capsule identification) failed to impress both novice and experts. UT usefulness domain was highly acceptable for 77.7% and slightly acceptable for 100% of the novices and experts, respectively. The general realism domain was highly and slightly acceptable for 33.3% and 66.6% of the novices while slightly acceptable for 100% of the experts. CONCLUSION: Novice group found UT more useful than the experts group. Further modification is advisable to increase the realism of the UT.

Management of non-neoplastic renal hemorrhage by transarterial embolization.

OBJECTIVES: To assess the role of transarterial embolization (TAE) and critically appraise its feasibility and efficacy in the management of non-neoplastic renal hemorrhage. Percutaneous TAE is an effective method for the control of hemorrhage, irrespective of the cause. Injury to the renal artery or its branch, after trauma or during open or percutaneous urologic procedures, can be accurately diagnosed using angiography and treated by percutaneous embolization techniques. Because the technique and technology have evolved, it is now possible to perform highly selective embolization of the injured vessel while preserving vascularity of the rest of the renal parenchyma. METHODS: The medical records of all patients who underwent angioembolization for hemorrhagic urologic emergencies at our institute from January 1996 to December 2007 were reviewed. RESULTS: A total of 41 patients, aged 7-72 years, underwent TAE because of hemorrhage after percutaneous nephrolithotomy (n = 27), open pyelolithotomy (n = 3), renal biopsy (n = 8), and spontaneous occurrence (n = 3). All patients had a normal coagulation profile before surgery. A total of 35 patients (85.3%) underwent successful embolization and none required a postprocedural blood transfusion. Of those with postpercutaneous nephrolithotomy bleeding, angioembolization failed in 6 patients. Of these, only 2 required nephrectomy to save the patient's life. No serious procedure-related complications occurred. CONCLUSIONS: TAE is a minimally invasive, safe, simple, and highly effective modality, in expert hands, for the management of postprocedural renal bleeding. This option should be considered early in the management of these cases because it is not only a life-saving, but ultimately a kidney-sparing, procedure.

Measuring stone surface area from a radiographic image is accurate and reproducible with the help of an imaging program.

BACKGROUND AND PURPOSE: The surface area of the stone from a radiographic image is one of the more suitable parameters defining stone bulk. The widely accepted method of measuring stone surface area is to count the number of square millimeters enclosed within a tracing of the stone outline on graph paper. This method is time consuming and cumbersome with potential for human error, especially when multiple measurements are needed. The purpose of this study was to evaluate the accuracy, efficiency, and reproducibility of a commercially available imaging program, Adobe Photoshop 7.0 for the measurement of stone surface area. MATERIALS AND METHODS: The instructions to calculate area using the software are simple and easy in a Windows-based format. The accuracy of the imaging software was estimated by measuring surface areas of shapes of known mathematical areas. The efficiency and reproducibility were then evaluated from radiographs of 20 persons with radiopaque upper-tract urinary stones. The surface areas of stone images were measured using both graph paper and imaging software. Measurements were repeated after 10 days to assess the reproducibility of the techniques. The time taken to measure the area by the two methods was also assessed separately. RESULTS: The accuracy of the imaging software was estimated to be 98.7%. The correlation coefficient between the two methods was R(2) = 0.97. The mean percentage variation using the imaging software was 0.68%, while it was 6.36% with the graph paper. The mean time taken to measure using the image analyzer and graph paper was 1.9 +/- 0.8 minutes and 4.5 +/- 1.08 minutes, respectively (P < 0.001) CONCLUSION: The imaging program is accurate, fast, and highly reproducible in estimating two-dimensional stone surface area from radiographs compared with manual measurements using graph paper.

Fluid absorption during percutaneous nephrolithotomy: does it matter?

BACKGROUND AND PURPOSE: Large amounts of irrigating fluid are used during percutaneous nephrolithotomy (PCNL). This use may be associated with migrating calculus debris, infection, and fluid absorption. This study evaluated the presence of fluid absorption during PCNL, its clinical and biochemical significance, and maneuvers to reduce it. PATIENTS AND METHODS: Fluid absorption during PCNL was evaluated in 148 patients by estimating the expired breath ethanol concentration. Factors thought to affect the amount of fluid absorbed were studied, including the amount of irrigating fluid used, the number of nephrostomy tracts, the presence of a low-pressure system, the presence of existing tracts, and complications such as bleeding or perforation of the pelvicaliceal wall. RESULTS: Fluid absorption was evident in all patients, although no patient had any clinical or biochemical evidence of intraoperative or postoperative electrolyte imbalance. Creating a low-pressure system by using an Amplatz sheath, reducing the amount of irrigating fluid used, and staging the procedure significantly reduced the amount of fluid absorbed. CONCLUSIONS: Fluid absorption does take place during PCNL. This may be clinically significant in patients with compromised cardiorespiratory or renal status and in pediatric patients, leading to fluid overload. Using a low-pressure system, reducing the nephroscopy time and the amount of irrigating fluid used, and staging the procedure for large renal stone burdens, especially in the presence of complications such as perforation of the pelvicaliceal system, reduces fluid absorption and avoids volume overload. Fluid absorption may also be associated with both infective and noninfective pyrexia, necessitating adequate preoperative control of urinary infection.

Extracorporeal shock wave lithotripsy for lower calyceal stones: can clearance be predicted?

OBJECTIVE: To determine the influence of pelvicalyceal angle, size of the lower calyx infundibulum and lowerpole calyceal anatomy in predicting the clearance of fragments after extracorporeal shock wave lithotripsy (ESWL) for lower calyceal stones. PATIENTS AND METHODS: The study comprised a retrospective analysis of 133 patients, divided into 92 who were considered to be completely clear of fragments 6 months after ESWL and 41 who had residual stones. The pelvicalyceal angle, diameter of the lower calyx infundibulum and lower-pole calyceal pattern were determined from intravenous urograms. RESULTS: There were residual stones in 64% of the patients with a pelvicalyceal angle < 90 degrees, in 12% of those with an angle > 90 degrees, in 70% of patients with an infundibular diameter < 4 mm, in 16% of those with a diameter > 4 mm, in 78% with a complex calyceal pattern and 12% with a simple calyceal pattern. CONCLUSIONS: These three anatomical factors play a key role in predicting the clearance of stone and they should be assessed during intravenous urography to facilitate the planning of treatment for lower calyceal stones.

A new outlook in the management of complex female urethral injuries.

Management of complex female urethral injuries is challenging. We present our experience of 9 cases over the last 3 years with a mean follow-up of 14 months. The spectrum of clinical problems and results of various forms of innovative management are highlighted. Injuries which could not be managed by primary repair or by applying regular urethroplasty principles of using local vaginal flaps were treated with core-through urethrotomy (2), creation of distal urethrovaginal fistula (5), and continent urinary diversion (2). Individualised treatment technique to fit the special circumstance as presented by each patient is stressed because of the rarity of female urethral injury.

Primary benign vesical teratoma. A case report.

Primary benign vesical teratomas are rare. Most of the cases reported are paravesical teratomas rupturing into the bladder. A case of primary benign vesical teratoma suspected preoperatively and later confirmed at histopathology is reported.

Instillation of silver nitrate in the treatment of chyluria.

A series of 62 patients with chyluria received instillations of 1% silver nitrate in the renal pelvis over an 8-year period; 51 patients responded well but 11 showed no response to treatment. Follow-up ranged from 2 to 7 years. The treatment was found to be safe, effective and minimally invasive.

Giant ureteral stone.

A 58-year-old man presented with left flank pain and a high grade fever. Investigations revealed left pyonephrosis with a left renal stone and a giant left ureteral stone. Nephroureterectomy was performed. The ureteral stone measured 13 cm. long and weighed 90 gm.

Experience of continent urinary diversion with modified Koff's technique.

Continent abdominal neourethrostomy is a procedure in which a bladder flap from the dome is raised, converted into a tube and then brought out on the abdominal wall as a stoma, just below the umbilicus. We have done this procedure on 5 patients of different age groups and for various indications. All our patients are perfectly continent postoperatively during the day as well as night. They are doing regular self-catheterisation. They are dry in periods between self-catheterisations. The maximum follow-up is two years and six months.

Catheter-less suprapubic cystolithotomy in children.

Bladder stones in children are common in developing countries and the procedure of choice for their removal is suprapubic cystolithotomy. It is standard practice to drain the bladder for a few days post-operatively to prevent urinary leakage. We have observed that, if the bladder is closed meticulously in 2 layers, bladder drainage by means of a catheter is not required. We have analysed 86 children treated by suprapubic cystolithotomy without a catheter. Size of the stones and intra-operative findings were noted and it was found that 85% of the patients had an excellent result; 10% had a satisfactory result and 4.7% were unsatisfactory. The advantages of the procedure and selection of the patients are discussed.