A prospective comparative study to evaluate safety and efficacy of pneumatic versus laser lithotripsy in mini-percutaneous nephrolithotomy.

OBJECTIVE: The choice of lithotripter is an important part of planning in mini-percutaneous nephrolithotomy (mini perc) as the operating time is prolonged due to reduced sheath size and smaller working channel. Previous studies mostly reported the use of laser lithotripter for stone fragmentation while the literature on pneumatic lithotripter use in miniperc is scant. METHODS: In this study, we compared the efficacy and safety of the laser lithotripter (LL) vs pneumatic lithotripter (PL) in miniperc for small to medium-sized renal/upper ureteric stones (size: 1-2 cm). All consecutive patients who underwent miniperc from September 2020 to August 2022 were included in the study. Laser lithotripter was used in 81 patients (group LL), while pneumatic was used in 75 patients (group PL). The preoperative, operative, and postoperative findings were compared. RESULTS: Baseline patient characteristics (age, sex, body mass index, and co-morbid illness) and stone characteristics (size, stone number, laterality, presence of staghorn calculi, presence of hydronephrosis, Guy's stone scores) were comparable between the two groups (P>0.05). The mean operative time was comparable (P=0.38) while the mean fragmentation time was significantly higher in the PL group (35.42±6.34 vs 28.96±2.82 minutes; P<0.01). 29.3% required forceps/basket for stone removal in PL group as compared to 7.4% in LL group (P=0.02). Mean VAS (Visual Analog Scale) score on the first post-operative day, stone clearance, drop in hemoglobin, average hospital stay, stone clearance at 3 months postoperative, and complications were comparable (P>0.05). CONCLUSION: Lithotripsy with pneumatic lithotripter can be used as an equally effective and safe alternative to laser lithotripter in mini-perc for treatment of small-medium sized renal/upper ureteric calculi.

2/1 dose schedule of sunitinib is superior than the 4/2 regimen for the first-line therapy of clear cell metastatic renal cell carcinoma - An Indian experience.

BACKGROUND: Sunitinib remains the first-line treatment for favorable risk metastatic clear cell renal cell cancer (mccRCC). It was conventionally given in the 4/2 schedule; however, toxicity necessitated trying the 2/1 regimen. Regional variations in treatment response and toxicity are known, and there is no data from the Indian subcontinent about the outcomes of the alternative dosing schedule. METHODS: Clinical records of all consecutive adult patients who received sunitinib as first-line therapy for histologically proven mccRCC following cytoreductive nephrectomy from 2010-2018 were reviewed. The primary objective was to determine the progression-free survival (PFS), and the secondary objectives were to evaluate the response rate (objective response rate and clinical benefit rate), toxicity, and overall survival. A list of variables having a biologically plausible association with outcome was drawn and multivariate inverse probability treatment weights (IPTW) analysis was done to determine the absolute effect size of dosing schedules on PFS in terms of "average treatment effect on the treated" and "potential outcome mean." RESULTS: We found 2/1 schedule to be independently associated with higher PFS on IPTW analysis such that if every patient in the subpopulation received sunitinib by the 2/1 schedule, the average time to progression was estimated to be higher by 6.1 months than the 4/2 schedule. We also found 2/1 group to have a lower incidence than the 4/2 group for nearly all ≥ grade 3 adverse effects. Other secondary outcomes were comparable between both treatment groups. CONCLUSION: Sunitinib should be given via the 2/1 schedule in Indian patients.

A prospective longitudinal study to evaluate bone health, implication of FRAX tool and impact on quality of life (FACT-P) in advanced prostate cancer patients.

BACKGROUND: Androgen-deprivation therapy (ADT) as a treatment modality in advanced prostate cancer has deleterious effect on bone mineral density (BMD) and quality of life (QOL). Using FRAX (Fracture Risk Assessment) model, candidates at high risk of fractures can be predicted and appropriate treatment can be initiated at early step to prevent skeletal-related events. Objectives of the present study were to evaluate bone health, implication of FRAX tool in advanced prostate cancer and to see the impact of ADT and Bone-directed therapy (BDT) on FRAX and FACT-P QOL scores. MATERIAL & METHOD: We conducted a prospective longitudinal study of 83 localized and metastatic prostate cancer patients from March 2017 to Dec 2020. FRAX tool using BMD femoral neck (GE-Lunar) was used to compute the probability of 10-year Major osteoporotic fracture (MOF) and hip fracture risk %. Patients who received monthly Zolendronic acid with or without Vitamin-D/calcium supplementation were classified as BDT group. FRAX and FACT-P were measured at baseline and 12 months follow-up and compared between different therapeutic modalities to see the impact on clinical outcomes. RESULTS: Majority of patients had skeletal metastasis (78.3%) and high-grade disease at presentation. Secondary osteoporosis was the most commonly (82.05%) observed clinical risk factor (CRF) followed by smoking (19.23%). Hip fracture risk ≥3% accounted for larger proportion of patients than did MOF risk ≥20% (21.2% and 2.5%, respectively). Statistically significant reduction was observed in both MOF and hip fracture risk in BDT group, while worsening on ADT. ADT duration correlated positively with both MOF and hip fracture risk (R2=0.148, P<0.001 and R2=0.164, P<0.001, respectively). FRAX score accurately predict future fracture events in majority (80%) of high-risk patients. Statistically and clinically significant worsening in PWB, EWB, PCS, FACT-P Total, FACT-P TOI and FAPSI scores were observed in patients on ADT. Statistically and clinically significant improvement was noted in physical well-being in BDT group. However, other QOL domains and FACT-P total scores remained stable. CONCLUSIONS: ADT caused duration depended worsening of FRAX and FACT-P score in these patients while improvements of FRAX were seen on BDT. FRAX tool is advantageous in identifying the patients who require early intervention or therapy to decrease skeletal-related events.

Renal transplant in a patient of severe hemophilia.

Hemophilia is a rare disorder that is difficult to diagnose and manage. The prevalence of end-stage renal disease is increasing in hemophilic patients because of improved life expectancy. Renal transplant surgery in such patients is often complicated by adverse hematological events such as bleeding and intravesical thrombosis, both with a risk of renal allograft rejection. We report a case of a 46-year-old hemophilia A patient on hemodialysis who underwent renal transplant and show that although challenging, renal transplant in hemophilic patients is possible.

Pitcher pot neourethral modification of ileal orthotopic neobladder achieves satisfactory long-term functional and quality of life outcomes with low clean intermittent self-catheterization rate.

Objective: To describe a decade of our experience with a neo-urethral modification of ileal orthotopic neobladder (pitcher pot ONB). Multiple investigators have reported similar modifications. However, long-term longitudinal functional and quality of life (QOL) outcomes are lacking. Methods: Prospectively maintained hospital registry for 238 ONB patients comprising a mix of open and robotic surgery cohorts from 2007 to 2017, and minimum of 2 years of follow-up was retrospectively queried. QOL was evaluated using Bladder Cancer Index (BCI). Longitudinal trends of QOL domain parameters were analysed. List of perioperative variables that have a biologically plausible association with continence, potency, and post-operative BCI QOL sexual, urinary, and bowel domain scores was drawn. Variables included surgery type, Body Mass Index (BMI), T and N stage, neurovascular bundle (NVB) sparing, age, and related pre-operative BCI QOL domain score. Prognostic associations were analysed using multivariable Cox proportional hazard models and multilevel mixed-effects modeling. Results: The study comprised 80 and 158 patients who underwent open and robotic sandwich technique cohorts, respectively. Open surgery was associated with significantly higher "any" complication (40% vs 27%, P-value .050) and "major" complication rate (15% vs 11%, P-value .048). All patients developed a bladder capacity >400 cc with negligible post-void residual urine, and all but one patient achieved spontaneous voiding by the end of study period (<1% clean intermittent self-catheterization [CISC] rate). By 15 months, QOL for all three domains had recovered to reach a plateau. About 45% of patients achieved potency, and the median time to achieve day and night time continence was 9 and 12 months respectively. Lower age and NVBs spared during surgery were found to be significantly associated with the earlier achievement of potency, day and night time continence, as well as better urinary and sexual summary QOL scores. Conclusions: Pitcher pot neobladder achieves satisfactory long-term functional and QOL outcomes with negligible CISC rate. Results were superior with incremental nerves spared during surgery.

COVID-19 Infection in Kidney Transplant Recipients: A Single Centre Study from Northern India.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has resulted in significant morbidity and mortality worldwide. The pre-immunosuppressed state along with other existing co-morbidities can influence the outcomes of COVID-19 in transplant patients. MATERIAL AND METHODS: This was a single centre prospective cohort study done in kidney transplant recipients (KTRs), who underwent kidney transplantation (from December 2012 to November 2020), who were actively followed up at our centre and were diagnosed with COVID-19 disease between 1 April and 30 November 2020. RESULTS: A total of 62 kidney-transplant recipients tested positive for COVID-19. Their median age was 39 (19-61). Males were predominantly infected (87.1%). Fever was the most common symptom (77.42%). Thirteen (20.9%) had mild form of disease, 32 (51.6%) had moderate form and 17 (27.4%) had severe disease. Based on initial symptom, 18 (29.03%) were given home treatment, 29 (46.7%) were treated in isolation wards and 15 (24.1%) were treated in intensive care unit. Decrease in the dose of immunosuppressant (anti-metabolites in 67.7%, calcineurin inhibitor in 22.5%) was predominantly carried out as the initial mode of treatment. Remdesivir in 64.5% and anticoagulant therapy in 54.84% were given as a modality of treatment. Mortality rate in our study was 14.5%. CONCLUSIONS: Patients of kidney transplant are at high risk of getting infected with COVID-19, due to their immunosuppressed state. Initial symptoms in KTRs with COVID-19 are similar to that of the general population. Mortality rate is comparatively higher in KTRs as compared to general population.

Robot assisted intra-corporeal ileocalicostomy ureteral substitution for complex uretero-pelvic junction obstruction: a novel and feasible innovation.

A 33-year-old female presented to the emergency department of our hospital with urosepsis and hematuria with clot retention secondary to a complicated pyelolithotomy for left-sided pelvic calculus. A percutaneous nephrostomy was placed for drainage as a DJ stent could not be traversed into the left renal pelvis with retrograde pyelography demonstrating complete cut-off at L4-L5 level. After stabilization, she was found to have uretero-pelvic junction obstruction (UPJO) in left solitary functioning kidney with long-segment upper ureteric stricture and nadir serum creatinine 1.5 mg/dL. Nephrostogram and CT scan revealed an intra-renal pelvis with no passage of contrast into the ureter. Primary hyperparathyroidism secondary to parathyroid adenoma was also detected and she underwent excision of the same. The long-segment ureteric stricture and need for a wide drainage ruled out pyeloplasty and ureterocalicostomy as treatment options. A wide-bore communication between the lower calyx and bladder was necessary and robot assisted ileocalicostomy was performed in this case. A 20-cm-long segment of ileum was used to replace the ureter with a suprapubic 16 Fr Foley's catheter as splint. Postoperative course was uneventful with all tubes removed by third postoperative week. Nephrostogram demonstrated gravity-dependent drainage into the bladder with no leak or anastomotic narrowing. The patient is doing well at 6 months of follow-up with a stable renal function. Robot assisted ileocalicostomy is a safe and effective technique which provides wide gravity-dependent drainage in complex UPJO with long-segment ureteric stricture and intra-renal pelvis.

Robot-assisted boari flap calycovesicostomy for failed uretero-pelvic junction obstruction: a novel approach to a complex problem.

Uretero-pelvic junction obstruction (UPJO) is a common condition, often presenting in adulthood in developing countries. These cases can pose significant problems owing to late presentation and complications such as infection, stones, and impaired renal function. We present the case of a 28-year-old female who presented to us with recurrent symptoms and impaired drainage following a failed open pyeloplasty and robot-assisted ureterocalycostomy for right UPJO. She was managed by robot-assisted boari flap calycovesicostomy, an innovation which helped in salvaging her kidney; ensuring good drainage in the involved kidney. To our knowledge, this is the first such case in the literature in the management of complex UPJO.