Comparative analysis of outcomes and long-term follow-up of robot-assisted pediatric kidney transplantation, with open counterpart.

How does the robotic kidney transplant fare against the open technique, in pediatric patients? No one knows. To address this question, this study compares the outcomes of robotic kidney transplants, with those of open transplant in these patients. This study was a retrospective analysis of outcomes (renal function and complications), of all pediatric patients (<18 years of age), who underwent kidney transplant at our institute, after 2014, till their last follow-up. Fisher's exact test was used to compare proportions. Continuous variables were analyzed using Mann-Whitney test. P value of <.05 was considered significant. Of the twenty-five patients included, 21 belonged to open group, and 4 to the robotic group. Patients in the robotic group had significantly higher Re-WIT (P value .002) and had lower analgesia requirement (P value .04). Median follow-up period was 31 months. Both groups were comparable in terms of length of hospital stay, blood transfusion, and renal function post-operatively till their last follow-up. Three patients in the open group had surgical site infection as compared to none in the robotic group. All the patients had functioning grafts till their last follow-up. Robotic transplant is safe and delivers functional results similar to open technique, with lesser pain and better cosmesis. Longer Re-WIT in robotic transplant has no impact on post-operative renal function. Ours is the first known effort to compare robotic technology with the established open technique of transplant in this population. A prospective randomized controlled trial should refine the results of the present study.

Role of laparoscopy in the era of robotic surgery in urology in developing countries.

With the rapid expansion of robotic platforms in urology, there is an urgent and unmet need to review its cost and benefits in comparison to the traditional laparoscopy, especially in reference to a developing country. A nonsystematic review of the literature was conducted to compare the outcomes of pure laparoscopic and robot-assisted urologic procedures. Available literature over the past 30 years was reviewed. Robot-assisted surgery and laparoscopy were found to have similar outcomes in the areas of radical prostatectomy, partial and radical nephrectomy, radical cystectomy, retroperitoneal lymph node (LN) dissection, inguinal LN dissection, donor nephrectomy, and kidney transplantation. Robot-assisted surgery was found to be significantly costlier than pure laparoscopy. In the absence of a clear advantage of robot-assisted surgery over pure laparoscopy, lack of widespread availability and the currently prohibitive cost of robotic technology, laparoscopic urological surgery has a definite role in the developing world.

Management of donor kidneys with double renal arteries with significant luminal discrepancy: A retrospective cohort study.

INTRODUCTION: Side-to-side pantaloon anastomosis for renal grafts with double renal arteries (RA) with significant luminal discrepancy between graft arteries has not been reported. We hypothesized that the pantaloon technique is feasible and safe in these cases. MATERIALS AND METHODS: A retrospective review of all consecutive, open, live-related renal transplants with double RA with significant luminal discrepancy performed at our center from January 2014 to September 2018 was undertaken. Significant luminal discrepancy was defined as smaller RA constituting 30% ± 5% of total RA diameter on preoperative computed tomography angiogram. Three groups were defined: Group A - pantaloon anastomosis, Group B - end-to-side anastomosis of smaller to main RA, and Group C - separate implantation of each artery. The primary objective was to study feasibility and safety of pantaloon anastomosis measured by recipient serum creatinine levels, Doppler ultrasound, and vascular complications (vascular thrombosis and anastomotic bleed). Secondary objectives included measurement of cold ischemia time, warm ischemia time in recipient (WIR), and nonvascular recipient complications. RESULTS: Fifty-eight recipients had donors with double RA with significant luminal discrepancy. Group A - included 40, Group B - 5, and Group C - 13 patients. Recipient creatinine at day-7, - 30, and - 90 were similar among the groups. The 30-day perioperative complication rate was also similar. Group A and B had significantly lower WIR and higher cold ischemia time compared to Group C. CONCLUSION: Pantaloon anastomosis is feasible in renal grafts with double RA with significant luminal discrepancy and offers advantage of lower WIR compared to separate implantation technique.

Predictors for progression of metastatic prostate cancer to castration-resistant prostate cancer in Indians.

BACKGROUND & OBJECTIVES: There is lack of data on natural history and progression of prostate cancer (PC) which have implications in the management of the disease. We undertook this retrospective study to analyze factors predicting progression of metastatic PC to castration-resistant prostate cancer (CRPC) in Indian men. METHODS: Complete records of 223 of the 489 patients with metastatic PC were obtained from computerized data based system in a tertiary care hospital in north India between January 2000 to June 2012. Patients with follow up of < 6 months were excluded. Age (≤ and > 65 yr), baseline PSA (< and ≥ 50 ng/ml), bone scan and Gleason score (≤7 and >7) were recorded. Extent of bone disease (EOD) was stratified according to the number of bone lesions i.e., < 5, 5-10, > 10. CRPC was defined as two consecutive PSA rise of > 50 per cent from nadir or an absolute value of > 5 ng/ml. RESULTS: Mean age of patients was 61.5 ± 12.45 yr and their PSA level was 325.6 ± 631.35 ng/dl. Of the 223 patients, 193 (86%) progressed to CRPC at median time of 10.7 (4-124) months. Median follow up was 24 (6-137) months. On univariate and multivariate analyses EOD on bone scan was found to be a significant predictor ( P=0.006) for time to CRPC. Median time to CRPC was 10 months (CI 95%, 7.5-12.48) with >10 lesions or super scan versus 16 months (CI 95%, 10.3-21.6) with <10 bone lesion (P=0.01). Ninety (46.6 %) patients of CRPC died with median time to death from time of CRPC 21 (10-120) months. INTERPRETATION & CONCLUSIONS: Median time for progression of metastatic PC to CRPC ranged from 10-16 months depending on the extent of the bone involvement. In Indians, the aggressive course of advanced prostate cancer warrants further clinical trials to explore the need for additional treatment along with initial castration.

Trifecta and Pentafecta Outcomes in Laparoscopic and Robotic Nephron-Sparing Surgery for Highly Complex Renal Tumors: A Propensity Score-Matched Cohort Analysis.

Purpose: To compare the trifecta and pentafecta outcomes of laparoscopic partial nephrectomy (LPN) and robotic partial nephrectomy (RPN) in highly complex renal tumors (RENAL nephrometry score ≥10) using a matched cohort analysis. Methods: Patients undergoing LPN or RPN for renal tumors with RENAL score ≥10 between January 2014 and December 2019 were matched using 1:2 propensity score match analysis based on age, body mass index, gender, laterality of tumor, RENAL score, and American Society of Anesthesiologists (ASA) score. The two groups were compared for trifecta and pentafecta outcomes. Results: Thirty patients undergoing LPN (Group A) were matched with 60 patients undergoing RPN (Group B). The mean age (standard deviation) was 53.7 (12.9) years. The median (interquartile range) RENAL score was 10 (10-11). In comparison, the mean warm ischemia time in Group A was significantly longer than that in Group B (26.2 vs 23.0 minutes, p = 0.013). The overall complication rate was 36.7% in Group A as compared with 20% in Group B (p = 0.440). The trifecta outcomes could be achieved in 11 patients (36.7%) in Group A compared with 40 patients (66.7%) in Group B (p = 0.012). Moreover, 10 patients (33.3%) in Group A and 28 patients (46.7%) in Group B achieved pentafecta outcomes (p = 0.227). Conclusions: In a matched cohort of patients undergoing nephron-sparing surgery for highly complex renal tumors (RENAL score ≥10), the robotic approach offers a superior advantage in the achievement of trifecta outcomes as compared with the laparoscopic approach. However, both LPN and RPN can achieve similar pentafecta outcomes.

Influence of caspases 8 and 9 gene promoter polymorphism on prostate cancer susceptibility and early development of hormone refractory prostate cancer.

OBJECTIVE: To investigate, by genotyping CASP8 (-652 6N del/ins) and CASP9 (-1263 A > G; -293 19N del/ins), whether inactivation of apoptosis by genetic polymorphism of caspases 8 and 9 play an integral role in the mechanism of cancer development. To investigate the role of these polymorphisms in susceptibility to early development of hormone refractory prostate cancer. PATIENTS AND METHODS: The study included 175 histologically confirmed cases of prostate cancer and 198 age and ethnicity matched healthy controls. CASP9-1263 A > G polymorphism was genotyped using the polymerase chain reaction-restriction fragment length polymorphism method. CASP9-293 del/ins and CASP8-652 del/ins polymorphisms were genotyped and the deletion pattern analysed by polyacrylamide gel electrophoresis. RESULTS: Our results demonstrated that presence of CASP9-1263 G allele was associated with reduced risk for prostate cancer (odds ratio 0.6, 95%CI 0.39-0.92, P= 0.02). Other variant CASP9 was not associated with prostate cancer risk. Coincidentally, the presence of CASP9-1263 G allele was associated with increased risk for progression of prostate cancer to bone metastasis (odds ratio -2.28, 95%CI 1.14-4.53, P= 0.02). CASP8-652 (+/-) genotype was associated with increased hazard for early development of hormone refractory prostate cancer (hazard ratio 2.44, 95%CI 1.2-5.85, P= 0.045). CONCLUSION: Our results support the hypothesis that variants of CASP9 may influence the susceptibility to prostate cancer and its progression to bone metastasis. CASP8 polymorphism may influence the progression of prostate cancer disease to a hormone refractory state.

Establishing a Robot-Assisted Kidney Transplant Program: Independent Evaluation of the Learning Curve and Surgical Nuances.

Background: Robot-assisted kidney transplantation (RAKT) is a technically challenging procedure and there has been limited reporting of its learning curve (LC), mostly by a single surgical working group. The aim of the current study was to perform an independent analysis of LC and describe our modifications in the technique of RAKT. Materials and Methods: All consecutive cases performed at our center from April 2016 to March 2020 were reviewed. LC was analyzed by using the cumulative summation method for total anastomosis time (technical outcome) and serum creatinine at days 7 and 30 (functional outcome). Patient safety was assessed by using Shewhart control charts, and a comparison of safety outcomes before and after achieving LC was done by using Chi-square or Fischer exact test as appropriate. A descriptive review of technical modifications made during our experience was conducted. Results: Ninety patients underwent robot-assisted renal transplant during the study period. LC was crossed at 24 cases (total anastomosis time) and 15 to 25 cases (serum creatinine). Shewhart control charts showed that total anastomosis time remained below alert/alarm line in 94.4%/98.9% cases, with the alert line being crossed a significantly greater number of times before the LC. Serum creatinine values remained below alert/alarm line in 85.5%/90% cases at day 7 and 92.2%/96.7% cases at day 30, with no difference made due to LC. Key technical modifications included arterial and ureteric spatulation at bench, use of polypropylene 5 to 0 holding stitch in graft vessels to facilitate intraoperative handling, keeping anterior arterial wall smaller to visualize posterior arterial wall anastomosis, and leaving a small amount of fatty tissue on the supero-lateral surface of the kidney for handling after jacket removal. Conclusion: Our LC of RAKT was crossed at 24 cases (technical outcome) and 15 to 25 cases (functional outcome). We have also detailed valuable technical modifications in the procedure.

Renal autotransplant for major ureteric loss: Results from median 11 years of follow-up.

OBJECTIVE: Renal autotransplant (RA) is an underutilized procedure to treat major ureteric loss. Studies on long-term outcomes and follow-up after RA are scarce. This study aimed to report the long-term outcomes and follow-up after RA. MATERIAL AND METHODS: We identified 9 patients, from 2007 to 2019, who underwent RA after major ureteric loss (where direct restoration of continuity was not possible). We collected data regarding the etiology of ureteric loss, preoperative differential renal function, method of nephrectomy (laparoscopic or open), method of anastomosing the residual ureter/pelvis to the bladder, postoperative complications, duration of hospital stay, and renal function and drainage postoperatively and until the last follow-up. Changes in renal function and/or any obstruction to urinary drainage of the ipsilateral kidney postoperatively or during follow-up were measured. The Wilcoxon matched-pairs signed-rank test was used to compare the mean creatinine values preoperatively, postoperatively, and at last follow-up (p<0.05 was considered statistically significant). RESULTS: All the patients had uneventful intraoperative and postoperative periods. The mean hospital stay was 6.4 (5-8) days. The median follow-up was 132 (46-156) months. The mean preoperative serum creatinine level was 1.0 (0.7-1.7) mg/dL. The mean creatinine value postoperatively and at last follow-up had no significant difference with preoperative value (p=0.96 and 0.75, respectively). The postoperative diethylene triamine pentaacetic acid scan demonstrated good perfusion and drainage. There was no deterioration of renal function or drainage during the follow-up. CONCLUSION: RA is an excellent modality to treat major ureteric loss. It preserves renal function and avoids the problems related to bowel interposition and the need for long-term follow-up.

Laparoscopic pyeloplasty: a versatile alternative to open pyeloplasty.

OBJECTIVE: To report the safety, efficacy and versatility of laparoscopic pyeloplasty (LPP) in treatment of pelviureteric junction obstruction (PUJO). PATIENTS AND METHODS: From January 2002 to November 2006, 185 patients (186 units; 182 with primary and 4 with secondary PUJO) underwent LPP (transperitoneal approach in 184; retroperitoneal approach in 2). A double J stent was placed antegradely in 121 (68.4%) units, cystoscopically in 50 units (28.2%), and 6 units (3.4%) were stentless. Patients were followed up clinically, with additional diuretic renogram. RESULTS: Surgery was completed laparoscopically in 177 units, and conversion was required in 9 (4.8%) units. Pyeloplasty was dismembered in 143 units, Foley YV plasty in 26 units, and Fenger pyeloplasty in 8 units. The median estimated blood loss, operative time and hospital stay were 50 ml, 180 min and 4 days, respectively. Overall, 18 (9.6%) patients had complications. Improvements in drainage patterns of 167 out of 177 units (94.3%) were shown on a renal scan at a median follow-up of 39 months (range: 3-63 months). CONCLUSION: LPP is a safe, effective and versatile method for treatment of PUJO, which is applicable to all age groups, even in the presence of secondary stones, crossing vessels and secondary PUJO.

Is modified Raz technique of midurethral sling a reliable and cost-effective method of treating stress urinary incontinence?

OBJECTIVES: We report our experience of pure stress urinary incontinence (SUI) treated by midurethral synthetic sling placement by modified Raz technique. MATERIALS AND METHODS: Fifty-three patients with pure SUI operated at our institute between June 2003 and December 2008 were included in this study. Midurethral sling tape, fashioned from commercially available large pore synthetic mesh, was placed using the modified Raz technique. The technique consisted of placing the tape within retropubic space using double-pronged needle, which is passed under finger control through the fascia and retropubic space. Outcomes were assessed on the basis of patient's interview in follow-up OPD. RESULTS: Mean age was 57.68 (28-69) years. Forty-five (85%) patients were totally dry and eight (15%) socially dry at the end of the follow-up. Mean operative time was 46.5 + 11.3 minutes (35-80 minutes). None of the patients required blood transfusion or had bladder/bowel injury. Mean duration of hospital stay was 2.17 days (2-4 days). Mean duration of follow-up was 46.1 months (12-78 months). CONCLUSIONS: Modified Raz technique is safe and cost-effective for placing midurethral sling for genuine stress incontinence.

Partial siamese twin as potential organ donor.

During evaluation of a partial Siamese twin for removal of nonviable parasitic part in an 8-year-old male child, a fully functional kidney was found. The functional status of the extra kidney was found to be within acceptable limits for the purpose of transplant, which was subsequently done in a 24-year-old patient with end-stage renal disease. The recipient is healthy 19 months after the surgery. The possibility of using organs from a partial Siamese twin makes this a unique case report.

Impact on sexual function after reconstructive surgery for anterior urethral stricture disease.

OBJECTIVE: To evaluate the effect of urethral reconstructive surgery on sexual drive, erectile function and ejaculation. MATERIALS AND METHODS: The study group consisted of 150 men with a median (range) age of 40 (18-73) years who underwent 168 urethral reconstructive procedures for anterior urethral stricture disease between October 2003 and May 2009. We evaluated sexual functioning using the O'Leary Brief Male Sexual Function Inventory before and after surgery. RESULTS: The median follow-up was 33 months (range 4-72). There were no significant changes in sexual drive and erectile function scores postoperatively for men in the 20-29, 30-39, 40-49, 50-59 and 60-69 years age groups. Overall, there was a significant improvement in ejaculatory function scores after surgery. This improvement was most robust in men in the 20-29, 30-39 and 40-49 years age group. CONCLUSION: Overall, anterior urethral reconstruction appears no more likely to cause postoperative sexual dysfunction. Different types of urethroplasties, surgical complexity with long stricture excision and the use of buccal graft, preputial flap/tube did not influence outcome.

Laparoscopic pyeloplasty in pediatric patients: the SGPGI experience.

OBJECTIVES: To determine the safety, efficacy and long-term outcome of laparoscopic pyeloplasty in pediatric patients. MATERIALS AND METHODS: A prospective analysis of data of pediatric patients under the age of 15 years, who had undergone laparoscopic pyeloplasty from January 2000 to June 2008 was done. The various parameters analyzed were; operative time, blood loss, need for analgesics, intra/postoperative complications, hospital stay and postoperative outcome. Success was defined on the basis of either improvement in the symptoms/or better drainage on postoperative isotope renography. RESULTS: A total of 82 patients with a mean age of 7.12 years (four months to 15 years) and male to female ratio of 4.3:1 were included in the study. Dismembered pyeloplasty was done in 70 patients and Foley Y-V plasty in 12 patients via transperitoneal approach using three ports in 79 or four ports in three children. Mean operative time was 151 minutes (78-369); mean blood loss was 88.01 ml (50-250) with a mean hospital stay of 5.05 days (2-11). Conversion to open surgery was required in four (4.87%) patients. Follow-up renograms were available in 74 patients who showed improvement in drainage in 69 patients and obstructed pattern in five; of these two patients had significant deterioration in split function. Two patients among the obstructed group underwent redo pyeloplasty by open technique while the rest three elected for conservative approach. At a mean follow-up of 41.58 months (8-75) the overall success rate was 91.89%. CONCLUSION: Laparoscopic pyeloplasty is effective and safe in children with minimal morbidity and gives excellent long-term results.