Abraham Kurien

Laparoendoscopic single-site donor nephrectomy: a single-center experience.

OBJECTIVES To present our experience with 13 patients undergoing laparoendoscopic single-site live donor nephrectomy. METHODS The Quadport/Triport (Advanced Surgical Concepts, Ireland) was inserted through an incision in the umbilicus. Apart from standard laparoscopic instruments, we used extra-long harmonic scalpel, suction, and bent instruments, particularly for upper pole dissection. After securing the hilum, the graft was brought near the umbilical extraction site with a grasper inserted through an extra 3- or 5-mm port and easily retrieved with the help of 2 fingers. The parameters analyzed were warm ischemia time, operative time, blood loss, postoperative visual analogue score, grafts retrieval time, and artery, vein, and ureteral length. RESULTS Mean body mass index was 22.18 +/- 3.42 kg/m(2) (range 17.9-29.78). The mean operative time, blood loss, warm ischemia time, and hospital stay were 176.9 +/- 42.47 minutes, 158 +/- 78 mL, 6.79 +/- 1.7 minutes, and 3 +/- 0.45 days (range 2-5), respectively. Graft artery, vein, and ureteral length was 3.8 +/- 0.4, 4 +/- 0.12, and 14.5 cm (range 13-16), respectively. The urine output was prompt in all cases. Visual analogue score in the donor at 2 weeks was 0/10 in all cases. Eleven patients required extra 3- or 5-mm port. Cosmesis was excellent, with the mean incision length of 5.23 +/- 0.96 cm. CONCLUSIONS The laparoendoscopic single-site donor nephrectomy in our initial experience is efficacious and a feasible, minimally invasive option for donors in renal transplantation. Further prospective studies with conventional laparoscopic donor nephrectomy are required to establish its current status.

Urolithiasis in the horseshoe kidney: a single‐centre experience

To report the operative management and subsequent stone‐free rates of patients with urolithiasis in a horseshoe kidney and treated at one centre.

Questioning the wisdom of tubeless percutaneous nephrolithotomy (PCNL): a prospective randomized controlled study of early tube removal vs tubeless PCNL

Study Type – Therapy (RCT)
Level of Evidence 1b

Laparoscopic ureteral reimplantation: a single center experience and literature review.

BACKGROUND Laparoscopic Boari flap, psoas hitch, and direct ureteral reimplantation have all been described in the management of benign distal ureteral strictures. PATIENTS AND METHODS A retrospective review of a single center experience of laparoscopic reconstructive surgery for benign distal ureteral strictures was undertaken. The results of this initial series were compared with the published literature. To date, six patients with benign distal ureteral strictures have undergone laparoscopic reconstructive surgery at our center. Stricture etiology was stone disease in two patients, postvaginal hysterectomy in one patient, and unknown in the remaining two. In all cases, the operative procedure was undertaken with five-port transperitoneal access. Depending on healthy ureteral length, a decision for direct reimplantation was made in two patients, and Boari flap reconstruction was undertaken in the remaining three patients. RESULTS Mean operative time was 322 minutes (range 240-360 min), which is longer than in the published literature, reflecting our initial learning curve in reconstructive laparoscopy. The mean drop in hemoglobin, however, was only 0.5 g/dL, which is comparable to that in other series. Further, there were no complications, and patients were discharged at a mean of 6.6 days postoperatively (range 5-9 days). All patients had satisfactory follow-up intravenous urograms with a mean follow-up period of 4 months. CONCLUSION Laparoscopic reconstructive surgery for managing benign distal ureteral strictures is both safe and effective. Although open surgery currently remains the gold standard for these patients, all operative steps can be replicated laparoscopically, and this may become the future standard treatment.

Validation of Virtual Reality Simulation for Percutaneous Renal Access Training

OBJECTIVE The objective of this study was to assess the face, content, construct, convergent, and predictive validities of virtual reality-based simulator in acquisition of skills for percutaneous renal access. MATERIALS AND METHODS A cohort of 24 participants comprising novices (n = 15) and experts (n = 9) performed a specific task of percutaneous renal puncture using the same case scenario on PERC Mentor. All objective parameters were stored and analyzed to establish construct validity. Face and content validities were assessed by having all experts fill a standardized questionnaire. All novices underwent further repetition of the same task six times. The first three were unsupervised (pretest) and the later three after the PERC Mentor training (posttest) to establish convergent validity. A subset of five novice cohorts performed percutaneous renal access in an anesthetized pig before and after the training on PERC Mentor to assess the predictive validity. Statistical analysis was done using Students t-test (p <or= 0.05 statistically significant). RESULTS The overall useful appraisal was 4 in a scale of 1 to 5 (1 is poor and 5 is excellent). Experts were significantly faster in total performance time 187 +/- 26 versus 222 +/- 29.6 seconds (p < 0.005) and required fewer attempts to access 2.00 +/- 0.20 versus 2.8 +/- 0.4 (p < 0.001), respectively. The posttest values for the trained novice group showed marked improvement with respect to pretest values in total performance time 42.7 +/- 6.8 versus 222 +/- 29.6 seconds (p < 0.001), fluoroscopy time 66.9 +/- 10.20 versus 123.3 +/- 19.40 seconds (p < 0.0001), decreasing number of perforation 0.8 +/- 0.3 versus 1.3 +/- 0.2 (p < 0.001), and number of attempts to access 1.3 +/- 0.10 versus 2.00 +/- 0.20 (p < 0.001), respectively. Access without complication was attained by all five when compared with one with three complications (baseline vs. posttraining group, respectively) in the porcine model. CONCLUSION All aspects of validity were demonstrated on virtual reality-based simulator for percutaneous renal access.

Predicting effectiveness of extracorporeal shockwave lithotripsy by stone attenuation value.

PURPOSE The aim of this study was to evaluate the effect of stone attenuation value on the effectiveness of extracorporeal shockwave lithotripsy (SWL) for upper urinary tract stones. METHODS In this prospective study, 99 patients underwent SWL for solitary renal and upper ureteral stones from January 2007 to March 2009. All patients underwent CT scan before SWL. The mean attenuation value of stones in our study was 1213.3 +/- 314.5 Hounsfield units (HU). Group A consisted of 42 patients with stones of attenuation value <1200 HU and group B had 57 patients with stones of attenuation value >1200 HU. Stone size, location, requirement of number of shockwaves, shock intensities (power), retreatment rate, complication rate, auxiliary procedure rate, and effectiveness quotient (EQ) ratio were studied. RESULTS The mean total number of shocks required to fragment the stones in groups A and B were 1317.1 +/- 345.3 and 1646.5 +/- 610.8, respectively (p = 0.001), with a mean shock intensity of 12.2 +/- 0.7 and 12.4 +/- 0.5 kV, respectively (p = 0.03). Retreatment was not required in patients of group A, but 14.03% patients in group B required retreatment (p < 0.0001). Clearance rate in group A was 88.1%, whereas in group B it was 82.5% (p = 0.35). Auxiliary procedure rates were 9.5% and 10.5% in groups A and B (p = 0.22), respectively. EQ was 80.4% and 66.2% in groups A and B (p = 0.03), respectively. Complication rates were similar with 2.4% and 3.5% in groups A and B, respectively (p = 0.37). Significant correlation was recorded for total number and intensity of shocks with stone attenuation value. CONCLUSIONS The EQ of SWL for upper urinary tract stones was significantly better for stones with lower attenuation value. The number and intensity of shocks required to fragment these stones with lower attenuation value were also significantly lower.

Percutaneous renal access training: content validation comparison between a live porcine and a virtual reality (VR) simulation model

Study Type – Operational research (education) content analysis
Level of Evidence 3b

A novel training model for laparoscopic pyeloplasty using chicken crop.

PURPOSE To create a model for laparoscopic pyeloplasty training using the crop and esophagus of a chicken. The model can be used to simulate the steps taken during laparoscopic pyeloplasty and to help trainees practice laparoscopic suturing skills. MATERIALS AND METHODS The chicken crop and esophagus were used to simulate the renal pelvis and ureter, respectively. These were exposed by reflecting the skin overlying the neck and thorax. The crop was thoroughly cleaned and filled with water via the esophageal end to simulate the dilated renal pelvis. The chicken was positioned within an indigenously made laparoscopic training box. Laparoscopic pyeloplasty was performed using the dismembered Anderson Hynes technique. The model was used over a period of 1 month by three urology trainees in their final year of training. They were assessed with respect to time needed to complete anastomosis and quality of anastomosis. RESULTS The mean operative time showed a marked reduction from the second to the fourth attempt. There was also a significant improvement in the quality of anastomosis from the first to the fourth attempt. At the end of four attempts, all trainees were able to satisfactorily complete a good quality ureteropelvic anastomosis in a mean time of 67.7 minutes (range 62-76 min). CONCLUSION Laparoscopic suturing skills require effective training and constant practice to perfect the technique. Adequate practice on this chicken model shortens the learning curve, makes the trainee more confident of his or her skills, and improves his operative performance.

The Impact of Percutaneous Nephrolithotomy in Patients with Chronic Kidney Disease

INTRODUCTION The impact of percutaneous nephrolithotomy (PCNL) in chronic kidney disease (CKD) patients was retrospectively analyzed in this study. We analyzed the factors that can impair renal function and predict the need for renal replacement therapy (RRT) after PCNL. PATIENTS AND METHODS Ninety-one chronic kidney patients with a mean age of 52.5 +/- 13 involving 117 renal units underwent PCNL in our institution for 5 years. A mean of 1.6 +/- 1.1 tracks and 1.3 +/- 0.6 sittings per renal unit was required for PCNL. The estimated glomerular filtration rate (eGFR) pre-PCNL (postdrainage), peak eGFR on follow-up, and eGFR at last follow-up were recorded. The CKD stage pre-PCNL was compared with the CKD stage at last follow-up. RESULTS Complete clearance, auxiliary procedure, and complication rates were 83.7%, 2.5%, and 17.1%, respectively. The mean eGFR pre-PCNL and peak eGFR at follow-up were 32.1 +/- 12.8 and 43.3 +/- 18.8 mL/minute/1.73 m(2), respectively (p < 0.0001). At a mean follow-up of 329 +/- 540 days, deterioration with up-migration of CKD stage was seen in 12 patients (13.2%). Eight patients (8.8%) required RRT in the form of either maintenance hemodialysis or renal transplantation. Postoperative bleeding complication requiring blood transfusions was seen in seven (5.9%) and two (1.7%) of the renal units subsequently required super selective angioembolization. There were two mortalities in the postoperative period. Postoperative complications and peak eGFR (less than 30 mL/minute/1.73 m(2)) at follow-up are two factors that predict renal deterioration and RRT. Renal parenchymal thickness (<8 mm) also predicts the need for RRT. CONCLUSION PCNL has a favorable impact in CKD patients with good clearance rates and good renal functional outcome. PCNL in this high-risk CKD population is to be done with care and full understanding of its complications.

Extracorporeal shock wave lithotripsy in children: equivalent clearance rates to adults is achieved with fewer and lower energy shock waves.

To compare the outcome, safety and efficiency of extracorporeal shock wave lithotripsy (ESWL) using an electromagnetic lithotripter for upper urinary tract stones in children and adults.