Aditya Prakash Sharma

Perinephric Stranding and Bulky Psoas Mimicking Pyelonephritis in a Case of Non-Hodgkin Lymphoma of Kidney

A 68-year-old male patient presented with fever and right groin pain. He had leukocytosis with azotemia. Computed tomography revealed enlarged right kidney with thickening and enhancement of walls of pelvicalyceal system and perinephric fat stranding, suggestive of pyelonephritis. Multiple enlarged lymph nodes encased right renal vessels and were present in the retrocaval region. The right psoas muscle was bulky. Fine-needle aspiration cytology and biopsy from the lesions showed features of non-Hodgkin lymphoma. Immunohistochemistry confirmed the diagnosis of diffuse, large, B-cell lymphoma. We emphasize lymphoma in differential diagnosis of atypical renal imaging suggestive of pyelonephritis and perinephritis.

Efficacy of holmium laser urethrotomy and intralesional injection of Santosh PGI tetra-inject (Triamcinolone, Mitomycin C, Hyaluronidase and N-acetyl cysteine) on the outcome of urethral strictures.

Introduction To study the efficacy of holmium laser urethrotomy with intralesional injection of Santosh PGI tetra-inject (Triamcinolone, Mitomycin C, Hyaluronidase and N-acetyl cysteine) in the treatment of urethral strictures. Material and methods A total of 50 patients with symptomatic urethral stricture were evaluated by clinical history, physical examination, uroflowmetry and retrograde urethrogram preoperatively. All patients were treated with holmium laser urethrotomy, followed by injection of tetra-inject at the urethrotomy site. Tetra-inject was prepared by diluting acombination of 40 mg Triamcinolone, 2 mg Mitomycin, 3000 UHyaluronidase and 600 mg N-acetyl cysteine in 5–10 ml of saline, according to the stricture length. An indwelling 18 Fr silicone catheter was left in place for 7–10 days.All patients were followed-up for 6-18 months postoperatively by history, uroflowmetry, and if required, retrograde urethrogram and micturating urethrogram every 3 months. Results 41 (82%) patients had asuccessful outcome,whereas 9 (18%) had recurrences during a follow-up ranging from 6–18 months. In <1 cm length strictures, the success rate was 100%, while in 1–3 cm and >3 cm lengthsthe success rates were 81.2% and 66.7% respectively. This modality, thus, has an encouraging success rate, especially in those with short segment urethral strictures (<3 cm). Conclusions Holmium laser urethrotomy with intralesional injection ofSantosh PGI tetra-inject (Triamcinolone, Mitomycin C, Hyaluronidase, N-acetyl cysteine) is a safe and effective minimally-invasive therapeutic modality for short segment urethral strictures.

Needle in a haystack: lost in transition

A lost needle during minimally invasive surgery is a cause of undue anxiety to the entire surgical team and also causes prolongation of surgical time. There is no literature reporting follow-up of any patient with needle left behind as they are considered as a ‘never event’ during a surgical procedure. Preventing such events needs vigilance on part of the surgeon and assistant. Here, we report a case of lost needle during performance of a robot-assisted nephron sparing surgery. The robot needed to be de-docked and converted to laparoscopy. After a thorough search, the needle was found to be lodged at an unusual place. A brief review of available literature is also provided alongside.

Laparoscopic Intraperitonealization of Accidentally Misplaced Peritoneal Dialysis Catheter: A Salvage Procedure.

Tenckhoff catheter placement is a well-established procedure to facilitate continuous ambulatory peritoneal dialysis (CAPD) in end-stage renal disease (ESRD) management. Catheter malposition is a possible cause of catheter malfunction. Options to deal with early malfunction are re-exploration, omentectomy, repositioning, or new catheter placement. Technical malpositioning can be dealt with early, with minimal morbidity and cost. Here we report a case of a CAPD catheter accidentally placed preperitoneally which was salvaged using videolaparscopy.

Complex pelvic–ureteric junction obstruction (PUJO): successful management with robotic assistance

The management of complex pelvic–ureteric junction obstruction (PUJO) is challenging. The traditional open surgical approach used large incisions with prolonged post-operative recovery. Laparoscopic reconstruction in complex PUJO requires surgical expertise and is challenging to master. Robotic assistance has provided a viable minimally invasive alternative replicating the open surgical approach for such complex cases. In the present study, we evaluated the feasibility and success of robot-assisted reconstructive procedures in such situations.

An unusual case of emphysematous pyelonephritis with features of IgG4-related tubulointerstitial nephritis on histology

Immunoglobulin G4-related disease (IgG4-RD) is a fibrolymphoproliferative systemic disease which affects diverse organs including the kidney, lymph nodes, pancreas, salivary glands, liver, gastrointestinal tract, lungs, retroperitoneum, lacrimal glands, skin and central nervous system.1–3 IgG4-related kidney disease (IgG4-RKD) manifests as tubulointerstitial nephritis (TIN) with IgG4positive plasma cell infiltration, obliterative phlebitis and granulomas.4 Patients with IgG4-RKD generally present with renal dysfunction, radiological abnormalities or urinary abnormalities. Serology usually demonstrates high levels of serum IgG4 (>135 mg/dl) and total IgG levels.5 Radiologically malignant lymphoma, urinary tract carcinomas, renal infarction and pyelonephritis can mimic IgG4-RKD. Here we report an unusual case of emphysematous pyelonephritis (EPN) in a patient with uncontrolled diabetes mellitus mimicking IgG4-RKD on histology.

Predicting trifecta outcomes after robot-assisted nephron-sparing surgery: Beyond the nephrometry score

Purpose RENAL nephrometry score (RNS) was devised for deciding the approach for renal tumors. It is increasingly used in predicting perioperative outcomes with variable results. The actual difficulty encountered during surgery depends on a number of other variables. The main purpose of this prospective study was to identify these variables which are not addressed by current RNS. Materials and Methods Forty-nine patients undergoing robotic nephron sparing surgery from January 2015 onward were included. RNS was calculated from the imaging. Operating surgeon rated each surgery on a Likert scale of 0–4 after the completion of the procedure. The questionnaire was pre-validated in 5 cases before administration. The correlation between the surgeon rating and RNS with perioperative parameters and trifecta outcomes were calculated. Results Forty-seven percent surgeries were rated easy, and 53.0% were rated as difficult. Surgeries for hilar, posterior location and presence of supernumerary vessels were found to be the a cause of difficulty. Trifecta outcomes were achieved in 37/49 patients (75.5%). The mean rating was 2.580±0.900 in trifecta negative patients while it was 1.410±0.832 in trifecta positive patient (p<0.0001). Surgeons rating correlated positively with trifecta outcomes (likelihood ratio=15.75, p=0.006). Conclusions The RNS remained a useful tool for determining renal tumor complexity. The intraoperative difficulty faced by the surgeon can be rated which can better predict perioperative trifecta outcomes. A useful predicting tool can be developed using the two parameters (RNS and surgeon rated difficulty).

STAMPEDEing metastatic prostate cancer: CHAARTing the LATITUDEs

With the emergence of recent landmark trials, the treatment for hormone-sensitive metastatic prostate cancer (hsMPC) is changing from androgen deprivation therapy (ADT) alone to combination therapy. Both, docetaxel chemotherapy and abiraterone in addition to ADT have been extensively studied in well-conducted randomized controlled trials and were shown to improve outcomes. However, this paradigm shift in the treatment has also raised some queries. This mini review reflects upon the four landmark trials and tries to provide some perspective about the decision-making process for the patients with hsMPC.

Re: Wei Gan JJ, Lia Gan JJ, Hsien Gan JJ, Lee KT. Lateral percutaneous nephrolithotomy: A safe and effective surgical approach. Indian J Urol 2018;34:45-50

Upper portions of both the kidneys are generally located anterior to the 11th and 12th ribs. In about 85% of the cases, the upper pole calyces are located above the 12th rib.[2] Hence, anatomically, it is always easier to access the upper pole calyx through a supracostal puncture (above 12th rib) which will provide the shortest and the straightest path to the pelvicalyceal system. This supracostal puncture rate has been reported to be around 25%–50% in various series.[3,4] In the index article by Gan et al.[1], it is mentioned in Table 2 that the upper polar puncture was made in 254 cases out of the total of 347 cases. However, it was surprising that supracostal puncture (above 12th rib) was required in only 4 out of the 347 (1.1%) cases. Is it due to the use of the triangulation technique, use of the kidney break, an anatomical variation in the patient population included or just by chance, this has not been explained in the text. If the lateral position of the patient with the table broken makes access to the upper pole calyx by a subcostal approach easier, then it is a significant advantage of lateral position PCNL over prone position and has implications in avoiding thoracic complications.

Comparison of RENAL, PADUA, and C-index scoring systems in predicting perioperative outcomes after nephron sparing surgery

Introduction and Objective: The RENAL, PADUA and centrality index (C-index) nephrometry scoring systems (SS) have been individually evaluated for their role in predicting trifecta outcomes after nephron-sparing surgery (NSS). However, there is little data on their comparative superiority. The present study was designed to evaluate the predictive value of three SS and to assess interobserver reliability. Materials and Methods: Fifty patients undergoing NSS at our center between January 2014 and April 2016 were included in the study. The demographic details were noted. Images (computed tomography [CT] scans or magnetic resonance imaging) were reviewed by a urologist and a radiologist independently and RENAL, PADUA, and C-index were calculated. The correlation between these scoring system and trifecta outcomes were calculated. Results: The RENAL and PADUA score did not correlate with any of the perioperative parameters. However, C-index had a significant correlation with operative time (OT) (P = 0.02) and trifecta outcomes (P < 0.05). There was an excellent concordance between the two observers in scoring the RENAL score (α = 0.915; intraclass correlation coefficient [ICC] = 0.814) and PADUA score (α = 0.816; ICC = 0.689 [P < 0.001]). There was lesser although acceptable concordance in the calculation of C-index (ICC −0.552; α −0.711). Conclusions: There is good correlation among all the 3 SS. C-index has lower reproducibility due to difficult mathematical calculation but correlated best with trifecta outcomes.