Amit Suri

Inferior Vena Cava in Urology: Importance of Developmental Abnormalities in Clinical Practice

Anomalies of the inferior vena cava (IVC) have been known since 1793, when Abernethy first described a congenital, mesocaval shunt and azygous continuation of the IVC in a 10-month-old infant with polysplenia and dextrocardia. The IVC is formed by a complex process of embryogenesis during the sixth to tenth week of gestation. It forms from continuous appearance and regression of the three paired veins: posterior cardinal, subcardinal, and supracardinal. Improper completion of the developmental process may result in at least 14 anatomic anomalies, out of which the following four are usually encountered in clinical practice: duplication of the IVC, transposition or left-sided IVC, retroaortic left renal vein, and circumaortic left renal vein. It is suggested that the preoperative diagnosis of the vascular anomalies reduces the complication rate of abdominal vascular procedures. Our vast experience with approximately 400 kidney donors who were evaluated preoperatively with spiral CT scan with three-dimensional reconstruction (3D) reconfirmed this view. Thereafter, it became easier to choose the side and decide between laparoscopic vs. open approach. This prompted us to write the present article focusing on those developmental anomalies of the IVC that may be encountered by the urologist and their implication on the clinical practice.

Chyluria - SGPGI experience

Purpose:0 We analyzed various modes of presentation of chyluria in our patients. Various treatment options available and associated complications were also studied. Materials and methods:0 Retrospective review of records of patients of chyluria treated at our institute between January1987 to June 2005 was done. Chyluria was diagnosed by urine examination. Treatment was tailored according to severity of chyluria, which included dietary modification, antifilarial drugs and sclerotherapy. Those not responding to two sessions of sclerotherapy were taken up for chylolymphatic disconnection. Results:0 A total of 600 patients were treated between January 1987 and June 2005. Before 1999 we routinely used 1% silver nitrate. Between January 1999 and June 2003, povidone iodine (0.2%) and dextrose (50%) were also used besides silver nitrate (1%). Instillation of dextrose was used in 21 patients only and its use was discontinued because of high immediate failure (57%) and recurrence rate (38%). Instillation of povidone iodine was as effective as silver nitrate. 91% of the patients in the silver nitrate and 98% in the povidone group showed immediate clearance. The chyluria recurred in 21 and 22% in two groups, respectively. The cumulative success rate after two courses of sclerotherapy was 82% in the silver nitrate and 83% in the povidone group. Side effects were much less with povidone iodine. Those who did not responded to two courses of sclerotherapy did well after chylolymphatic disconnection. Conclusion:0 Presenting symptoms of chyluria vary according to severity of the disease. Most patients respond to dietary modifications, antifilarial drugs and sclerotherapy. Those not responding to sclerotherapy do well after chylolymphatic disconnection.

Comparison of endopyelotomy and laparoscopic pyeloplasty for poorly functioning kidneys with ureteropelvic junction obstruction

Endopyelotomy and laparoscopic pyeloplasty are established procedures for ureteropelvic junction obstruction (UPJO) and historically a high failure rate has been observed in poorly functioning units with UPJ obstruction. The aim of this study is to compare the results of laparoscopic pyeloplasty with endopyelotomy in poorly functioning renal units, i.e., GFR under 25 ml/min. Materials and Methods: Retrospective analysis of all the patients who underwent either laparoscopic pyeloplasty or endopyelotomy for ureteropelvic junction obstruction in poorly functioning units between January 1998 and June 2005 was done. Follow-up renal scans, done at three, six, 12 months and yearly thereafter, were studied. Success was defined as symptomatic relief and/ or improvement in function (10% over baseline) in renal scan. Results: There were 23 patients in the endopyelotomy group and 15 patients in the laparoscopic pyeloplasty group with mean age of 25.3 years (9-53) and 26 years (10-44), respectively. Mean pelvic volume was 41.2 8cc ± 9.5 and 39.1cc ± 9.85 in the endopyelotomy group and laparoscopic pyeloplasty group, respectively. Mean preoperative GFR was 17.4 ± 5.7 ml/min and 21 ± 4.5 ml/min in the endopyelotomy group and laparoscopic pyeloplasty group, respectively and mean postoperative GFR was 21 ± 3.5 ml/min and 22 ± 3.9 ml/min, respectively. Eighteen and 11 patients were symptomatic in ethe ndopyelotomy group and laparoscopic pyeloplasty group, respectively while symptomatic improvement was seen in 14 and 11 patients, respectively. Mean follow-up was 12 months in the laparoscopy group and 28 months in the endopyelotomy group. Success rate was better for laparoscopic surgery group (15/15 = 100%) than for endopyelotomy (18/23 = 78.26%). Conclusions: Though the improvement in renal function is less in patients with UPJO with poorly functioning kidneys undergoing endopyelotomy or laparoscopic pyeloplasty, laparoscopic pyeloplasty gives better results in the form of symptomatic relief; however, renal function remains stable whichever the approach chosen.

Prolene (mesh) bulbourethral sling in male incontinence

Objective: We present our preliminary results of bulbar urethral sling (single bolster) in treatment of postprostatectomy urinary incontinence (PPUI). Materials and Methods: From May 2003 to June 2005, six patients with postprostatectomy urinary incontinence (transurethral resection of prostate in five patients and after open prostatectomy in one patient) underwent prolene mesh bulbar urethral sling surgery. Preoperative evaluation included physical examination, neurological assessment, stress cystogram and urethrocystoscopy. Urodynamic evaluation was done in all patients for abdominal leak point pressure and ruling out bladder pathology. Results: Urodynamic studies did not demonstrate bladder instability in any patient. Mean abdominal leak point pressure was 43cm of water (range 26–80 cm of water). Mean duration of hospital stay was 3.2 days. Follow-up ranged from 6–22 months. Four patients out of six patients were completely dry till their last follow-up. One patient developed mild stress incontinence after one year of the surgery and required use of one to two pads per day. Mean pad use after surgery was 0.6 pads per day in comparison to mean pad usage of 6.4 pads per day preoperatively. One patient was over-continent after the procedure and required clean intermittent catheterization till last follow-up (six months). Mean cost of the procedure was

Bladder neck broad based polypropylene sling for stress urinary incontinence

350+15. Conclusion: Prolene bulbar urethral sling (single bolster) is an economically effective option in patients with postprostatectomy urinary incontinence.

Vascular complications after percutaneous nephrolithotomy: are there any predictive factors?

Objectives : Bladder neck suspension using polypropylene is an established technique for treatment of stress urinary incontinence (SUI). We report our retrospective audit of the bladder neck sling in SUI. MaterialS and Methods : Twenty-one patients with SUI operated at our institute were included in the study. The audit was performed using the case records for - patient demographics, detailed history and examination, routine hemogram, renal function tests, urine culture sensitivity, urine microscopic examination and uroflowmetery + cystometrogram(CMG). After complete evaluation, all patients underwent bladder neck suspension using polypropylene mesh. Results : Twenty-one patients with mean age of 55 years underwent bladder neck sling surgery. Mean duration of surgery was 67 minutes (50-100 minutes). Mean operative blood loss of 100ml. Mean duration of hospital stay was 2days (1-5 days). Eighteen patients had complete or significant decrease in the severity of stress urinary incontinence in immediate post-operative period. Mean duration of follow up of patients was 19 months (3-28 months). All patients were dry at the end of the follow up. Conclusions : Broad base polypropylene mesh gives good continence results in patients of SUI.