Aneesh Srivastava

Buccal mucosal urethroplasty: a versatile technique for all urethral segments

Authors from India describe their experience in a series of patients with bulbar urethral strictures in whom they used a buccal mucosal graft. They found this to be the most versatile substitute.

Risk factors for progression to end-stage renal disease in children with posterior urethral valves

OBJECTIVE To identify the variables which affect long-term renal outcome in children with posterior urethral valves (PUV). MATERIALS AND METHODS Retrospective analysis of 260 children with PUV who underwent ablation of valves in 1992-2008 at our tertiary care center. The following risk factors for progression to end-stage renal disease (ESRD) were analyzed: nadir serum creatinine greater than 1.0mg/dl, bilateral grade 3 or higher VUR at diagnosis, recurrent febrile UTIs, and severe bladder dysfunction. Patients were divided into two groups: those who developed ESRD (group 1) and those who did not (group 2). RESULTS Forty (17.62%) patients had nadir serum creatinine >1mg/dl. At time of initial presentation, high-grade VUR was seen in 63.1% and 33.5% of groups 1 and 2, respectively (P=0.002). Overall, 77 (34%) of the boys developed breakthrough urinary tract infections: 37.03% and 33.5% in groups 1 and 2, respectively (P=1). Fifty-nine (26%) patients were found to have severe bladder dysfunction: 77.8% and 19% in groups 1 and 2, respectively (P<0.0001). Twenty-seven (11.89%) patients progressed to ESRD, at mean age of 11.21 years (5-16). On univariate analysis, the risk-predicting variables were: nadir serum creatinine value greater than 1mg/dl (P<0.0001), bilateral high-grade VUR (P=0.002) and severe bladder dysfunction (P<0.0001). On multivariate logistic regression analysis, nadir serum creatinine greater than 1mg/dl (OR 23.79; CI 8.20-69.05) and severe bladder dysfunction (OR 5.67; CI 1.90-16.93) were found to be independent risk factors predictive of ultimate progression to ESRD. CONCLUSIONS Nadir serum creatinine and bladder dysfunction are the main factors affecting long-term renal outcome in cases of PUV. Early identification and treatment of bladder dysfunction may thus be beneficial.

Routine stenting after ureteroscopy for distal ureteral calculi is unnecessary: results of a randomized controlled trial.

BACKGROUND AND PURPOSE Insertion of a ureteral stent is routinely done after ureteroscopy. Recently, several authors have questioned routine stenting after ureteroscopy for distal ureteral stones. We report our results of a randomized study comparing ureteroscopy with and without placement of stents for distal ureteral stones. PATIENTS AND METHODS A total of 48 patients undergoing ureteroscopy for distal ureteral stones were randomized to a stented group (N = 26) or a nonstented group (N = 22). Ureteroscopy was carried out with Wolf 8.5F semirigid endoscope, and the Swiss Lithoclast was used as the source of energy. Any stent was removed at 3 weeks. Patients were assessed for success, operative time, postoperative pain score, analgesic requirement, stent-related symptoms, and risk of ureteral stricture formation. Baseline variables were not significantly different in the two groups. RESULTS There was no significant difference in the two treatment groups with regard to need for ureteral dilation, use of intracorporeal lithotripsy, or occurrence of intraoperative and postoperative complications. A successful outcome was achieved in 100% of both groups. The mean pain score on day 0 was 5.23 +/- 0.95 of 10 in the stented group and 4.82 +/- 0.96 in the nonstented group; this difference was not statistically significant. Similarly, the analgesic requirement in the two treatment groups was not significantly different. However, patients with stents had significantly more pain (including flank pain with voiding: P = 0.01), urgency (P = 0.04) and dysuria (P <0.01). Radiologic follow-up was available for 83.33% of the patients at the 3-month visit. None of the patients had evidence of ureteral stricture or residual stone fragments. CONCLUSION In select patients undergoing ureteroscopy for distal ureteral stones, stents can be safely omitted. Patients without stents have significantly fewer lower-urinary symptoms of pain, urgency, and dysuria and are not at risk of increased complications. Avoiding stents may be particularly cost effective in developing countries.

MANAGEMENT OF FUNCTIONAL BLADDER NECK OBSTRUCTION IN WOMEN: USE OF α-BLOCKERS AND PEDIATRIC RESECTOSCOPE FOR BLADDER NECK INCISION

PURPOSE Functional bladder neck obstruction has been definitively diagnosed in the last few years due to detailed synchronous pressure flow, electromyography and video urodynamics. Clean intermittent self-catheterization and bladder neck incision are the modalities of treatment. To our knowledge the role of alpha-blockers is not yet defined in women. A new technique was developed to perform bladder neck incision using a pediatric resectoscope. MATERIALS AND METHODS A total of 24 women with obstructive voiding symptoms or retention were evaluated with video pressure flow electromyography, and diagnosed with functional bladder neck obstruction due to high pressure and low flow on silent electromyography and bladder neck appearance on fluoroscopy. Patients were initially treated with clean intermittent self-catheterization and alpha-blockers. Catheterization was stopped when post-void residual was less than 50 ml. and only alpha-blocker therapy was continued. Bladder neck incision was performed in patients who had a poor response to or side effects of alpha-blocker therapy, or when therapy was discontinued due to economic reasons. Clean intermittent self-catheterization was continued in patients who had a poor response to alpha-blockers or refused to undergo bladder neck incision. Bladder neck incision was performed in the initial 2 cases with an adult resectoscope using a Collins knife and subsequently a pediatric resectoscope (13F). Uroflow and post-void residual measurements were performed in all cases. RESULTS Of the 24 patients 12 (50%) showed improvement in symptoms, peak flow and post-void residual (p <0.01) with alpha-blocker therapy only. Of the 12 patients who had a poor response to alpha-blockers 6 underwent bladder neck incision subsequently and 6 remained on clean intermittent self-catheterization. All 8 patients treated with bladder neck incision, including 2 who had a good response but discontinued alpha-blocker therapy, had sustained improvement in post-void residual and peak flow (p <0.01) after a mean followup of 3.8 +/- 2.4 years. Grade 1 stress incontinence in 2 adult resectoscope cases responded to conservative treatment. None of the pediatric resectoscope cases had stress incontinence. CONCLUSIONS Clean intermittent self-catheterization and alpha-blockers are the initial treatment options for functional bladder neck obstruction. The alpha-blockers were successful in 50% of our patients. Bladder neck incision should be offered judiciously with minimal risk of curable stress incontinence. The pediatric resectoscope is useful to make a well controlled incision safely in the female urethra.

Aggressive Approach to Staghorn Calculi—Safety and Efficacy of Multiple Tracts Percutaneous Nephrolithotomy

OBJECTIVES To evaluate the safety and efficacy of an aggressive approach to staghorn calculi using multiple-tract percutaneous nephrolithotomy. METHODS We retrospectively analyzed the data from 149 patients with staghorn calculi, who underwent percutaneous nephrolithotomy using multiple (two or more) access tracts, at our institute from 1999 to 2006. The data were analyzed with regard to stone burden, stone clearance, perioperative morbidity, complications, and the number of ancillary procedures. RESULTS A total of 164 renal units in 149 patients (118 men and 31 women, mean age 39.8 years, range 12 to 65 years) were treated. Of the 164 renal units, 43 (26.2%) had a complete staghorn, 85 (51.8%) had a partial staghorn and 36 (21.9%) had a borderline stone bulk. A total of 420 tracts were established in the 164 renal units. The maximal number of tracts used in a single renal unit was six (range two to six), most required three tracts. Supracostal access was established in 98 renal units (59.7%). The complications included blood transfusion in 46 patients, pseudoaneurysm in 4, sepsis in 8, hydrothorax in 7, hemothorax in 1, and perinephric collection in 1 patient. A complete stone clearance rate of 70.7% was achieved after a single session of percutaneous nephrolithotomy that increased to 89% after a second-look procedure (n = 30) and extracorporeal shock wave lithotripsy (n = 16). CONCLUSIONS The results of our study have shown that an aggressive approach to staghorn calculi using multiple-tract percutaneous nephrolithotomy is safe and effective in achieving a greater stone clearance rate with acceptable morbidity. A supracostal approach can be used more often without increasing the risk of significant complications.

The efficacy of tolterodine for prevention of catheter-related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study.

Bladder discomfort secondary to an indwelling urinary catheter is distressing, particularly for patients awakening from anesthesia. We sought to discover the incidence and severity of bladder discomfort in patients who were catheterized intraoperatively and to evaluate the efficacy of tolterodine, a pure muscarinic receptor antagonist, in preventing this. Two-hundred-fifteen consecutive adult patients, ASA physical status I and II, either sex, undergoing urologic surgery requiring bladder catheterization were enrolled. Group C (control, n = 165) received placebo and group T (tolterodine, n = 50) received tolterodine 2 mg. Drugs were administered orally 1 h before surgery. After induction of anesthesia, patients were catheterized with a 16F Foley catheter and the balloon was inflated with 10 mL of normal saline. In the postanesthesia care unit, bladder discomfort was assessed on arrival (0), 1, 2 and 6 h. Severity of bladder discomfort was graded as mild, moderate, and severe. Bladder discomfort observed in group C was 55% (91 of 165). Tolterodine reduced both the incidence 36% (18 of 50) and severity of bladder discomfort (P < 0.05).

Predictive factors for mortality and need for nephrectomy in patients with emphysematous pyelonephritis

Study Type – Therapy (case series)
Level of Evidence 4

Impact of age and gender on the clinicopathological characteristics of bladder cancer

Purpose: To determine the impact of age and gender on the clinicopathological characteristics of histologically confirmed bladder cancer in India. Materials and Methods: From January 2001 to June 2008, records of patients with bladder cancer were evaluated for age and gender at presentation, clinical symptoms, cystoscopic finding, history of smoking, and histopathological characteristics. A total of 561 patients were identified from the computer-based hospital information system and the case files of patients. Results: A total of 97% of the patients presented with painless hematuria. The mean age was 60.2 ± 4.4 years old (range: 18–90 years old) and the male to female ratio was 8.6:1. Transitional cell carcinoma (TCC) was the most common histological variety, which was present in 97.71% (470 of 481) of the patients. A total of 26% of the patients had muscle invasive disease at the time of presentation. However, 34.5% (166 of 481) of the patients did not show any evidence of detrusor muscle in their biopsy specimen. In patients with nonmuscle-invasive bladder carcinoma, 55% had p Ta while 45% had p T1. Overall, 44.7% (215 of 481) of the patients had low-grade disease. Among patients younger than 60 years old, low-grade (51.0% vs. 38.1%; P = 0.006) and low-stage (77.1% vs. 70.8%; P = 0.119) disease were more prevalent than in patients older than 60 years old. The incidence of smoking was much higher among males compared with females (74% vs. 22%). Conclusion: TCC is the predominant cancer, with significant male preponderance among Indian patients. Younger-aged patients have low-grade disease. Hematuria is the most common presentation and greater awareness is needed not to overlook bladder cancer.

LONG-TERM FOLLOWUP OF ELDERLY DONORS IN A LIVE RELATED RENAL TRANSPLANT PROGRAM

PURPOSE It is a concern that elderly donors may have increased risks in the perioperative period due to age related changes in various organ systems. Nephrosclerosis, atherosclerosis and low glomerular filtration rate may portend a poor graft outcome. We performed a study to determine function and outcome of kidneys from elderly donors. MATERIALS AND METHODS A retrospective analysis of our live related transplant program from November 1989 to December 1998 revealed that 112 donors were older than 55 years (range 55 to 81). Of the recipients of these kidneys from elderly donors 98 had a followup of more than 2 years (group 1), and they were compared to a cohort of 87 patients whose kidney donors were younger than 45 years (group 2). Allograft function was evaluated by serum creatinine and differential glomerular filtration rate was determined by (99m)technetium diethylenetriamine pentaacetic acid renal scan. All donors were followed regularly. RESULTS Mean donor age plus or minus standard deviation was 57.4 +/- 4.3 and 31.4 +/- 7.6 years in groups 1 and 2, respectively. Mean followup plus or minus standard deviation was 42.44 +/- 20.46 months in group 1 and 40.04 +/- 27.28 months in group 2. The 1-year graft survival rate was 91.84% and 88. 51%, and the 5-year graft survival rate was 72.72% and 75.13% in groups 1 and 2, respectively. Serum creatinine was 1.5 +/- 0.65 and 1.7 +/- 1.52 mg./dl. in group 1 and 1.4 +/- 0.55 and 1.5 +/- 1.41 mg. /dl. in group 2 at 1 year and last followup, respectively. Glomerular filtration rate was 37.2 +/- 11.2 and 37.3 +/- 10.7 ml. per minute in group 1 and it was 45.3 +/- 8.6 and 47.7 +/- 11.3 ml. per minute in group 2 at 1 year and last followup, respectively. Acute rejection rate was significantly higher in group 1 (42%) compared to group 2 (19%). Both groups were comparable in terms of infectious episodes, antihypertensive requirement and incidence of acute tubular necrosis. There was no added morbidity for elderly compared to younger donors. CONCLUSIONS In view of acute donor shortage and if properly screened, elderly kidneys can be used without increasing the risk to donor or compromising graft outcome.

Urethral stricture assessment: a prospective study evaluating urethral ultrasonography and conventional radiological studies.

Authors from India have found that sono‐urethrography is an accurate method of evaluating the length of anterior urethral strictures, being more accurate than retrograde urethrography, and that it gives additional information about spongiofibrosis.