Ankush Jairath

Management Protocol for Chylous Ascites After Laparoscopic Nephrectomy

OBJECTIVE To devise a management protocol for chylous ascites after laparoscopic nephrectomy. PATIENTS AND METHODS We retrospectively reviewed the data of the patients that underwent laparoscopic nephrectomy between January 2010 and January 2014 in our institution for different indications and were diagnosed with chylous ascites. We also analyzed a different management protocol that was used. RESULTS The overall incident rate of chylous ascites was 0.77%. It was more commonly seen on left side and with simple nephrectomy rather than radical. Three out of 9 patients were managed by surgical intervention, rest were successfully managed on conservative treatment in the form of dietary modification, total parenteral nutrition, or octreotide. CONCLUSION Chylous ascites is a rare but morbid condition following laparoscopic nephrectomy. To manage this complication, we propose preventive and treatment strategies based on symptoms and amount of chylous ascites using our experience and review of the literature.

Oxalobacter formigenes: Opening the door to probiotic therapy for the treatment of hyperoxaluria

Abstract Objective. The aim of this study was to determine the early effect of the administration of Oxalobacter formigenes on the metabolic pattern of patients with calcium oxalate stones, comparing it with potassium magnesium citrate (KMgCit). Materials and methods. Eighty patients were randomized to receive either 30 mEq of KMgCit or 700 million O. formigenes, both twice a day. Serum creatinine, serum urate, serum calcium and phosphorus, serum intact parathyroid hormone (if serum calcium >10.5 mg/dl) and 24 h urine metabolic evaluation for various metabolites (e.g. oxalate, calcium, phosphorus, citrate, magnesium, urate and creatinine) were evaluated at baseline and 1 month after starting the treatment. Results. In both groups hyperoxaluria was the most common abnormality, followed by hypercalciuria. The incidence of hyperoxaluria decreased at 1 month compared to baseline in both KMgCit (77.5% vs 37.5%, p = 0.0006) and O. formigenes preparation (82.5% vs 15%, p < 0.0001) groups, while other urinary metabolic abnormalities were similar at baseline and 1 month in both groups. Three patients in the KMgCit had mild self-limiting secondary symptoms. Conclusion. Compared with KMgCit, O. formigenes preparation is more effective in decreasing the incidence of hyperoxaluria, opening the door to probiotic therapy as a potential new weapon against hyperoxaluria.

Percutaneous nephrolithotomy in pelvic kidneys: is the ultrasound-guided puncture safe?

OBJECTIVE To demonstrate our experience with the use of ultrasound (USG) for puncture guidance while performing percutaneous nephrolithotomy in ectopic pelvic kidneys. METHODS From January 1990 to December 2013, we have performed percutaneous nephrolithotomy in 26 patients with USG-guided punctures. The stones were solitary in 15 patients (58%) and multiple in 11 patients (42%). The mean stone size was 22 mm (range, 10-50 mm), including 3 staghorn calculi. All procedures were performed in an oblique-supine position, and the intraoperative complications as the postoperative outcome were reviewed. RESULTS The mean operative time was 93 minutes, achieving complete stone clearance in 22 (88%) of the patients. One of the patients had urine leakage after removing nephrostomy, needing postoperative double J stenting. One patient had significant intraoperative bleeding requiring staging of the procedure and blood transfusion. No bowel injuries were identified. Mean hospitalization time was 5.6 days. CONCLUSION USG-guided puncture is a safe and effective approach to the collecting system even in renal anomalies like in pelvic ectopic kidneys when performed in experienced hands.

Can CT Virtual Cystoscopy Replace Conventional Cystoscopy in Early Detection of Bladder Cancer

Aim. To correlate findings of conventional cystoscopy with CT virtual cystoscopy (CTVC) in detecting bladder tumors and to evaluate accuracy of virtual cystoscopy in early detection of bladder cancer. Material and Method. From June 2013 to June 2014, 50 patients (46 males, four females) with history and investigations suggestive of urothelial cancer, with mean age 62.76 ± 10.45 years, underwent CTVC by a radiologist as per protocol and subsequently underwent conventional cystoscopy (CPE) the same day or the next day. One urologist and one radiologist, blinded to the findings of conventional cystoscopy, independently interpreted the images, and any discrepant readings were resolved with consensus. Result. CTVC detected 23 out of 25 patients with bladder tumor(s) correctly. Two patients were falsely detected as negative while two were falsely labeled as positive in CTVC. Virtual and conventional cystoscopy were comparable in detection of tumor growth in urinary bladder. The sensitivity, specificity, positive predictive value, and negative predictive value of virtual cystoscopy were 92% each. Conclusion. CTVC correlates closely with the findings of conventional cystoscopy. Bladder should be adequately distended and devoid of urine at the time of procedure. However, more studies are required to define the role of virtual cystoscopy in routine clinical practice.

Robotic repair of vesicovaginal fistula - initial experience.

ABSTRACT Objective The most common acquired fistula of the urinary tract is Vesicovaginal fistulae (VVF) (1) posing social stigmata for the patient as well as a surgical challenge for the urologist. Here we present our initial experience with Robotic assisted laparoscopic repair of VVF, its safety and efficacy. Materials and Methods Seven out of eight fistulas were post hysterectomy; five had undergone abdominal while two had laparoscopic hysterectomy while one was due to prolonged labour. Two had associated ureteric injury. All underwent robotic assisted laparoscopic trans abdominal extravesical approach. Three 8 mm ports for robotic arms, one 12 mm port for camera and another 12 mm for assistant were used in a fan shaped manner. All had preoperative ureteric catheter placed. Bladder was closed in two layers and vagina in one layer. Omental flap placed in all cases except two where it was not possible. Drain and per urethral catheter placed in all cases. Double J stents were placed in two cases requiring ureteric implantation additionally. Results The mean age of presentation was 39.25 years (26-47 range) with mean BMI being 26.25 kg/m2 (21-32 range). Mean duration between insult and repair was 9.37 months (3-24 months). Only in single case there was history of previous repair attempt. On cystoscopy four had supratrigonal VVF and four were trigonal with mean size of 13.37 mm (7-20 mm). Mean operative time was 117.5 minutes (90-150). There were no intraoperative/postoperative complications or need for open conversion. Mean haemoglobin drop was 1.4 gm/dL (0.3-2 gm). Drain was removed once 24-48 hours output is negligible. One patient had post-operative urinary leak at 2 weeks which ceased with continuation of catheterisation for another 2 weeks. Catheter was removed after voiding cystourethrogram showed no leak at 2-3 weeks postoperatively. Mean duration of drain was 3.75 days (3-5) and per urethral catheterisation (which was removed after voiding cystourethrography) was 15.75 days (9-28). Mean hospital stay was 6.62 days (4-14). Post-operative bladder capacity was 324.28 cc (280-350) on voiding diary. Follow up ranged from 3-9 months. At 3 months of follow-up, these patients continued to void normally and there was no evidence of recurrence of VVF. Conclusion Robotic repair of VVF is safe and feasible and has additional advantages in the form of precise suturing under 3D vision and certainly a more striking and effective option especially in complex VVF repair associated with ureteric injuries (2).

Anaesthesia Concerns for Laparoscopic Donor Nephrectomy

Anesthesia during laparoscopic donor nephrectomy remains the key component for success. The various aspects that the treating medical professionals should know in this regard are the details regarding the preanaethesia check up, intraoperative management anaethesia related issues and the post-operative care. In this chapter these points are detailed.

Robotic Donor Nephrectomy (RDN)

The single most important factor in case of renal transplant is to avoid any complication in donor. Recovery from a surgery, which is done to benefit another human being, should be early and complication free as far as possible. Innovation in laparoscopy and robotics surgery has greatly reduced complications associated with open donor nephrectomy, while maintaining the same graft survival. Any complication in donor is considered drastic; hence, prevention of complications in live donor is of utmost importance in case of renal transplant. We emphasize the importance of knowing renal anatomy before taking the donor for operation in order to reduce or rather prevent complications during the procedure. This chapter also summarizes the importance of preoperative evaluation, reasons for complication at each step of donor nephrectomy, prevention and further management, if at all any injury occurs, in a simplified organized manner.

Urolithiasis in anomalous kidneys- witnessing the changing trends in the Endourological management

To present our single‐centre experience of urolithiasis management in anomalous kidneys, highlighting the need for an algorithm‐based approach in deciding the appropriate treatment method for each type.

PD10-07 RELIABILITY OF PROSTATE HISTOSCANNING IN THE LOCALIZATION AND VOLUME ESTIMATION OF CARCINOMA PROSTATE

was shown to bind to cells expressing PSMA demonstrating significant staining of prostatic adenocarcinoma. We performed the first in-human FDA-approved phase I 3+3 dose finding study of intravenously (IV) administered MDX1201 in intermediateto high-risk patients undergoing RARP and extended lymph node (LN) dissection. METHODS: Patients received a single intravenous infusion of MDX1201 four days prior to RARP to allow for safety evaluation. A 488 nanometer laser was attached to the da Vinci Si surgical robot camera at the time of RARP to allow for visualization of fluorescent dye marking presence of prostatic cancerous tissue. 5 mg dose was given to the first 3 patients, and then the dose was escalated to 15 mg provided safety considerations permit. Patients with prior prostate cancer treatment were excluded. RESULTS: MDX1201 was successfully administered to 5 patients, with no adverse events observed. Initial 5 mg dose failed to show visualization of fluorescent dye in first 3 patients. Of the 15 mg dose patients, patient #4 demonstrated fluorescence ex vivo within the sectioned prostate that correlated with pathological findings, while patient #5 demonstrated fluorescence in-vivo with mild prostatic fluorescence at the right apex, left apex, left mid, and also moderate fluorescence demonstrated at the right external iliac LNs. For patient #5, histopathologic examination confirmed tumor to the mid right lobe (dominant nodule), with a minor focus in anterior left lobe near the base. There was no LN metastasis in this patient (pT2cN0). In the five patients (median PSA 9.5, 80% intermediate-risk, 100% > pT2c), the median LN yield was 18 with no LN involvement in any patient. No positive margins were detected. CONCLUSIONS: We demonstrate the first in human study using an anti PSMA antibody demonstrating fluorescence in the prostate. Identification of prostatic tissue using a conjugated fluorescent marker with specificity against PSMA may help guide preservation of critical structures.

Percutaneous nephrostomy step by step

Percutaneous renal access remains the cornerstone initial step in varied clinical settings. For obtaining the best surgical outcome and minimizing patient morbidity, an appropriate access to the target calyx is needed. Though the site of entry depends upon anatomy of pelvicalyceal system and indication for access, a proper technique should be used for gaining access and at the same time minimizing the associated complications. This article describes our technique of gaining access to the pelvicalyceal system and subsequent percutaneous nephrostomy placement in a stepwise manner.