Anurag Khaitan

Post-ESWL, clinically insignificant residual stones: reality or myth?

OBJECTIVES To assess the significance of asymptomatic residual stone fragments of less than 4 mm (clinically insignificant residual fragments [CIRFs]) after extracorporeal shock wave lithotripsy (ESWL). METHODS Eighty-one patients were followed up for 6 to 60 months (mean 15) after ESWL to determine the fate of the CIRFs. RESULTS Of the 81 patients, 6 were lost to follow-up, leaving 75 patients. During follow-up, fragments passed spontaneously in 18 patients, remained stable in 13 patients, and became clinically significant in 44 patients who developed one or more complications. For the latter patients, repeated ESWL was done in 16, percutaneous nephrolithotomy in 3, and ureteroscopic stone removal in 4 patients. The remaining 21 patients were treated conservatively with analgesics. We found that 53% of the CIRFs located in the pelvis passed spontaneously, and most of the CIRFs in caliceal location became clinically significant. Also, as the stone burden and number of stone fragments increased, the risk of CIRFs becoming clinically significant increased. The outcome was the same whether a metabolic abnormality was present or not, provided the patient received appropriate treatment. The clearance rate was highest in the first 6 months. Finally, as the duration of follow-up increased, the rate of complications increased. CONCLUSIONS Patients with residual stones after ESWL require close follow-up and timely adjuvant therapy. As the number and size of residual fragments increased, the risk of complications increased. A pelvic location was a favorable factor for spontaneous passage. Metabolic defects, if treated adequately, did not increase the regrowth rate. Although the complete clearance rate of CIRFs with repeated ESWL was lower than for the operative interventions, most patients improved with this modality.

Retroperitoneoscopic Ureterolysis and Reconstruction of Retrocaval Ureter

We report a case of circumcaval ureter in a symptomatic young man who was managed successfully by retroperitoneoscopic ureterolysis and ureteroureteral reconstruction using three-port technique.

Impact of Imaging and Thrombus Level in Management of Renal Cell Carcinoma Extending to Veins

Objectives: To evaluate the role of newer imaging modalities in the diagnosis and evaluation of management according to extent of renal vein (RV) or inferior vena cava (IVC) thrombi in patients with renal cell carcinoma. Material and Methods: Fifty-nine patients with renal cell carcinoma and tumor thrombus extension into the RV or IVC were studied. Diagnosis was based on contrast-enhanced CT, magnetic resonance imaging or color-Doppler ultrasonography. Surgical treatment was contemplated in 42 suitable patients and complete resection could be done in all but 3 cases. Results: There were 48 males and 11 females with mean age of 51.8 years. Isolated RV involvement was seen in 27 cases whereas IVC extension was present in 32 cases. The thrombus extent was infrahepatic in 62.5% (20/32) patients with IVC extension. With the newer imaging modalities like contrast-enhanced CT, color-Doppler ultrasound and/or magnetic resonance imaging, correct diagnosis of the extent of the thrombus was possible in 95% of the patients. The accuracy of color-Doppler ultrasound was same as magnetic resonance imaging in the evaluation of the extent of the thrombus. In the present series a median follow-up of 4 years revealed a high incidence of local and distant recurrences and decreased survival in patients presenting with advanced disease, who had venous wall invasion. Conclusions: The extent of RV or IVC thrombi can be accurately diagnosed with contrast-enhanced CT scan and in case of doubt color-Doppler ultrasound is a good alternative to magnetic resonance imaging. Management can be planned according to the level of the tumor thrombus. Invasion of the venous wall was found to be a bad prognostic factor affecting survival.

Management of Renal Angiomyolipoma in Complex Clinical Situations

Renal angiomyolipoma (AML) is associated with complex clinical situations such as tumour in a solitary kidney, bilateral, large or multicentric tumours or those associated with tuberous sclerosis (TS) or pregnancy. Management in these situations may be challenging. Fifteen patients (20 kidneys) were admitted with symptomatic AML over last 10 years. Eleven patients had one or the other complicating factor. Ten patients had a tumour of >10 cm, 4 had TS, 5 had multiple and bilateral tumours, 1 patient was pregnant and 1 had a solitary functioning kidney. With the newer imaging modalities correct diagnosis was possible in 12 cases and renal cell carcinoma (RCC) was suspected in 3 cases. Selective angioembolization (SAE) was done in 3 patients, which successfully controlled bleeding in all. Nephron-sparing surgery (NSS) was performed in 5 patients. Total nephrectomy was done in 4 cases, in 3 due to suspicion of RCC and in 1 due to extensive involvement of the kidney. Three patients with multiple and bilateral tumours were chosen for conservative treatment and none developed recurrence of bleeding on strict follow-up. In a pregnant patient, bleeding was successfully controlled with angioembolization. However, 1 patient with a solitary functioning kidney with large-sized tumour (20 × 18 cm) underwent NSS. In conclusion, the basis of management of AML is preservation of renal tissue, which can be effectively achieved with SAE or NSS. In a solitary functioning kidney, NSS or SAE is the ideal treatment, if feasible. The patients in the TS group are usually more complicated and require life-long follow-up after initial management with NSS or SAE. Pregnant AML patients can be safely managed with SAE. Conservative treatment without any intervention and regular follow-up may be more helpful in some patients with multiple, bilateral extensive tumours.

Prognostic Significance of p53 Nuclear Overexpression in Patients of Muscle Invasive Urinary Bladder Carcinoma Treated with Cystectomy

Introduction: The objective of the study was to determine the pattern of p53 expression in patients with muscle invasive bladder cancer treated with cystectomy and to assess the prognostic value of p53 expression in this group of patients. Materials and Methods: We retrospectively analyzed data of 100 patients who underwent cystectomy for invasive transitional cell carcinoma of the urinary bladder. These patients were seen at 3-monthly intervals during the first 2 years, 6-monthly in the third year, and yearly thereafter. Immunohistochemical analysis for p53 was done on paraffin-fixed tissues with DO-7 antibodies. The tumours with >30% cells staining for p53 proteins were considered p53 positive. Results: There were 95 males and 5 females with a mean age of 54 years. Two patients died in the perioperative period and were excluded from analysis. Over a median follow-up period of 2 years (range 3 months to 10 years) 62 patients are alive without disease while 36 had relapse and of these, 31 have died. The p53 expression was significantly related to stage and grade of the tumour. p53-negative tumours were more likely to be organ confined and of lower grade as compared to p53-positive tumours. The stage of tumour was significantly related to outcome but grade and p53 immunohistochemistry did not provide any prognostic information. Conclusions: p53 immunostaining was positive in 57% of muscle invasive urinary bladder tumours. The p53 positivity correlated well with the stage and grade of the disease, whereas it has no additional prognostic value.

Endoscopic management of an unusual foreign body in the urinary bladder leading to intractable symptoms

A 70-year old female patient presented with intractable lower abdominal painand recurrent urinary tract infection following an endoscopic bladder necksuspension. Investigations revealed it to be a case of suture and pledgetmigration leading to foreign body granuloma in urinary bladder. It is beingreported as an uncommon complication of endoscopic bladder necksuspension. An early endoscopic evaluation should be carried out in casesof unexplained lower urinary tract symptoms following any surgicalprocedure for incontinence. It is also appropriate to retrieve these foreignbodies endourologically without resorting to open surgery and thusextending safe, comfortable, and short postoperative course with good longterm results.

Ectopic prostate: An unusual bladder tumor

A 25-year-old man presented with gross painless hematuria. Cystoscopy revealed a smooth surfaced mass in the supratrigonal region. Complete transurethral resection of the mass was done. Histopathological examination revealed benign prostatic tissue situated ectopically.

Renal Cell Carcinoma in Cases of Adult Polycystic Kidney Disease: Changing Diagnostic and Therapeutic Implications

Renal cell carcinoma in adult polycystic kidney disease is of rare occurrence and poses a diagnostic and therapeutic challenge. We have treated three such patients in our department. One was male and two were females ranging in age from 20 to 60 years. All were diagnosed preoperatively with ultrasonography or contrast-enhanced CT. Radical nephrectomy was performed in all patients. During the follow-up no patient had recurrence in the contralateral kidney. One patient had local recurrence in the renal fossa and was treated with local radiotherapy and immunotherapy. In the past due to difficulty in diagnosis, invasive investigations like angiography were recommended and prophylactic contralateral nephrectomy was often undertaken. With the availability of reliable noninvasive investigations these patients can be diagnosed accurately and the contralateral kidney saved in most cases.

Primary Non-Hodgkin’s Lymphoma of Urinary Bladder

Primary extranodal lymphoma of the urinary bladder is a rare disorder that is diagnosed on the basis of histopathology and immunostaining. We report a case of diffuse B cell primary lymphoma of the urinary bladder and review the literature.

Is there a need for pelvic CT scan in cases of renal cell carcinoma

Objectives.To determine the necessity of pelvic computed tomography (CT) in patients of renal cell carcinoma (RCC).Materials and methods. We reviewed the records of 400 patients of RCC, who underwent treatment at our institution between January 1988 and February 2001. These patients were evaluated pre-operatively with ultrasonograms (USG) and contrast enhanced CT scan of the abdomen and pelvis. USG or CT scans of these cases were reviewed for presence of pathology in the pelvis, which were classified into 3 categories viz; benign and likely to be insignificant, benign and likely to be significant; and malignant.Results. Of the 400 cases, 114 were stage I, 68 were stage II, 99 were stage III and 119 were stage IV. In all patients, tumour was identified in the kidney on preoperative CT scan. Fourteen patients (3.5%) had an abnormality on pelvic CT. Five (1.25%) had category 1, three (0.75%) had category 2 and six (1.5%) had category 3 abnormality on pelvic CT. However, all these abnormalities in pelvis were detected prior to CT by other investigations (USG or plain x-ray). Of the six cases with malignant findings, two had superficial bladder cancer, one had RCC in a pelvic kidney and three had bone metastases in the pelvis. Conclusions. Pelvic CT doesnot offer additional information in the vast majority of cases with RCC and should be performed selectively. Thus the cost of diagnostic imaging in RCC can be reduced.