Apul Goel

Upper and mid-ureteric stones: a prospective unrandomized comparison of retroperitoneoscopic and open ureterolithotomy

Objectives To review our experience of retroperitoneoscopic ureterolithotomy (RPUL) and to compare the results with those from open surgery.

Retroperitoneoscopic nephrectomy and nephroureterectomy for benign nonfunctioning kidneys: a single-center experience

OBJECTIVES To report our experience of 185 cases of retroperitoneoscopic nephrectomy and nephroureterectomy for benign nonfunctioning kidneys with various modified techniques for differing etiologies. The feasibility, complications, and long-term outcomes are discussed. METHODS The present study comprised 185 patients who underwent retroperitoneoscopic nephrectomy or nephroureterectomy during a 57-month period beginning July 1995. All procedures were done using the retroperitoneoscopic approach. Thirty-two patients had a history of previous surgery, 20 patients had a percutaneous nephrostomy, and 12 patients had mild renal impairment. RESULTS Retroperitoneoscopic nephrectomy and nephroureterectomy were completed successfully in 167 patients. Eighteen patients required conversion to open surgery, 4 on an emergent basis and 14 electively. The mean operating time was 100 minutes (range 45 to 240), mean blood loss was 133 mL (range 30 to 1200), and mean hospital stay was 3 days (range 2 to 8). A total of 37 complications (16.2% were minor and 3.78% were major) occurred. Re-intervention was needed in 1 patient. No mortality resulted. Previous surgery, percutaneous nephrostomy, and chronic renal impairment did not affect the outcome. Apart from one incisional hernia, no long-term complications occurred. CONCLUSIONS Retroperitoneoscopic nephrectomy and nephroureterectomy can be performed safely and successfully with obvious advantages for benign nonfunctioning kidneys regardless of the etiology or pathogenesis, with modifications in the approach in very difficult cases. Patients with conditions often considered to be contraindications (ie, genitourinary tuberculosis, pyonephrosis, history of previous surgery, percutaneous nephrostomy, stone disease, chronic renal failure, and horseshoe kidney) can also be successfully treated by skillful dissection and modifications in the surgical technique.

Taurine – a possible fingerprint biomarker in non-muscle invasive bladder cancer: A pilot study by 1H NMR spectroscopy

Urinary bladder cancer is a major epidemiological problem that continues to grow each year. It opens avenues for investigative research for the identification of new disease markers and diagnostic techniques. In this pilot study, utility of non-invasive (1)H NMR spectroscopy has been evaluated for probing the metabolic perturbations occurring in non-muscle invasive urinary bladder cancer. (1)H NMR spectra of urine of bladder cancer patients and controls (healthy and urinary tract infection/bladder stone) (n = 103) were acquired at 400MHz. The non-overlapping resonances of citrate, dimethylamine, phenylalanine, taurine and hippurate were first identified and then quantitated by (1)H NMR spectra, with respect to an external reference sodium-3-trimethylsilylpropionate (TSP). The concentrations of these metabolites were then statistically analyzed. The cancer patients showed significant (p < 0.05) variations in concentration of hippurate and citrate as compared with healthy controls and benign controls. The significant elevation in concentration of taurine was observed in urine of bladder cancer patients, which was below the sensitivity limit of 400MHz in control cases. However, stages Ta, T1 and carcinoma in situ (CIS) cannot be differentiated on the basis of altered metabolite indices but their composition may reflect the biochemical alterations in metabolism of cancer cells.

Minimally Invasive Retroperitoneoscopic Ureterolithotomy

PURPOSE We assessed the efficacy of modified technique of retroperitoneal ureterolithotomy for managing ureteral stones. MATERIALS AND METHODS Between December 1999 and March 2002, 31 patients underwent retroperitoneal ureterolithotomy. In most cases only 3 ports (a 10 mm., 2 5 mm. and in a few 2, 3 mm.) were used without any ureteral stent or catheter. The stone was removed from the primary port site, while visualizing retrieval through the 3/5 mm. port using fine laparoscope. Ureterotomy closure was performed by intracorporeal interrupted sutures of 4-zero polyglactin. RESULTS The 20 males and 11 females had a mean age of 38.5 years. Mean operative time was 67 minutes and mean hospital stay was 2.4 days. The mean analgesic requirement was 42.2 mg. meperidine. Mean followup was 8 months. There were no significant postoperative complications except persistent urine leakage in 2 patients 48 hours after surgery. An internal stent was placed and leakage subsided without any consequences. CONCLUSIONS The modified, minimally invasive technique of retroperitoneal ureterolithotomy is highly effective and efficient without an associated increase in the complication rate.

Evaluation of role of retroperitoneoscopic pyelolithotomy and its comparison with percutaneous nephrolithotripsy.

Objectives: To evaluate the role ofretroperitoneoscopic pyelolithotomy (RPPL) forthe management of renal pelvic calculus and itscomparison with percutaneous nephrolithotripsy(PCNL).Patients and methods: Eighteen RPPLs wereperformed between March 1995 and March 2002,and 16 out of these were comparedretrospectively with 12 cases of PCNL performedin the year 2000 for solitary renal pelvicstone more than 3-cm in size.Laparoscopicpyelolithotomy was carried out withretroperitoneal approach and subsequent tostone removal pyelotomy was sutured withintracorporeal interrupted sutures.Results: The two groups were similar asregards the patient age and sex. The mean stonesizes in RPPL and PCNL groups were 3.6 and4.2 cm respectively (p < 0.006). There were 2conversions in the RPPL group due to stonemigration into calyx and dense perirenaladhesions making dissection difficult. The meanoperating time was 142.18 min for RPPL ascompared to 71.6 min for PCNL (p < 0.000). Theblood loss was 173.1 ml in RPPL as compared to147.9 ml for PCNL (p NS). The mean hospitalstay was 3.8 and 3-days in RPPL and PCNL groupsrespectively.Conclusions: Laparoscopic pyelolithotomytakes longer to perform, more invasive, lesscosmetic and requires more skills at present ascompared to PCNL. In this limited study it isclearly demonstrated that PCNL is the better treatment modality for renal stones andlaparoscopy should be offered to those whoneeds adjunctive procedure such as pyeloplastyor puncture during PCNL under vision.

Survivin: A molecular biomarker in cancer

Survivin, a member of the inhibitor of apoptosis (IAP) protein family that inhibits caspases and blocks cell death, is highly expressed in most cancers and is associated with a poor clinical outcome. Survivin has consistently been identified by molecular profiling analysis to be associated with high tumour grade cancers, different disease survival and recurrence. Polymorphisms in the survivin gene are emerging as powerful tools to study the biology of the disease and have the potential to be used in disease prognosis and diagnosis. The survivin gene polymorphisms have also been reported to influence tumour aggressiveness as well as survival of cancer patients. The differential expression of survivin in cancer cells compared to normal tissues and its role as a nodal protein in a number of cellular pathways make it a high target for different therapeutics. This review discusses the complex circuitry of survivin in human cancers and gene variants of survivin, and highlights novel therapy that targets this important protein.

Prospective evaluation of complications using the modified Clavien grading system, and of success rates of percutaneous nephrolithotomy using Guy's Stone Score: A single-center experience

Introduction and Objectives: To prospectively document the perioperative complications of percutaneous nephrolithotomy (PCNL) using the modified Clavien grading system. Evaluation of complications and clearance rates according to stone complexity using the validated Guys Stone Score (GSS) was also done. Materials and Methods: A total of 221 renal units underwent 278 PCNL procedures at a urology resident training center between September 2010 and September 2011 and data were recorded prospectively in our registry. Patients with co-morbidities like diabetes, renal failure, hypertension and cardiopulmonary diseases were excluded. Stone complexity was classified according to the GSS while peri-operative complications were recorded using the modified Clavien grading system. Results: Two hundred and forty-five complications were encountered in 278 PCNL procedures involving 116 renal units (41.72%). Complications of Grades 1, 2, 3a, 3b, 4a, 4b and 5 were seen in 52 (18.7%), 122 (43.8%), 42 (15.1%), 18 (6.4%), 6 (2.1%), 4 (1.4%) and 1 (0.3%) renal units respectively. There were 68, 98, 50 and 5 renal units in GSS I, II, III and IV groups, respectively. All grades of complications were more common in GSS III and IV (P<0.05). For GSS I, II, III and IV 100%, 74%, 56% and 0% of renal units, respectively, were stone-free after one session and 0%, 24%, 44% and 60% respectively needed two sessions to be stone-free. Conclusion: Although the complication rates were higher most were of low grade and self-limiting. Complications were significantly more common with higher GSS and the GSS effectively predicted stone-free rates.

Clavien Classification of Semirigid Ureteroscopy Complications: A Prospective Study

OBJECTIVE To prospectively report and grade the perioperative complications of ureteroscopy (URS) for stone removal using a semirigid ureteroscope with the modified Clavien classification system and to identify the determinants of the complications. METHODS From August 2010 to November 2011, the prospective data from 120 consecutive patients (71 men and 49 women) who had undergone primary unstented URS at a resident training center were analyzed. Patients with renal failure, pyonephrosis, diabetes mellitus, hypertension, and congenital ureteral abnormalities were excluded (n = 29). The data recorded included patient demographics, stone size and location, and complications according to the modified Clavien classification system. RESULTS Of the 120 patients, 36 (30%) experienced 79 complications. The stone size was ≤ 10 mm in 56 and >10 mm in 64 patients. The stone location was the lower, mid-, and upper ureter in 62, 58, and 3 patients, respectively. The latter 3 were excluded because of the small sample size. Grade 1, 2, 3a, 3b, 4a, and 4b complications were encountered in 46 (38.3%), 18 (15%), 3 (2.5%), 10 (8.3%), 1 (0.8%), and 1 (0.8%) patient, respectively. The incidence of complications was greater for stones >10 mm, a mid- versus distal ureteral location, impacted stones, and surgery performed by a resident. The incidence was not affected by patient sex, stone laterality, or lithotripter type. The patients with complications had a longer operative time (75 vs 46.5 minutes), longer hospitalization (4.8 vs 1.5 days), and lower stone-free rate (64% vs 97%). CONCLUSION Most complications were grade 1-3 (98%), and grade 4 complications were rare (<2%) with URS. The present study is probably the first to prospectively study the complications of URS using the modified Clavien classification system.

Retrograde Intrarenal Surgery vs Extracorporeal Shock Wave Lithotripsy for Intermediate Size Inferior Pole Calculi: A Prospective Assessment of Objective and Subjective Outcomes

OBJECTIVE To assess objective and subjective outcomes of retrograde intrarenal surgery (RIRS) and extracorporeal shock wave lithotripsy (SWL) for the treatment of intermediate size (1-2 cm) inferior calyceal (IC) stones in a prospective randomized fashion. METHODS Between March 2011 and January 2013, 70 symptomatic adults who had isolated IC stone between 10 and 20 mm underwent RIRS or SWL by computer-generated pseudorandom assignment (1:1). Success rate, mean procedure time, hospital stay, pain score on day 1 and 2 using visual analog scale, analgesic requirement after discharge, complications, retreatment rate, auxiliary procedure, and patient-reported outcomes (using self-made nonvalidated questionnaire) were compared. RESULTS Baseline parameters and mean stone size (SWL 16.45 ± 2.28 mm, RIRS 15.05 ± 3.56 mm; P = .0542) were comparable. Success rate was significantly higher after a single session of RIRS compared with 3 sessions of SWL (85% vs 54%; P = .008). Retreatment rate (65% vs 5.7%; P = .0001) and auxiliary procedure (45% vs 8%; P = .0009) were significantly higher in SWL. Pain score on postoperative day 1 and 2 was significantly higher in RIRS, but patients with SWL required significantly more analgesics afterward. Most of the complications were of Clavien grade I and/or II in both groups. Average time to return to normal activity and voiding symptoms were significantly higher in RIRS. Overall satisfaction score (2.17 ± 1.24 vs 2.82 ± 1.17; P = .026) was significantly higher in RIRS than SWL. CONCLUSION For the treatment of intermediate size IC calculi, RIRS is superior to SWL in terms of objective and subjective outcomes.

Cost‐effective laparoscopic pyeloplasty: Single center experience

Objective:  Laparoscopic pyeloplasty (LPP) is a minimally invasive treatment option for ureteropelvic junction (UPJ) obstruction. We report here our experience of performing cost‐effective LPP on 24 patients at a single center.