Brusabhanu Nayak

Outcomes of Robot-Assisted Laparoscopic Pyeloplasty in Children: A Single Center Experience

OBJECTIVES Open pyeloplasty is the standard treatment for ureteropelvic junction obstruction in children. The introduction of robotic surgical system has facilitated precise intracorporeal suturing and shortened the learning curve for minimal invasive procedures for the surgeons. There is sparse data over the outcomes of robot-assisted laparoscopic pyeloplasties in children. We describe our technique and outcomes of robotic pyeloplasty in children. PATIENTS AND METHODS Operative data for all patients undergoing a robot-assisted procedure at our center is prospectively recorded in a database. We retrieved data of patients below the age of 16 years undergoing robot-assisted pyeloplasty between July 2007 to March 2011 and evaluated their operative parameters, recovery, and functional outcomes. RESULTS In the period under review, 34 pediatric patients (mean age 12 years, range 5-15 years) underwent robot-assisted laparoscopic pyeloplasty at our center. All patients underwent unilateral pyeloplasty but one patient underwent a simultaneous contralateral pyelolithotomy. The mean total operative time (range) was 105 minutes (75-190 minutes), average dissection time and the anastomosis time was 23 minutes (20-58 minutes) and 46.5 minutes (28-70 minutes) respectively. The mean blood loss was 30 mL. Follow-up of 36, 24, 18, 12, and 6 months was completed in 14, 21, 24, 28, and 31 patients respectively. Postoperatively, one patient had an omentum herniation through the camera port site and another had an ileocaecal volvulus. With a mean follow-up of 28.5 months (2-56 months), the success rate was 97% (32/33), whereas postoperatively one patient had deterioration of function. CONCLUSION Robot-assisted laparoscopic pyeloplasty is a safe and effective minimally invasive treatment modality in children.

Paediatric percutaneous nephrolithotomy: Single-centre 10-year experience

INTRODUCTION Percutaneous nephrolithotomy (PCNL) is a standard management option for complex and large renal calculi. In children, there is some concern over potential perioperative complications. We reviewed our 10 years of experience of PCNL in children and present our data. MATERIAL AND METHODS Data for paediatric patients who underwent PCNL at our centre in the last decade were retrieved. PCNL was performed in standard prone position under fluoroscopic guidance. Patient characteristics, outcomes and complications were reviewed. Complications were graded according to the modified Clavien system. A comparison was also made between supracostal and infracostal accesses. RESULTS 95 children underwent PCNL in our institute in the last decade. 7 patients had bilateral PCNL. The most common presentation was flank pain (85%). 83% patients were stone-free after first PCNL and overall 94% were stone free after second-look PCNL and auxillary procedures. 6 cases had clinically insignificant residual fragments. Supracostal puncture was performed in 32 cases. Complications were higher in the supracostal puncture group (16 (50%)) and included fever in 11, sepsis in 2 and hydrothorax in 3 patients. There were 7 (10%) complications in the infracostal group: fever in 5 and perinephric collection in 2 patients. 16 patients had grade 1, 9 had grade 2 and another 2 cases developed grade 3 complications. CONCLUSION PCNL is a safe and effective procedure in children. It enables excellent stone clearance with minimal number of interventions.

Extraperitoneal robot-assisted laparoscopic radical prostatectomy: Initial experience

Objectives: To report our initial experience and technique of performing robot-assisted laparoscopic radical prostatectomy (RALP) with the extraperitoneal approach. Materials and Methods: Twenty-seven patients, between September 2010 to January 2012, were included in the study. All patients underwent extraperitoneal robot-assisted radical prostatectomy. Patients were placed supine with only 10-150 Trendelenburg tilt. The extraperitoneal space was developed behind the posterior rectus sheath. A five-port technique was used. After incision of endopelvic fascia and ligation of the deep venous complex, the rest of the procedure proceeded along the lines of the transperitoneal approach. Results: The mean patient age, prostate size and Gleason score were 67 ± 1.8 years, 45 ± 9.55 g and 6, respectively. The mean prostate-specific antigen (PSA) was 6.50 ng/mL. The mean time required for creating extraperitoneal space, docking of robot and console time were 22, 7 and 94 min, respectively. The mean time to resume full oral feeds was 22 ± 3.45 h. There were no conversions from extraperitoneal to transperitoneal or open surgery in our series. Pathological stage was pT1, pT2a and pT3b in 11 (40.74%), 14 (51.85%) and two (7.4%) patients, respectively. Two patients had positive surgical margins and two had biochemical recurrence at the last follow-up. Our mean follow-up was 12 ± 3.30 (2-17) months. The overall continence rate was 83.33% and 92.4% at 6 and 12 months, respectively. Conclusions: Extraperitoneal RALP is an efficacious, minimally invasive approach for patients with localized carcinoma of the prostate.

Perioperative outcome of initial 190 cases of robot-assisted laparoscopic radical prostatectomy - A single-center experience.

Objective: To analyze the perioperative outcome of the first 190 cases of robot-assisted laparoscopic radical prostatectomy performed at our center from July 2006 to December 2010. Materials and Methods: Operative and recovery data for men with localized prostate cancer undergoing robot-assisted radical prostatectomy at our center were reviewed. All surgeries were performed using the 4-arm da Vinci-S surgical robot. Preoperative data included age, body mass index (BMI), prostate specific antigen (PSA) level, prostate weight, biopsy Gleason score and TNM staging, while operative and recovery data included total operative time, estimated blood loss, complications, hospital stay and catheter time. These parameters were evaluated for the safety and efficacy of this procedure in our center. Results: The mean age of our patients was 65 ± 1.2 years. The mean BMI was 25.20 ± 2.88 and the median PSA was 14.8 ng/ml. Majority of our patients belonged to clinical stage T2 (51.58%). The mean total operative time was 166.44 ± 11.5 min. Six patients required conversion to open procedure and there was one rectal injury. The median estimated blood loss was 302 ± 14.45 ml and the median duration of hospital stay was 4 days. The overall margin positivity rate was 12.63%. Conclusion: Despite our limited robotic surgery experience, our perioperative outcome and complication rate is comparable to most contemporary series. Robot-assisted laparoscopic prostatectomy (RALP) is easy to learn and provides the patient with the benefits of minimally invasive surgery with minimal perioperative morbidity.

Robotic versus conventional laparoscopic pyeloplasty: A single surgeon concurrent cohort review

INTRODUCTION The increasing availability of robotic devices has led to an increase in their use for procedures such as pyeloplasty, which have been conventionally performed laparoscopically or through open surgery. We perform both laparoscopic and robotic-assisted pyeloplasty routinely and have compared these techniques in a set of concurrent cohorts, operated by the same surgeon. MATERIALS AND METHODS A chart review was performed of all cases of Robot-assisted laparoscopic pyeloplasty (RALP) and conventional laparoscopic pyeloplasty (CLP) performed by a single surgeon, from September 2006 to July 2010. The choice of procedure depended upon the availability of the robot on the given day. A lateral transperitoneal approach was used in all cases. All anastomoses were stented antegrade. A diuretic renogram was obtained in all patients between six to twelve weeks after stent removal. Success was defined as a resolution of symptoms with non-obstructive outflow on the renogram. RESULTS Thirty patients underwent 31 laparoscopic pyeloplasties (20 RALPs and 11 CLPs), with one patient undergoing bilateral simultaneous robotic procedures. The robotic procedures were superior in terms of shorter operating time by 20 minutes on an average. Furthermore, 35% of the robotic procedures were performed in under 90 minutes, while the minimum time taken for laparoscopy was 110 minutes. All procedures in both cohorts were successful with no complications in either group. The surgeon recorded subjective ergonomic benefits with the use of the robot. CONCLUSIONS Robotic assistance helps decrease the operative time for laparoscopic pyeloplasty. It seems ergonomically superior for the surgeon, allowing multiple procedures in the same list. These may be important benefits in busy centers.

Percutaneous Management of Systemic Fungal Infection Presenting As Bilateral Renal Fungal Ball.

Abstract Background: Zygomycoses are uncommon, frequently fatal diseases caused by fungi of the class Zygomycetes. The majority of human cases are caused by Mucorales (genus—rhizopus, mucor, and absidia) fungi. Renal involvement is uncommon and urine microscopy, pottasium hydroxide mount, and fungal cultures are frequently negative. Case Presentation: A twenty-one-year-old young unmarried lady presented to our emergency department with bilateral flank pain, fever, nausea, and decreased urine output of one-month duration. She was found to have azotemia with sepsis with bilateral hydronephrosis with a left renal pelvic obstructing stone. Even after nephrostomy drainage and broad spectrum antibiotics, her condition worsened. She developed disseminated fungal infection, and timely systemic antifungal followed by bilateral nephroscopic clearance saved the patient. Conclusion: Although renal fungal infections are uncommon, a high index of suspicion and early antifungal and surgical intervention can give favorable outcomes.

Primitive neuroectodermal tumors of kidney: Our experience in a tertiary care center

OBJECTIVES Primitive neuroectodermal tumors (PNET) are rare highly aggressive neoplasms. The diagnosis is made by histopathology with the support of immunohistochemistry (IHC) and cytogenetics. The aggressive multimodality treatment is recommended for the management of these tumors. The purpose of our study is to review our experiences in the diagnoses and treatment of PNET of the kidneys. MATERIALS AND METHODS We retrospectively reviewed the data of all the patients, who were treated for the PNET of the kidneys at our institute between April and March 2011 and compared with the available literature. RESULTS A total of eight patients were treated for PNET of the kidney. Out of the eight patients, four were males and four females. Nearly 50% of our patients had inferior vena caval thrombus at the time of presentation. The diagnosis was made on histopathology supported by IHC. Out of the eight patients, one patient had intraoperative death due to massive pulmonary thromboembolism and another died on the 7th post-operative day due to disseminated intravascular coagulation and multiorgan failure. Rest six patients were treated with post-operative chemotherapy or a combination of chemotherapy and radiotherapy. For these six patients, overall median survival was 45 months with a 3 year disease-free survival of 66% and 5 year survival of 44%. CONCLUSIONS PNET of the kidneys are rare peripheral neuroectodermal tumors with an aggressive clinical course. These tumors carry a very poor prognosis. An aggressive treatment approach using a combination of surgery, chemotherapy and radiotherapy is recommended for a reasonable survival in these tumors.

Pregnancy with a ruptured renal artery aneurysm: management concerns and endovascular management

Renal artery aneurysm (RAA) affects <0.01% of the general population. Rupture of RAA is a rare catastrophe that can complicate pregnancy and is associated with high maternal and fetal mortality. Presentation is usually acute with severe flank pain, with or without haematuria, and haemodynamic instability requiring exploration and nephrectomy. A 26-year-old pregnant woman had sudden onset of gross haematuria and on evaluation was found to have a left RAA with an intrapelvic rupture and thinned out renal parenchyma. In view of the high risk of surgery, she was managed with endovascular placement of an Amplatzer type II vascular plug. Immediate and complete occlusion of blood flow was achieved and nephrectomy was avoided. Follow-up Doppler ultrasound revealed a reduced 5 cm mass in the left renal fossa with no internal flow and plug in position. She is currently on follow-up with 3–6 monthly ultrasonography not requiring any intervention.

Letter to the editor regarding the article “Evaluation of pain perception associated with use of the magnetic-end ureteric double-J stent for short-term ureteric stenting”

We recently reviewed the article by Sevcenco et al. [1] in our journal club. The authors described a novel magnetic end ureteral stent retrieved by a special catheter tip with a complementary magnetic end. The magnetic ureteral stent retrieval with the special catheter was compared with flexible cystoscopic retrieval of the standard ureteral stent for pain perception. The results of their data showing significantly less pain perception with magnetic ureteral stent retrieval were appealing for implementation of such stents on regular basis. But, there seem to be some queries to be clarified. Altarac et al. describe a similar stent with a permanent magnet on the distal part. The retrieval device was a Nelaton catheter with a magnet at the tip [2]. However, removal was not always successful due to lack of mobility of the catheter and decoupling of the magnets [3]. Hence, it is worth discussing whether the magnetic tip stents were retrieved in the first attempt in all patients? Also, how many times the special catheter needed to be re-inserted while it may induce urethral trauma as the tip contains complementary magnet tip and not the blunt tip as of Foley’s catheter. Finally, we would recommend the authors to give some insights regarding bladder fill amount before inserting the special catheter as it may influence the position of the bladder coil of the stent depending on the amount of urine in the bladder. We look forward to the author’s reply to clarify our queries.

Re: Tom J.H. Arends, Ofer Nativ, Massimo Maffezzini, et al. Results of a Randomised Controlled Trial Comparing Intravesical Chemohyperthermia with Mitomycin C Versus Bacillus Calmette-Guerin for Adjuvant Treatment of Patients with Intermediate- and High-risk Non–Muscle-invasive Bladder Cancer. Eur Urol 2016;69:1046–52

We read with great interest the paper by Arends et al. [1] presenting the first randomized controlled trial comparing intravesical bacillus Calmette-Guérin (BCG) instillations with intravesical chemohyperthermia (CHT) among patients with intermediateand high-risk non–muscleinvasive bladder cancer (NMIBC). The authors reported a higher 24-mo recurrence-free survival with CHT therapy compared with BCG therapy. This paper raises an important concern of ideal adjuvant intravesical treatment after endoscopic resection of bladder tumor. However, certain aspects of this research paper need further clarification. Intermediateand high-risk tumors form a separate category in the treatment algorithm of NMIBC and grouping them together to study the recurrence-free survival introduced a bias in the study. The rate of recurrence varies from 45% in intermediate-risk group to 54% in the high-risk group, with the relative risks of recurrence in the low-risk versus intermediate-risk and high-risk groups being 1.37 and 1.87, respectively [2]. Therefore, we would like to know if the authors had performed the subgroup analysis for intermediateand high-risk category to compare the CHT therapy with BCG therapy separately. As per the recent European Association of Urology guidelines, intravesical full-dose BCG instillation for 1–3 yr is the recommended treatment for high-risk NMIBC, while both intravesical BCG therapy and chemotherapy can be offered to the patients with intermediate risk [3]. We would like to raise an ethical concern regarding the inferior treatment (intravesical chemotherapy) being offered to the patients with high-risk disease included in this study.