Chandra Shekhar Biyani

Vesical Lithiasis: Open Surgery Versus Cystolithotripsy Versus Extracorporeal Shock Wave Therapy

We compare the different methods of treating vesical calculi to establish the most effective and safe modality. Of 128 patients with bladder calculi 5 underwent an open operation, 80 underwent mechanical cysto-lithotripsy and 43 underwent extracorporeal shock wave therapy. Severe complications included hematuria, bladder perforation and mucosal injury in the mechanical cystolithotripsy group. We find extracorporeal shock wave therapy to be a simple, effective and safe modality for the management of vesical lithiasis.

Ureteroscopic Endopyelotomy with the Holmium:YAG Laser

Objective: Various modalities ranging from acucise balloon to endoincision with electrocautery, cold knife, and lasers have been used to treat ureteropelvic junction obstruction (UPJO). We assessed the intermediate effectiveness of endopyelotomy with the holmium(Ho):YAG laser.Patients and Methods: Between November 1994 and May 1998, 20 patients with 16 primary and 4 secondary symptomatic UPJO were treated. All patients were evaluated clinically and radiologically before and after the procedure at 3 months, and yearly thereafter. The mean follow–up was 34 months (12–38 months).Results: A total of 22 procedure were performed on 20 patients with an average operating time of 44.3 min and mean hospital stay of 1.9 days. All patients were stented after the procedure for 6 weeks. Complication included urinoma (1) and guidewire fracture in 1 patient. 15 patients had a successful outcome determined by a diuretic renography and/or Whitaker test. Three patients with poor preoperative renal function (<25%) had an unsatisfactory outcome. There were 2 failures and they were treated with nephrectomy (1) and open pyeloplasty (1).Conclusions: A controlled, precise, safe and almost ‘bloodless’ endopyelotomy can be performed with the holmium laser. Success rate tends to be poor in patients with poor renal function.

Dendritic Cell-Based Immunotherapy of Renal Cell Carcinoma

Dendritic cells potently stimulate antigen-specific immune responses and recent data indicate that they are also capable of eliciting antitumor immune responses. We are performing a pilot study which tests the safety and efficacy of antigen-loaded, cultured blood dendritic cells in patients with metastatic renal cell carcinoma. Dendritic cells are simultaneously pulsed with lysate from autologous tumor cells and with the immunogenic protein keyhole limpet hemocyanin. During the pulse, the cells are activated with a combination of tumor necrosis factor-alpha and prostaglandin E2. Patients receive 5-10 X 10(6) dendritic cells per intravenous infusion and up to six infusions at monthly intervals. The first results demonstrate that this treatment modality is very well tolerated and can be associated with strong immunological and clinical responses. The present article discusses the importance of dendritic cell maturation and the role of helper antigens in dendritic cell-based immunotherapy.

TRANSURETHRAL INCISION OF THE PROSTATE USING THE HOLMIUM: YAG LASER: A CATHETERLESS PROCEDURE

AbstractPurpose: Transurethral incision of the prostate is a well established technique for relieving bladder outflow obstruction caused by prostate glands less than 30 gm. We present data showing that the holmium:YAG laser can prevent postoperative catheterization without compromising the outcome of surgery.Materials and Methods: We prospectively followed 100 men an average of 62 years old with symptomatic bladder outflow obstruction and a benign prostate gland less than 30 gm. clinically in whom serum prostate specific antigen was less than 4 micro g./l. They were assessed using International Prostate Symptom Score, urinary flow rate, post-void residual estimation and sexual function questionnaires preoperatively, and 6 weeks, and 1 and 2 years postoperatively. With the patient under general anesthesia a single incision was made from the ureteral orifice to the verumontanum and out to fat using holmium:YAG laser energy transmitted through a 400 nm. fiber sheathed in a ureteral catheter.Results: A total ...

Xanthogranulomatous Pyelonephritis with Bilateral Nephrocutaneous Fistulae

This case report describes a patient with bilateral nephrocutaneous fistulae and xanthogranulomatous pyelonephritis. Contralateral involvement of the psoas muscle is a rare occurrence and has not been previously documented.

Calculus disease in duplex system-role of extracorporeal shockwave lithotripsy

We report 8 patients with urolithiasis in a duplex system. These patients (7 males and 1 female) underwent 16 extracorporeal shock wave lithotripsy (ESWL) treatments. Five had renal and 3 had ureteral stones. The mean stone size was 21 mm (12-54 mm). Five patients had incomplete and 3 had complete duplication, of which one had an associated horseshoe kidney. Retrograde ureteropyelography was done in all the patients and in 7 a JJ stent was inserted. The JJ stent could not be inserted in 1 patient with incomplete duplication and retrograde catheterization with saline infusion was used as an auxiliary procedure. One patient with complete duplication had stones in both the ipsilateral ureters with a stone bulk of 54 mm and required two JJ stents. Only 1 paediatric patient required general anaesthesia. The 3-month stone-free rate was 100%.

Extracorporeal Shockwave Therapy for Urolithiasis with Renal Insufficiency

Management of urolithiasis with renal insufficiency poses a multidimensional nephrourological situation. Sixty-two patients of potentially reversible calculus obstructive nephropathy and azotemia were treated with extracorporeal shockwave lithotripsy (ESWL) on the Siemans Lithostar. These patients were treated under sedoanalgesia after the initial therapeutic ureteral stenting. Satisfactory fragmentation was achieved in all the patients. The incidence of major complications was 3.2% with an 85% stone-free rate at 6 months. Pre- and post-ESWL hemodialysis was required in 14 and 3 patients, respectively. All patients had variable levels of improvement in the renal function. Proper selection of cases is mandatory for satisfactory outcome. The combination of ureteral stenting followed by phased ESWL represents an attractive alternative to traditional surgical management of stones with renal insufficiency.

Postoperative Spindle Cell Nodule of the Bladder: A Diagnostic Problem

A case of postoperative spindle cell nodule of the bladder is reported. Initial pathological analysis was interpreted as leiomyosarcoma for which the patient underwent radical cystectomy, but subsequent reviews were consistent with a postoperative spindle cell nodule. Recognition of this benign, yet rare lesion is of significant importance to urologists, pathologists, and to the patient who may undergo extensive surgical procedure unnecessarily.

TRANSURETHRAL INCISION OF THE PROSTATE USING THE HOLMIUM: YAG LASER

PURPOSE Transurethral incision of the prostate is a well established technique for relieving bladder outflow obstruction caused by prostate glands less than 30 gm. We present data showing that the holmium:YAG laser can prevent postoperative catheterization without compromising the outcome of surgery. MATERIALS AND METHODS We prospectively followed 100 men an average of 62 years old with symptomatic bladder outflow obstruction and a benign prostate gland less than 30 gm. clinically in whom serum prostate specific antigen was less than 4 microg./l. They were assessed using International Prostate Symptom Score, urinary flow rate, post-void residual estimation and sexual function questionnaires preoperatively, and 6 weeks, and 1 and 2 years postoperatively. With the patient under general anesthesia a single incision was made from the ureteral orifice to the verumontanum and out to fat using holmium:YAG laser energy transmitted through a 400 nm. fiber sheathed in a ureteral catheter. RESULTS A total of 97 patients voided without postoperative catheterization. Average International Prostate Symptom Score decreased from 19.2 to 3.7 at 6 weeks and it remained improved at 2 years (average 3.5). Reciprocal results were achieved with improvement in average urinary flow rate from 9.79 to 19.23 and 18.27 ml. per second at 6 weeks and 2 years, respectively. Residual urine measurement decreased from 133.6 ml. preoperatively to 27 and 10 ml. at 6 weeks and 2 years, respectively. All 77 patients potent preoperatively remained so, although retrograde ejaculation developed in 8. CONCLUSIONS The holmium:YAG laser allows transurethral prostatic incision to be performed without the need for postoperative catheterization while maintaining efficacy.

Laparoscopic nephrectomy for benign disease: The early learning curve

SummaryThe objective is to present our experience and results with laparoscopic nephrectomy for poorly functioning kidney and compare them with reported series. Ten symptomatic patients (five men and five women, age range 14–62) with poorly functioning kidney have been treated by laparoscopic nephrectomy between July 1992 and October 1995. Seven procedures were completed successfully. Complications occurred in two cases; one of them underwent conversion to open nephrectomy. Mean operating time was 220 min (210 for laparoscopically completed procedures) and total inpatient stay was 6 days (five for laparoscopically completed procedures). Laparoscopic nephrectomy is feasible and has potential advantages compared to open nephrectomy. These need to be evaluated with more extensive studies.