George P. Abraham

Ex-vivo nephron-sparing surgery and autotransplantation for renal tumours: Revisited

INTRODUCTION We studied the feasibility of ex-vivo nephron-sparing surgery and autotransplantation for complex renal tumours. We also studied the role of laparoscopy in these situations. METHODS All patients who underwent renal autotransplantation for renal tumour at our centre were included in this retrospective study. Patient profiles were recorded in detail. Operative and postoperative details were also recorded. RESULTS Our series includes 3 patients. Two patients had complex renal cell carcinoma and 1 patient had bilateral large angiomyolipoma. In first 2 patients, laparoscopic approach was used for nephrectomy. Operative time for case 1, 2 and 3 was 5.5, 4.5, 8 (right side) and 6 (left side) hours, respectively. Cold ischemia time was 110, 90, 150 and 125 minutes, respectively. One patient required temporary postoperative hemodialysis. CONCLUSION Ex-vivo nephron-sparing surgery and autotransplantation still remain a viable option for complex renal tumours. It offers satisfactory renal functional outcome with acceptable morbidity. The laparoscopic approach should be used whenever possible to reduce morbidity.

Laparoscopic extirpation of giant adrenal ganglioneuroma.

Laparoscopic adrenalectomy is the standard of care for management of adrenal neoplasms. However, large sized adrenal lesions are considered as relative contraindication for laparoscopic extirpation. We report laparoscopic excision of giant ganglioneuroma of adrenal gland in a 33-year-old female patient. Patient was presented with left loin pain of 2 months duration. Computed tomography (CT) scan was suggestive of non-enhancing left suprarenal mass measuring 17 × 10 cm. Preoperative endocrine evaluation ruled out functional adrenal tumor. Patient underwent transperitoneal excision of suprarenal mass. The lesion could be completely extirpated laparoscopically. Duration of surgery was 250 minutes. Estimated blood loss was 230 milliliters. Specimen was extracted through pfannenstiel incision. No significant intraoperative or postoperative happenings were recorded. Microscopic features were suggestive of ganglioneuroma of adrenal gland.

Laparoscopic management of recurrent ureteropelvic junction obstruction following pyeloplasty

Objective: The aim was to analyze the operative, postoperative and functional outcome of laparoscopic management of previously failed pyeloplasty and to compare operative and postoperative outcome with laparoscopic pyeloplasty for primary ureteropelvic junction obstruction (UPJO). Materials and Methods: All patients who underwent laparoscopic management for previously failed dismembered pyeloplasty were analyzed in this study. Detailed clinical and imaging evaluation was performed. Transperitoneal approach was followed to repair the recurrent UPJO. Operative, postoperative, and follow-up functional details were recorded. Operative and postoperative outcomes of laparoscopic redo pyeloplasty were compared with that of laparoscopic primary pyeloplasty. Results: A total of 16 patients were managed with laparoscopic approach for previously failed pyeloplasty. Primary surgical approach for dismembered pyeloplasty was open in 11, laparoscopy in four patients and robotic assisted in one patient. Fifteen were treated with redo pyeloplasty and one with ureterocalicostomy. Mean operative time was 191.25 ± 24.99 min, mean duration of hospital stay was 3.2 ± 0.45 days and mean follow-up duration was 29.9 ± 18.5 months with success rate of 93.3%. Operative time was significantly prolonged with redo pyeloplasty group compared with primary pyeloplasty group (191.25 ± 24.99 vs. 145 ± 22.89, P = 0.0001). Conclusion: Laparoscopic redo pyeloplasty is a viable option with a satisfactory outcome and less morbidity.

Laparoscopic Reconstruction for Obstructive Megaureter: Single Institution Experience with Short- and Intermediate-Term Outcomes

PURPOSE To narrate our experience with laparoscopic reconstruction of obstructive megaureter (MGU) and assess the intermediate-term outcome achieved. PATIENTS AND METHODS Patients were evaluated in detail including presenting complaints, biochemical profile, and imaging (ultrasonography [USG], diuretic renography [DR], magnetic resonance urography [MRU], and voiding cystourethrography [VCUG]). All patients with a diagnosis of obstructive MGU and salvageable renal unit were offered laparoscopic reconstruction. The standard laparoscopic exercise included ureteral adhesiolysis until the pathologic segment, dismemberment, straightening of the lower ureter, excisional tapering, and a nonrefluxing ureteroneocystostomy. Operative and postoperative parameters were recorded. Patients were evaluated postprocedure on a 3-month schedule. Follow-up imaging included USG and VCUG at 6 months and 1 year postprocedure and then at yearly intervals. MRU and DR were repeated at 1 year postprocedure. RESULTS Twelve patients (13 units-11 unilateral, and 1 bilateral) underwent laparoscopic tailoring and reimplantation for obstructive MGU. Mean age was 98.6 months. All patients were male. Mean body mass index was 17.69 kg/m(2). Presenting complaints were flank pain (n=8) and recurrent urinary infection (n=12). All procedures were completed via a laparoscopic approach. Mean operation duration was 183 minutes, and mean blood loss was 75 mL. Mean duration of hospital stay was 2.1 days. No major intraoperative or postoperative happenings were recorded. All patients were asymptomatic at follow-up with stable renal profile. Follow-up MRU revealed a decrease in ureteral and upper tract dilatation with satisfactory drainage in all. Follow-up VCUG demonstrated grade I vesicoureteral reflux in one patient. Eight patients completed 3-year follow-up with a satisfactory outcome. CONCLUSION Laparoscopic reconstruction of obstructive MGU offers satisfactory immediate- and intermediate-term outcome without undue prolonged morbidity.

Laparoscopic reconstruction of iatrogenic-induced lower ureteric strictures: Does timing of repair influence the outcome?

Context: Influence of timing of repair on outcome following laparoscopic reconstruction of lower ureteric strictures Aims: To assess the influence of timing of repair on outcome following laparoscopic reconstruction of lower ureteric strictures in our adult patient population. Settings and Design: Single surgeon operative experience in two institutes. Retrospective analysis. Materials and Methods: All patients were worked up in detail. All patients underwent cystoscopy and retrograde pyelography prior to laparoscopic approach. Patients were categorised into two groups: early repair (within seven days of inciting event) and delayed repair (after two weeks). Operative parameters and postoperative events were recorded. Postprocedure all patients were evaluated three monthly. Follow-up imaging was ordered at six months postoperatively. Improvement in renal function, resolution of hydronephrosis and unhindered drainage of contrast through the reconstructed unit on follow-up imaging was interpreted as a satisfactory outcome. Statistical Analysis Used: Mean, standard deviation, equal variance t test, Mann Whitney Z test, Aspin-Welch unequal variance t test. Results: Thirty-six patients (37 units, 36 unilateral and 1 simultaneous bilateral) underwent laparoscopic ureteral reconstruction of lower ureteric stricture following iatrogenic injury - 21 early repair (Group I) and 15 delayed repair (Group II). All patients were hemodynamically stable at presentation. Early repair was more technically demanding with increased operation duration. There was no difference in blood loss, operative complications, postoperative parameters, or longterm outcome. Conclusions: In hemodynamically stable patients, laparoscopic repair of iatrogenically induced lower ureteric strictures can be conveniently undertaken without undue delay from the inciting event. Compared to delayed repairs, the procedure is technically more demanding but morbidity incurred and outcome is at par.

Laparoscopic reconstruction of ureteral strictures involving solitary renal units-1 year and 5 year outcomes

Context: Long-term outcome following a laparoscopic reconstruction of ureteral strictures (US) involving solitary renal units (SRU) are scarcely reported. Aims: The aim was to report short-term (1 year) and long-term (5 years) outcomes following a laparoscopic reconstruction of US in a solitary kidney. Settings and Design: Retrospective. Materials and Methods: Records of patients operated for similar scenarios between January 2004 and January 2014 were evaluated. Clinical, biochemical and radiological profile were noted. Operative and post-operative profile were recorded. Follow-ups were scheduled at regular intervals (3 months post-procedure, 6 monthly for 2 years and yearly thereafter. Imaging was repeated at yearly intervals). Outcome was assessed by comparing pre-operative and post-operative clinical, biochemical, and radiological parameters. Statistical Analysis Used: SAS software 9.2 version. A P < 0.05 was inferred as statistically significant. Results: Seven patients underwent a laparoscopic reconstruction. Stricture location was upper ureter (n = 1), mid ureter (n = 2), lower ureter (n = 4). Surgeries performed were ureteroureterostomy, Boari flap ureteroneocystostomy and ureteroneocystostomy with psoas hitch. Four patients reported prior contralateral nephrectomy. Three patients underwent prior endoscopic correction. Four patients presented with elevated serum creatinine (>1.4 mg/dl). Till last follow-up, improvement in symptomatology and improvement or stabilisation of serum creatinine was perceived in all. Ureteral patency with resolution of hydronephrosis was observed in five patients at 1 year follow-up. Two patients revealed ureteral patency with persistence of hydronephrosis. Clinical, biochemical and radiological outcomes were maintained till long-term follow-up. Conclusion: Laparoscopic reconstruction of US in SRU offers impressive short- and long-term outcome.

Retroperitoneal Migration of a Double-J Stent: An Unusual Occurrence

Double-J stents that are inserted to span the ureterovesical anastomosis at ureteoneocystostomy may be associated with problems such as coiling or migration. An unusual occurrence of retroperitoneal migration of a Double-J stent after bilateral open ureteroneocystostomy is reported. The migrated stents were retrieved laparoscopically with construction of a laparoscopic ureteroneocystostomy.

Dirofilaria-induced fibrosis: an unusual cause of pelviureteric obstruction

A 55-year-old lady from rural India presented with complaints of intermittent right flank pain. There was no significant past ailments or co-morbidities. Renal profile was normal. Screening ultrasound revealed right hydronephrosis. Computed tomography urogram revealed an extrinsic pathology encasing the right pelviureteric junction and upper ureter and resulting in right hydronephrosis (Fig. 1). Retrograde pyelogram revealed a long segment stenosis at level of upper ureter and pelviureteric junction obstruction. Ureteroscope was not negotiable. A laparoscopic approach was contemplated through transperitoneal route. After colonic mobilization, the ureteral course was identified and the ureter was dissected cranially towards the pelviureteric junction. The upper ureter and pelviureteric junction was entrapped by a fibrotic band of tissue. The entire fibrotic plaque was separated from the ureter and pelvis (Fig. 2). The unhealthy ureteral segment was excised. There was considerable distance between the dismembered ends and to ensure a tension-free approximation, the renal unit was mobilized along the plane between Gerotas’ fascia and renal capsule and displaced caudally. Ease of approximation of the dismembered ends was ensured. Pyeloplasty was conducted using 4-0 polyglactin suture. A 6F ureteral stent was inserted in an antegrade fashion prior to completion of anterior layer of anastomosis. She had an uneventful post-operative recovery and was sent home on third post-operative day. Ureteral stent was removed after 6 weeks. The specimen pathology revealed fibrosis secondary to nematode affection (Fig. 3). Parasitological assessment confirmed Dirofilaria as the offender. A history of intimate contact with dogs was elicited from the lady. She received ivermectin and diethylcarbamazine in adjusted doses and advised periodic surveillance. Until last follow-up (9 months post-procedure), she is asymptomatic. Last follow-up imaging revealed satisfactory pelviureteric drainage with resolution of hydronephrosis.