Maneesh Sinha

An in vitro study on human ureteric smooth muscle with the α1-adrenoceptor subtype blocker, tamsulosin

To study the effects of tamsulosin on ureteric contractions and its effects on the basal tone of human ureteric specimens, as clinical trials with tamsulosin have shown promising results in the spontaneous expulsion of lower ureteric calculus, but the mechanism of action of tamsulosin in the expulsion of ureteric calculus has not been elucidated in in‐vitro studies on human ureters.

Use of a vegetable model as a training tool for PCNL puncture.

Introduction: Training residents to perform a PCNL puncture is hampered by the non-availability of a good inanimate model that can be used for demonstration and practice. The ethics of surgical training during actual surgeries is being questioned and the role of simulation is increasingly important. Virtual reality trainers, however, are prohibitively expensive and the use of animal models is fraught with regulatory and ethical concerns. We have devised a model that can be used to teach the concept of depth perception during a PCNL puncture. Methods: A bottle gourd was used to mimic the posterior abdominal wall. Cotton pledgets dipped in intravenous contrast were fitted into 4 mm holes made at staggered levels in the bottle gourd which was strapped onto the operating table with the cotton pledgets facing away from the surgeon. Surgeons with varying degrees of experience made fluoroscopy-guided punctures onto the cotton pledgets. We recorded the time taken for puncture in seconds and the distance of the needle exit site from the center of the cotton ball. Speed was measured by recording the fluoroscopy time in seconds on the C-arm. Accuracy was documented by using a Vernier caliper to measure the distance from the edge of the target to the actual puncture. One second of fluoroscopy time and 0.1 mm distance were each given one point. The total points accumulated over a set of 10 punctures was added to give a total score. Longer fluoroscopy times and inaccurate punctures resulted in higher scores. Results: A surgeon with more than 1000 PCNLs to his credit had a score of 99. The average score of five residents was 555. Conclusion: The bottle gourd model provides an ethically acceptable, inexpensive, easy to replicate model that can be used to train residents in the PCNL puncture.

Supracostal percutaneous nephrolithotomy: A prospective comparative study.

Introduction: A widely prevalent fear of thoracic complications with the supracostal approach has led to its underutilization in percutaneous nephrolithotomy (PCNL). We frequently use the supracostal approach and compared the efficacy and thoracic complications of infracostal, supra 12th, and supra 11th punctures. Materials and Methods: This was a prospective study of patients who underwent PCNL between January 2005 and December 2012. The patients were divided into three groups based on the access: infracostal, supra 12th (between the 11th and 12th ribs) and supra 11th (between the 10th and 11th ribs). Clearance rates, fall in hemoglobin levels, transfusion rates, perioperative analgesic requirements, hospital stay and thoracic complications were compared. Results: Seven hundred patients were included for analysis. There were 179 (25.5%) patients in the supra 11th group, 187 (26.7%) patients in the supra 12th group and 334 (47.8%) patients in the infracostal group. The overall clearance rate was 78% with no difference in the three groups. The postoperative analgesic requirements were significantly higher in the supracostal groups and showed a graded increase from infracostal to supra 12th to supra 11th. During the study period, only 2 patients required angioembolization (0.3%) and none required open exploration. The number of patients requiring intercostal chest drain insertion was extremely low, at 1.6% and 2.2% in the supra 12th and supra 11th groups, respectively. Conclusions: Our results confirm the feasibility of the supracostal approach including punctures above the 11th rib, albeit at the cost of an increase in thoracic complications. Staying in the line of the calyx has helped us to minimize the most dreaded complication of bleeding requiring angioembolization.

False urethral anastomosis.

We present images of three cases with false urethral anastomosis following urethroplasty. The likely causes are inadequate posterior urethral dissection and blind use of Hey Grove dilator. We recommend use of antegrade flexible cystoscopy to prevent this complication.

Sildenafil induced priapism

An unmarried 35 years old male, who took 25mg sildenafil daily for 8 days followed by 12.5 mg daily for 4 days, with consultation with a local chemist for nocturnal emission developed priapism. He presented to an urologist after 72 hours where a corporal wash and distal shunt was tried but it did not give any relief to the patient. He had no other identified contributing factors for priapism. A proximal caverno-spongiosal shunting (Quackels cavernoso-spongiosal shunts) was done which subsequently relieved his symptoms. To our knowledge this is the first reported case of priapism resulting from supposedly safe doses of sildenafil in a healthy individual. Distal shunts are associated with high failure rates which may warrant a more proximal shunt. Even when seen after a considerable time a shunt may be useful. After the delayed surgery, relief of pain without complete detumesence suggests a role for watch-full waiting. This case also highlights the existence of unfortunate myths surrounding the omnipotence of sildenafil in all sorts of sex related problems. It points toward an urgent need for steps to prevent unauthorized prescription and misuse of this drug..

Use of Volume Rendered, Maximum Intensity Projection Images to Assess Whether the Medial Calyx Synonymous with the Posterior Calyx.

Introduction: This paper attempts to verify the anatomical veracity of the belief that in order to enter into a posterior calyx one must aim for the medial calyx during a percutaneous nephrolithotomy (PCNL). Methods: Volume rendered and maximum intensity projection reconstructions of normal pelvicalyceal systems were assessed in various rotational planes. An experienced urologist decided the appropriate access for PCNL in the upper, interpole and lower calyx on each side. The selected calyx was then viewed on anteroposterior sections to decide whether they were projecting laterally or medially. Results: Of the 508 calyces studied, the posterior calyx was projecting laterally in 72% and medially in 28%. In the upper calyx, the posterior calyx was projecting laterally in a majority of cases, 94% on the right and 89% on the left. In the right lower calyx, the posterior calyx was pointing laterally in 86%, whereas the distribution on the left was 64%. Conclusion: Our results refute the belief that the medial calyx is always synonymous with the lateral calyx.

An audit of suprapubic catheter insertion performed by a urological nurse specialist

Aims: To introduce the concept that a urological Nurse Specialist can perform Suprapubic Catheter (SPC) insertions independently without significant complications, if systematic training is given. Settings and Design: Retrospective study. Materials and Methods: A retrospective audit of Suprapubic Catheter insertions performed by a Urological Nurse Specialist was conducted between April 2009 and April 2011. Results: Of the total 53 patients, in 49 (92.45%) the procedure was successful. Out of the remaining four, two (3.77%) were done by a urologist. One patients (1.89 %) SPC did not drain after placement and ultrasonography reported that the Foley balloon was lying within the abdominal wall. The other patients SPC drained well for a month and failed to drain after the first scheduled change in a month. Since the ultrasonography showed the Foley balloon to be anterior to the distended bladder, an exploration was performed and this revealed that the SPC tract had gone through a fold of peritoneum before reaching the bladder. None had bowel injury. Conclusions: If systematic training is given, a urological Nurse Specialist can perform SPC insertions independently without significant complications.

A cost comparison of open versus percutaneous approaches to management of large staghorn calculi.

Aim: This paper compares the cost of open versus percutaneous approaches to the management of large staghorn calculi in a tertiary care hospital in India. Materials and Methods: Patients who underwent surgery for staghorn calculi larger than 6 cm between January 1998 and December 2003 were included. Those who had confounding factors in terms of cost such as additional surgical or medical procedures and complications unrelated to the surgery were excluded. The process of costing was done by following the clinical pathway. Results: There were 13 patients who had open stone surgery and 19 patients who underwent percutaneous nephrolithotripsy (PCNL). The major differences in cost were seen in the higher cost of instruments and consumables in the PCNL group. The cost of management of complications widened this gap. Two patients in the PCNL group and none in the residual group required redo surgery. The residual stones in the open and PCNL groups required a mean of 2525 and 3623 shocks per patient respectively. Complete clearance after redo surgery and Shockwave lithotripsy (SWL) was seen in 92% and 58% in the open and PCNL arms respectively. The overall cost per patient was

Use of pedicled tunica vaginalis flap in elaborated perineal approach for bulboprostatic anastomotic urethroplasty

625 per PCNL and

Tubercular ureteric strictures.

499 per open surgery. The final mean residual stone size in the PCNL group was 4.84 mm whereas it was 0.38 mm in the open group. The effective cost of achieving complete clearance in one patient was