Murigendra B. Hiremath

Flexible Ureteroscopy for Upper Ureteral Calculi in Children

INTRODUCTION Ureteroscopy is one of the therapeutic options in the management of urinary stone disease in children. Previous literature has described ureteroscopy primarily in mid to distal ureteral calculi. We report our experience with flexible ureteroscopy in the management of upper ureteral calculi. PATIENTS AND METHODS All children with upper ureteral stones were included prospectively in the study. Stone burden was measured in millimeters. Presentation, operative access, intraoperative complications, stone-free rates, and postoperative complications were evaluated. RESULTS A total of 80 children (69 boys and 11 girls) underwent 88 ureteroscopic procedures. In 72 (90%) children, complete stone clearance was achieved after a single ureteroscopic session. In 6 (7.5%) others, complete stone clearance was achieved after the second ureteroscopic session. CONCLUSIONS Complete stone clearance after single ureteroscopy is possible if the calculi are single, small (<10 mm), and below the level of the pelviureteral junction.

Laparoscopic adrenalectomy for adrenal masses in children

OBJECTIVE The laparoscopic approach to the adrenal gland was first reported in 1992. Since then numerous studies have been published, comprising of adults. Experience with the laparoscopic technique for adrenal disease in children and adolescents has been limited. We have reviewed our experience with laparoscopic adrenal surgery in children. PATIENTS AND METHODS All children with pathologic adrenal masses undergoing laparoscopic adrenal surgery were included. The primary study outcome measures included operative time, conversion to open surgery, complications, duration of hospital stay and outcome of surgery. RESULTS Eighteen children underwent laparoscopic adrenalectomy during the period January 2003-July 2009. The mean operating time was 95 min, mean blood loss was 30 ml and the average postoperative hospital stay was 50h. There were no conversions to open surgery and no major intra- or postoperative complications noted. CONCLUSIONS Laparoscopic adrenalectomy is a safe and feasible procedure with good results. It can be used to safely treat suspected benign and malignant adrenal masses in children with minimal morbidity and a shorter hospital stay.

Staged buccal mucosa urethroplasty in reoperative hypospadias

Introduction: Repeated attempts at surgical repair of serious complications involving either the partial or complete breakdown of the hypospadias repair are less likely to succeed because the penis is densely scarred, or significantly shortened, and the skin over the penis is immobile and hypovascular. Buccal mucosa (BM) has become the preferred material for reconstruction, whenever a child with skin-deficient hypospadias needs reoperation. We report the results of our surgical experience with staged reoperation using BM, in the repair of hypospadias in children with complications after multiple failed repairs. Materials and Methods: Children needing reoperation for hypospadias underwent a staged repair using buccal mucosa. The complications were noted. Results: Twenty-one children aged 3 – 16 years underwent this staged repair during the period May 2000 – April 2010. Two of these 21 children had a failed first stage. One child developed a urethro-cutaneous fistula following the second stage, which was corrected in an additional stage. Conclusions: The use of the buccal mucosa graft for urethral reconstruction in a child with hypospadias, needing a reoperation, is a successful method, with a low incidence of complications.

Type 2 diabetes mellitus and renal stones

Background: The incidence of urinary stone disease has shown a steep rise in recent decades along with marked modifications in dietary habits and life- style. There has been an increased prevalence of urinary stone disease in patients with diabetes. We took up this study to determine the association of diabetes mellitus with kidney stones in patients undergoing surgical treatment. Materials and Methods: Patients presenting with renal stones for surgical management formed the study group. Body mass index (BMI) was calculated by noting the weight and height of the patient. The extracted stone/stone fragments were analyzed to determine the chemical composition. Urinary pH was similarly noted in all. Results: The mean BMI among the diabetics was 26.35 ± 5.20 (range 17.75-35.60), whereas the mean BMI among the non-diabetics was 23.41 ± 2.85 (range 17.71-31.62) (P < 0.0004). The incidence of uric acid calculi in the diabetics was significantly high (P < 0.03). The mean urinary pH among the diabetics was 5.61 ± 0.36 and among the non-diabetics was 6.87 ± 0.32, which was significantly lower (P < 0.000044). Conclusions: There is a strong association between type 2 diabetes and uric acid stone formation. There is also a strong association between diabetes mellitus, BMI, and also with lower urinary pH.

In vitro antioxidant and anticancer activity of Leea indica leaf extracts on human prostate cancer cell lines

Background To determine the phytochemical constituents, antioxidant, and anticancer activities of Leea indica leaf extracts on DU-145 and PC-3 human prostate cancer cell lines. Methods Leaf sample was subjected to Soxhlet extraction method with increasing polarity of solvents, namely, chloroform, ethyl acetate, methanol, ethanol, and aqueous. Phytochemical screening was done using different biochemical tests. Quantitative analysis for phenol was determined by Folin–Ciocalteu reagent method. The antioxidant activity was tested using 2,2-diphenyl-1-picrylhydrazyl, ferric ion reducing power assay, and phosphomolybdenum assay. In vitro anticancer activity on DU-145 and PC-3 human prostate cancer cell lines was evaluated by (3-(4, 5-dimethyl thiazole-2yl)-2, 5-diphenyl tetrazolium bromide) MTT assay. Results Phytochemical screening confirmed the presence of phyto-constituents like alkaloids, flavonoids, glycosides, phenols, lignins, saponins, sterols, tannins, anthraquinone, and reducing sugar. Methanol and ethanol extracts exhibited higher phenolic content as compare to aqueous extract. Antioxidant capacities were shown highest in methanol and ethanol extracts based on the test performed. The methanol and ethanol leaf extracts were found to be selectively cytotoxic in vitro to (DU-145 and PC-3) prostate cancer cell lines with IC50 values 529.44 ± 42.07 μg/mL and 677.11 ± 37.01 μg/mL for DU-145 and 547.55 ± 33.52 μg/mL and 631.99 ± 50.24 μg/mL for PC-3 respectively, while it had no cytotoxic effect on normal mice embryo fibroblast cells. Conclusion The results indicate that Leea indica was a promising antioxidant and anticancer agent for DU-145 and PC-3 human prostate cancer cell lines. However, further studies are needed to conclude its therapeutic use.

Adrenal cysts: Our laparoscopic experience

INTRODUCTION: Cystic lesions of the adrenals are rare with an incidence of 0.06% in autopsies, and the most frequently found are either the endothelial cysts or the pseudocysts. We report our series of patients presenting with adrenal cysts. MATERIALS AND METHODS: The case records of patients presenting with adrenal cysts were reviewed and analyzed. Age, gender, presenting symptoms, physical examination findings, laboratory investigations and imaging records were all noted and analysed. RESULTS: During the 10-year study period, 14 patients, with a mean age of 41.36 ± 5.57 years, were diagnosed to have adrenal cysts. Laparoscopic excision of cysts was performed in three and laparoscopic adrenalectomy in the remaining eleven. CONCLUSIONS: Adrenal cysts are rare, and intervention is indicated whenever they are large (>5 cm), symptomatic, functional, and potentially malignant. Laparoscopic management of these cysts in the form of either decortication/excision is safe, effective, minimally invasive, with minimal blood loss and shorter duration of hospitalization.

Laparoscopic mitrofanoff appendicovesicostomy: Our experience in children

Introduction: The Mitrofanoff principle was originally described as a method to provide an alternative means to access the bladder. It creates a conduit to the bladder through which patients with a sensitive, absent, or traumatized urethra can perform clean intermittent catheterization (CIC) easily. We report our experience with complete laparoscopic Mitrofanoff appendicovesicostomy to promote a catheterizable abdominal stoma. Materials and Methods: A 4-port transperitoneal approach was used to create a complete laparoscopic Mitrofanoff appendicovesicostomy. Results: Six children with a mean age of 12.8 years (range 9-16 years) underwent laparoscopic Mitrofanoff appendicovesicostomy. Mean operative time was 139.6 min and Mean estimated blood loss was 46 cc. No cases of urinary leaks were noted. There have been no cases of either stomal stenosis or appendicovesical stenosis noted. Conclusions: Pure laparoscopic Mitrofanoff appendicovesicostomy is feasible and is associated with reasonable outcome with early recovery, resumption of normal activities and excellent cosmesis.

Preliminary experience with laparoscopic Foley's YV plasty for ureteropelvic junction obstruction in children

INTRODUCTION: Laparoscopic dismembered pyeloplasty is an acceptable option for ureteropelvic junction (UPJ) obstruction in the paediatric population. We compared our results of laparoscopic dismembered and non-dismembered Foleys YV pyeloplasty. MATERIALS AND METHODS: Children presenting with hydronephrosis secondary to UPJ obstruction formed the study group. Foleys YV plasty was planned whenever it was observed that a tension free dismembered pyeloplasty was not possible in spite of all possible manoeuvres. Children were followed up for urinary infection, and renogram was repeated after 3 months. RESULTS: During the study period, 108 children (63 male and 45 female) with a mean age of 4.94 ± 2.78 years underwent laparoscopic dismembered pyeloplasty and the remaining 11 children (5 male and 6 female) with a mean age of 4.00 ± 1.776 years underwent laparoscopic Foleys YV plasty. There were no major peri-operative complications noted and conversion to open was not necessary in any child. Renogram done at 3 months post-operatively showed good drainage and improvement of renal function. CONCLUSIONS: Laparoscopic Foleys YV pyeloplasty is a safe and effective technique in appropriately selected cases of primary UPJ obstruction in children.

Tumor doubling time of renal cell carcinoma measured by CT

Introduction: Increasing numbers of patients are now being incidentally detected with small-sized renal cell carcinoma (RCC). The natural history of small renal masses is not completely understood. Currently, there are no specific tumor markers to determine initial risk or progression to metastatic disease. Growth rate and tumor size are factors shown to be predictive of tumor biology. In this study, we attempted to examine the natural history of RCC and calculated the doubling times (DTs) of untreated RCC at the primary site. Materials and Methods: We retrospectively reviewed the records of all patients with RCC who had at least two measurements of the same tumor mass obtained on computed tomography (CT) imaging on two different dates (at least 6 months apart) during periods of non-treatment. The tumor volume was calculated at two points in time using images yielded by the CT imaging. The tumor DT was calculated using the following equation: DT = (T – T0) × log2/logV – logV0. Results: Twenty-two (13 male and nine female) patients with ages ranging from 32 to 71 years (mean 52.22 years) were included in the study. The initial maximum tumor diameter ranged from 2.8 to 6.8 cm (mean 3.93 cm) and the last maximum tumor diameter ranged from 3.2 to 7.8 cm (mean 4.39 cm). The DT for the entire population was 460.01 days (range 174-913 days). Conclusions: RCC is a diverse disease process, with the majority of lesions demonstrating malignant disorder. In our study, the DT for the patient population was 460.01 days (range 174-913 days).

Yang-Monti’s Catheterizable Stoma in Children

Background In 1981, Mitrofanoff described a procedure to create a continent urinary stoma for clean intermittent catheterization. Since then several procedures have been described including Yang-Monti ileovesicostomy for effective catheterization. Objectives We report on our experience from the use of Monti’s procedure in children at our center. Patients and Methods Children < 18 years of age undergoing urinary diversion/reconstruction with Yang-Monti’s procedure for congenital conditions or neuropathic bladder formed the study group. All these children, post-operatively were taught clean intermittent catheterization (CIC) and put on a regime using a 14/16 Fr catheter every 3 hours. The children were followed regularly at 3, 6, 12, 18 and 24months post-operatively, with special attention paid to any problems with catheterization and incontinence. Results During the period from Jan 2000 to Dec 2011, at our center, 19 children less than eighteen years of age underwent urinary diversion with Yang-Monti’s catheterizable stoma. The indications for urinary diversion was neuropathic bladder in eight, exstrophy bladder in seven , valve bladder syndrome in three and persistent urethral stricture in one. None of the children found CIC difficult during the post-operative period and there was no hindrance to the passage of the catheter. Conclusions Although the appendix remains the tissue of choice for creation of catherterizable stoma, the Yang-Monti ileovesicostomy is effective, convenient conduit for children. Long-term complications are minimal and children find this comfortable to do CIC.