Pankaj Wadhwa

Robotic Reconstruction for Recurrent Supratrigonal Vesicovaginal Fistulas

PURPOSE We report our experience with robotic reconstruction for recurrent supratrigonal vesicovaginal fistulas and its outcome. MATERIALS AND METHODS From August 2006 to October 2007 we treated 7 cases of recurrent supratrigonal vesicovaginal fistula. Salient features of our technique are 1) vaginoscopy and cystoscopy with bilateral Double-J stent or ureteral catheter placement and placement of a catheter through the fistula from vagina to bladder, 2) patient positioning in a low lithotomy position with a 60-degree Trendelenburg tilt and a 5-port transperitoneal approach, 3) peritoneoscopy and adhesiolysis with minimal posterior cystotomy encircling the fistulous opening, 4) mobilization of the bladder and vaginal flaps to allow tension-free closure, 5) excision of the fistulous rim, 6) bladder and vaginal edge freshening, 7) bladder and vaginal closure, 8) omental, peritoneal or sigmoid epiploic tissue interposition and 9) insertion of a Foley catheter and drain. Difficulty was primarily noted with regard to the safe establishment of pneumoperitoneum, the need for extensive adhesiolysis, dissection of the fistula from perifistulous fibrosis in close vicinity to the ureteral opening, tension-free closure of the larger defect and occasional absence of omentum for use as interposition tissue. RESULTS The average size of supratrigonal fistulas was 3.0 cm. Mean operative time was 141 minutes (range 110 to 160). Mean blood loss was 90 cc. No significant intraoperative or postoperative complications were observed. Mean hospital stay was 3 days. The catheter was removed 14 days postoperatively. All patients had a successful outcome. CONCLUSIONS Our experience suggests that robotic repair for recurrent vesicovaginal fistulas is feasible, results in low morbidity and provides outstanding results. It provides an attractive option for vesicovaginal fistula repair by a minimally invasive approach for the surgeon and the patient alike.

Radiation exposure to the patient and operating room personnel during percutaneous nephrolithotomy.

Introduction: The increased use of fluoroscopy during percutaneous nephrolithotomy (PCNL) places the urologist and operating room personnel at an occupational risk for measurable radiation exposure. We evaluated the degree of radiation exposure received by the patient and operating room personnel at our endourology facility during PCNL. Patients and method: The incident radiation dose to the patient and the urologist during 50 consecutive PCNL procedures was monitored using lithium fluoride thermo-luminescent dosimeter chips (TLD chips). A hand held radiation survey meter was used to measure the radiation in air at different positions occupied by various operating room personnel. The approximate distances of the various personnel from the X-ray tube were also measured. Results: PCNL was performed upon 35 males and 15 females. The average time for the procedure was 75 minutes (range: 30–150 min). The mean fluoroscopy screening time during the procedure was 6.04 min (range 1.8–12.16 min) with a mean fluoroscopy tube potential of 68 kVp and a mean tube current of 2.76 mA. The mean radiation exposure dose to the patient was 0.56 mSv (SD ± 0.35), while the mean incident radiation exposure to the finger of the urologist was 0.28 mSv (SD ± 0.13). Conclusion: The various operating room personnel are within safe radiation dose limits during PCNL. Efficient fluoroscopy further reduces the radiation scatter. All occupational personnel should ‘achieve as low as reasonably achievable’ dose by adhering to good practices.

Laparoscopic Radical Cystectomy and Extracorporeal Urinary Diversion: A Single Center Experience of 48 Cases with Three Years of Follow-up

OBJECTIVES To report our experience with laparoscopic radical cystectomy and extracorporeal urinary diversion for high-grade muscle invasive bladder cancer in a consecutive series of 48 patients with 3 years of follow-up. METHODS From June 1999 to April 2006, 48 patients (42 men and 6 women; mean age 59 years, range 24 to 80) with bladder cancer underwent laparoscopic radical cystectomy and bilateral pelvic lymph node dissection at our institution. Urinary diversion was done extracorporeally through the specimen extraction incision. RESULTS The mean operating time was 310 minutes, and the mean blood loss was 456 mL. In 1 patient, conversion to open surgery was required because of severe hypercarbia. Three major complications were observed intraoperatively (rectal injury in 2 and external iliac vein injury in 1 patient). However, all these complications were managed laparoscopically, with completion of the procedure laparoscopically. The mean hospital stay was 10.2 days (range 7 to 25). One patient died in the postoperative period of severe lower respiratory tract infection and septicemia. Histologic examination showed organ-confined tumors (Stage pT1/pT2/pT3a) in 34 patients (71%) and extravesical disease (pT3b/pT4) in 14 (29%). Of the 48 patients, 12 (25%) had lymph node involvement. The mean number of nodes removed was 14 (range 4 to 24). At a mean follow-up period of 38 months (range 10 to 72), 35 patients were alive with no evidence of disease (disease-free survival rate 73%). CONCLUSIONS The results of our study have shown that laparoscopic radical cystectomy is a safe, feasible, and effective alternative to open radical cystectomy. Extracorporeal urinary diversion through a small incision decreases the operating time, while maintaining the benefits of laparoscopic surgery. The 3-year oncologic efficacy was comparable to that of open radical cystectomy.

Cyclooxygenase-2 expression increases with the stage and grade in transitional cell carcinoma of the urinary bladder.

Objectives: Experimental models of carcinogenesis show that non-steroidal anti-inflammatory drugs (NSAIDs) increase apoptosis, inhibit angiogenesis and reduce metastases. A linkage between the activity of prostaglandin synthase enzyme cyclooxygenase-2 (COX-2), a known mediator of inflammation, and cancer angiogenesis is implicated. We investigated the expression of COX-2 in bladder cancer tissue specimens using immunohistochemistry. Methods: The immunohistochemical expression of COX-2 in bladder cancer was evaluated by scoring the intensity of immunoreactivity from 0 to 3. Further, the degree of COX-2 expression was correlated with the tumor grade and depth of invasion (T stage). Result: Fifty eight percent patients (n=22) had superficial bladder tumors, while 42% (n=16) were invasive bladder cancers. Overall, COX-2 immuno-positivity was seen in 84.2% (32/38) patients. COX-2 expression was positive in 76.4% (13/17) cases with pTa tumors, 100% (5/5) of pT1 tumors, 86.6% (13/15) of pT2 tumors and in 100% (1/1) of pT3 tumor. The higher stage tumors stained more intensely; this correlation wassignificant(p=0.01987; χ2=19.6977). With reference to the grade of tumors, a positive expression was seen in 81.25% (13/16) of the low-grade tumors and 89% (17/19) of the high-grade tumors. The differential COX-2 expression relative to the grade of tumor was found to be statistically significant (p=0.05; χ2=15.8612). Conclusion: The degree of COX-2 expression is significantly increased with advancing grade and T stage of disease (p < 0.05).

Renal lymphangiomatosis: Imaging and management of a rare renal anomaly

Renal lymphangiomatosis is a rare developmental malformation resulting in the development of cystic masses in the peri-pelvic or peri-renal areas. We report our experience in the management of this rare anomaly. Herein, we also describe the successful laparoscopic ablation of an uncommon subcapsular variant of renal lymphangiomatosis, which failed percutaneous drainage.

Localized primary amyloidosis of the prostate, bladder and ureters.

Primary amyloidosis of lower urinary tract is a rare entity and is usually localized to a single site. Its clinical features, and cystoscopic and radiological findings are indistinguishable from neoplastic or inflammatory lesions. We report an unusual case of amyloidosis involving multiple sites (prostatic stroma, trigone and lower ureters) in the lower urinary tract. MRI findings of bladder amyloid, which could be used to suspect this condition, are also described.

Current status of minimally invasive management of pediatric upper urinary tract calculi

The surgical management of pediatric upper urinary tract calculi has evolved from open surgery to minimally invasive techniques. With advancement in instrumentation, endourological procedures are being performed more commonly in children. However, the endourological management of renal and ureteral stones in the pediatric population is considered challenging, owing to the smaller size of the urinary tract. Various minimally invasive techniques that are being applied in the management of pediatric urolithiasis, include shock wave lithitripsy (SWL), percutaneous nephrolithotomy (PCNL), ureterorenoscopy and a combination of these procedures. The role of SWL is well established and is considered the first line of treatment in the management of urinary calculi in pediatric patients. Recent reports have confirmed the safety of PCNL and ureteroscopy in children, although they are not as widely practiced in children as in adults. This article reviews literature published till October 2005, pertaining to the minimally invasive management of pediatric upper urinary tract calculi.

Pure robotic extended pyelolithotomy: cosmetic replica of open surgery

Percutaneous nephrolithotomy (PCNL) has replaced open pyelolithotomy as the procedure of choice for treating large-burden renal stone disease, especially staghorn calculi. Although it is a minimally invasive procedure, it involves transgressing the renal parenchyma and is thus associated with its unique set of complications. The evolution of laparoscopic pyelolithotomy and robotic assistance has provided an opportunity to the surgeon to revisit pyelolithotomy in a minimally invasive manner following the age-old principles of the era of open renal surgery. We report the feasibility and our experience with this technique in three cases of partial staghorn calculus with intra-renal pelvis.

Transcatheter embolization of internal pudendal artery pseudoaneurysm following traumatic urethral catheterization

Urethral catheterization is a routine procedure. We report an unusual complication due to a traumatic urethral catheterization. The resulting pseudoaneurysm of the bulbar artery required selective embolization of the internal pudendal artery.

Midline intraprostatic cyst: An unusual cause of lower urinary tract symptoms

Symptomatic prostatic cyst presenting as obstructive lower urinary tract symptoms (LUTS) is an infrequent diagnosis in males. Midline cysts are much more likely to obstruct the bladder outlet. We report our experience with four such cases in the last one year, along with a short review of the literature. Two of these cases had additional presenting symptoms besides LUTS - febrile Urinary tract infection (UTI) with perinephric abscess and primary infertility. One case had an anterior midline prostatic cyst which is an extremely rare entity. The remaining three had midline posterior cysts. All cases were treated with transurethral marsupialization, had good relief of symptoms and no adverse effects.