Prem Nath Dogra

Comparison of standard transurethral resection, transurethral vapour resection and holmium laser enucleation of the prostate for managing benign prostatic hyperplasia of >40 g.

To compare the safety and efficacy of two alternatives for surgically treating symptomatic benign prostatic hyperplasia (BPH), i.e. transurethral vapour resection of the prostate (TUVRP) and holmium laser enucleation of the prostate (HOLEP), with transurethral resection of the prostate (TURP), the standard surgical therapy, as treating large prostates is associated with greater morbidity, and to date there is no simultaneous comparison of these three methods.

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.

Outcome analysis of robotic pyeloplasty: a large single‐centre experience

Study Type – Therapy (case series)
Level of Evidence 4

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.

Comparative Analysis of Outcome Between Open and Robotic Surgical Repair of Recurrent Supra-Trigonal Vesico-Vaginal Fistula

INTRODUCTION Recurrence of fistula is one of the very common complications of fistula repair. The disease has immense psychosomatic effect on the patients due to continuous leakage of urine. Management of recurrent vesico-vaginal fistula (VVF) repair poses a challenge to surgeons. MATERIALS AND METHODS Group I-12 patients with recurrent VVF, having robotic repair from August 2006 to June 2008, were included in the present study. Group II-20 patients matched in all possible parameters with recurrent VVF having open surgical repair in the past were taken as controls. Patients in both the groups were evaluated by assessing relevant clinical details; performing urine routine examination and culture, renal function test, three swab test, ultrasonogram-kidney, ureter, and bladder radiograph, intravenous urogram (to look for upper tract and rule out uretero-vaginal fistula), and urethro-cystoscopy. The details were retrospectively recorded from the case sheets. RESULTS In group I, 100% were successfully managed as compared with 90% in group II, but it was not statistically significant (p > 0.05). Mean blood loss was significantly less (p < 0.05) in group I compared with group II (mean 88 vs. 170 mL). The mean hospital stay also was significantly less (p < 0.05) in group I in comparison with group II (mean 3.1 vs. 5.6 days). None of the patients had complications in group I compared with group II, but it was not significant. CONCLUSION The present study suggests that robotic VVF repair is a better option for recurrent fistulas in view of its reduced morbidity, without compromising the results.

Safety and efficacy of PCNL for management of staghorn calculi in pediatric patients.

OBJECTIVES There are few reports on the use of PCNL for staghorn calculi in children. We evaluated the safety and efficacy of this technique, using adult equipment, in children below 16 years of age. METHODS Data for pediatric patients undergoing PCNL for staghorn renal calculi was prospectively recorded. A staghorn calculus was defined as a branched stone occupying more than one part of the collecting system. A standard fluoroscopy guided PCNL was performed in the prone position using adult nephroscopes. Stone clearance was assessed on fluoroscopy and X-ray in all patients and an ultrasound or CT scan in selected cases. RESULTS Beginning October 2007, 33 pediatric patients underwent 34 PCNLs at our center. 12 of these children had staghorn calculi. All patients had normal renal function and no metabolic abnormality. One child had a solitary kidney. In 5 children, the primary tract was placed into the superior calyx and 4 of these were above the 12th rib. A 21Fr nephroscope was used through a 24Fr tract in 9 children while a 26Fr nephroscope was used through a 30Fr tract in 3 cases. 10 children were managed through a single tract. One patient each required SWL and ureteroscopy for residual fragments. 11 patients had complete clearance while 1 had insignificant residue. One child required intravenous antibiotics for post-operative fever while another developed an abdominal collection that was managed conservatively. CONCLUSIONS PCNL is safe and effective in the management of pediatric staghorn calculi.

Bipolar energy for transurethral resection of bladder tumours at low-power settings: initial experience

Study Type – Therapy (case series)

Laser Welding of Vesicovaginal Fistula

Abstract: The management of vesicovaginal fistula remains a source of debate, despite extensive literature on the subject. It is difficult to prove the superiority of one surgical technique over another by randomized trials, given the variabilities of fistula etiology, the location and clinician expertise. Small epithelized fistulae following conservative treatment and residual or recurrent cases following transabdominal or transvaginal repair pose a therapeutic challenge. A case of a small vesicovaginal fistula following abdominal hysterectomy is presented, in which a successful outcome was achieved using endoscopic Nd-YAG laser fulguration.

Erectile Dysfunction After Anterior Urethroplasty: A Prospective Analysis of Incidence and Probability of Recovery—Single—center Experience

OBJECTIVE To evaluate the incidence and probability of recovery of erectile dysfunction after different types of one-stage urethroplasties for anterior urethral stricture disease. METHODS Seventy-eight men undergoing single-stage anterior urethroplasty from January 1, 2008 to March 31, 2010 were followed prospectively. Patients were divided into 3 groups: group 1 (n=25)-penile substitution urethroplasty; group 2 (n=32)--primary excision anastomotic bulbar urethroplasty; and group 3 (n=21)--bulbar substitution urethroplasty. Patients willing to participate completed the International Index of Erectile Function (IIEF) preoperatively and then on subsequent follow-up visits at 3, 6, 9, 12, and 15 months after urethroplasty. Pre- and post-urethroplasty erectile functions were compared. RESULTS Our mean follow-up period was 15.50+2.389 months. The mean age (years) was similar among groups. The mean stricture length (cm) was 4.78±0.747, 2.95±0.658, and 6.13±0.981 in-groups 1, 2, and 3, respectively (P=.001). Mean preoperative IIEF score was 24.60±2.365 (similar among groups). Erectile dysfunction (ED) was found in 15 (20%) patients: 4/25 (16%), 9/32 (28%), and 2/21 (10%) in groups 1, 2, and 3, respectively. Mean postoperative decline (3 months) in IIEF score was 22.54±4.823. Overall, the decline was not significant among groups (P=.502.) Recovery of erectile function was seen in 75/78 (96%) men at a mean follow-up time of 5.63±2.59 months. CONCLUSIONS Anterior urethroplasty has a probability of causing ED in as much as 20% of patients. The type of urethroplasty has no significant effect on ED. Recovery of erectile function occurs within 6 months of urethroplasty.

Outcomes of Robot-Assisted Laparoscopic Pyeloplasty in Children: A Single Center Experience

OBJECTIVES Open pyeloplasty is the standard treatment for ureteropelvic junction obstruction in children. The introduction of robotic surgical system has facilitated precise intracorporeal suturing and shortened the learning curve for minimal invasive procedures for the surgeons. There is sparse data over the outcomes of robot-assisted laparoscopic pyeloplasties in children. We describe our technique and outcomes of robotic pyeloplasty in children. PATIENTS AND METHODS Operative data for all patients undergoing a robot-assisted procedure at our center is prospectively recorded in a database. We retrieved data of patients below the age of 16 years undergoing robot-assisted pyeloplasty between July 2007 to March 2011 and evaluated their operative parameters, recovery, and functional outcomes. RESULTS In the period under review, 34 pediatric patients (mean age 12 years, range 5-15 years) underwent robot-assisted laparoscopic pyeloplasty at our center. All patients underwent unilateral pyeloplasty but one patient underwent a simultaneous contralateral pyelolithotomy. The mean total operative time (range) was 105 minutes (75-190 minutes), average dissection time and the anastomosis time was 23 minutes (20-58 minutes) and 46.5 minutes (28-70 minutes) respectively. The mean blood loss was 30 mL. Follow-up of 36, 24, 18, 12, and 6 months was completed in 14, 21, 24, 28, and 31 patients respectively. Postoperatively, one patient had an omentum herniation through the camera port site and another had an ileocaecal volvulus. With a mean follow-up of 28.5 months (2-56 months), the success rate was 97% (32/33), whereas postoperatively one patient had deterioration of function. CONCLUSION Robot-assisted laparoscopic pyeloplasty is a safe and effective minimally invasive treatment modality in children.