R. Sabnis

Management of Non-neoplastic Renal Hemorrhage by Transarterial Embolization

OBJECTIVESnTo assess the role of transarterial embolization (TAE) and critically appraise its feasibility and efficacy in the management of non-neoplastic renal hemorrhage. Percutaneous TAE is an effective method for the control of hemorrhage, irrespective of the cause. Injury to the renal artery or its branch, after trauma or during open or percutaneous urologic procedures, can be accurately diagnosed using angiography and treated by percutaneous embolization techniques. Because the technique and technology have evolved, it is now possible to perform highly selective embolization of the injured vessel while preserving vascularity of the rest of the renal parenchyma.nnnMETHODSnThe medical records of all patients who underwent angioembolization for hemorrhagic urologic emergencies at our institute from January 1996 to December 2007 were reviewed.nnnRESULTSnA total of 41 patients, aged 7-72 years, underwent TAE because of hemorrhage after percutaneous nephrolithotomy (n = 27), open pyelolithotomy (n = 3), renal biopsy (n = 8), and spontaneous occurrence (n = 3). All patients had a normal coagulation profile before surgery. A total of 35 patients (85.3%) underwent successful embolization and none required a postprocedural blood transfusion. Of those with postpercutaneous nephrolithotomy bleeding, angioembolization failed in 6 patients. Of these, only 2 required nephrectomy to save the patients life. No serious procedure-related complications occurred.nnnCONCLUSIONSnTAE is a minimally invasive, safe, simple, and highly effective modality, in expert hands, for the management of postprocedural renal bleeding. This option should be considered early in the management of these cases because it is not only a life-saving, but ultimately a kidney-sparing, procedure.

Spontaneous subcapsular renal hematoma: A case report and review of literature

Spontaneous subcapsular renal hematoma is not a common entity. We report a 38-year-old lady presenting with sudden onset right flank pain with uncontrolled hypertension and she was found to have subcapsular collection in the right kidney on ultrasonography. Finding was confirmed on computed tomography. Except hypertension, no particular cause for the condition could be found. Symptoms and size of the collection decreased on conservative treatment. They completely disappeared on ultrasonography at 6 months follow-up. She was asymptomatic at 18 months follow-up.

Management of urolithiasis in live-related kidney donors.

OBJECTIVEnTo analyze our experience in management of urolithiasis in renal donors.nnnMATERIALS AND METHODSnThe stones were treated either pretransplant or posttransplant. The Amsterdam forum criteria for acceptance of living donors were used for donor selection. The donors underwent the following procedures: pretransplant extracorporeal shock wave lithotripsy (ESWL) (n=5), pretransplant retrograde intrarenal surgery (RIRS) (n=1), ex-vivo ureteroscopy (ex-vivo URS) (n=1), and ex-vivo pyelolithotomy (ex-vivo Pyl) (n=2); intraoperative Double-J stent; and observation (n=3). Data were analyzed for technical feasibility, intraoperative and postoperative complications, and stone clearance.nnnRESULTSnThe male and female ratio was 4:8 and average age was 52.3 years (38-71). In the pretransplant ESWL group, average of 740 shocks (600-1500) was given; the power was not ramped up beyond 12u2009kV. Ex-vivo URS was performed on bench with 6F pediatric cystoscope, while in the ex-vivo Pyl, a 12F nephroscope was introduced via a pyelotomy and stones were retrieved intact with a dormia basket. A postoperative ultrasound at one month revealed complete clearance of stones in all except one donor. At a mean follow-up of 36 months (10-58), there was no stone recurrence in donor or recipient.nnnCONCLUSIONSnThis report shows the feasibility and safety of ex-vivo URS and ex-vivo Pyl in living donors, in select cases with subcentimeter calculi, an option of conservative management with Double-J stent is safe. ESWL/RIRS can be performed safely in the pretransplant setting. Proper donor selection and follow-up are crucial to success. We propose a treatment selection algorithm for management of these donors.

Donor gonadal vein reconstruction for extension of the transected renal vessels in living renal transplantation

Introduction: Donor gonadal vein is a readily available vascular reconstruction material for vascular reconstruction, for difficult situations, in living related renal transplantation. Vein extension with the gonadal vein has been described as a simple and safe method to elongate renal vein especially in right living donor kidneys. We applied the donor gonadal vein for lacerated accessory renal artery and renal vein reconstruction. Materials and Methods: The donor gonadal vein was used to reconstruct the lacerated accessory renal artery in one patient. The donor gonadal vein was isolated, used as an interposition graft to bridge the gap between transected accessory renal artery and external iliac artery of the recipient. In another patient, gonadal vein was used to reconstruct short right renal vein, which got damaged during retrieval. Results: This technique resulted in a tension-free anastomosis. There were no procedure related complications. The ischemia time remained within acceptable limits and grafts showed excellent outcomes. Conclusions: The use of gonadal vein for renal vascular reconstruction seems to be an acceptable option during living related renal transplantation, lest the need arise, with no increased graft morbidity.

Measuring stone surface area from a radiographic image is accurate and reproducible with the help of an imaging program.

BACKGROUND AND PURPOSEnThe surface area of the stone from a radiographic image is one of the more suitable parameters defining stone bulk. The widely accepted method of measuring stone surface area is to count the number of square millimeters enclosed within a tracing of the stone outline on graph paper. This method is time consuming and cumbersome with potential for human error, especially when multiple measurements are needed. The purpose of this study was to evaluate the accuracy, efficiency, and reproducibility of a commercially available imaging program, Adobe Photoshop 7.0 for the measurement of stone surface area.nnnMATERIALS AND METHODSnThe instructions to calculate area using the software are simple and easy in a Windows-based format. The accuracy of the imaging software was estimated by measuring surface areas of shapes of known mathematical areas. The efficiency and reproducibility were then evaluated from radiographs of 20 persons with radiopaque upper-tract urinary stones. The surface areas of stone images were measured using both graph paper and imaging software. Measurements were repeated after 10 days to assess the reproducibility of the techniques. The time taken to measure the area by the two methods was also assessed separately.nnnRESULTSnThe accuracy of the imaging software was estimated to be 98.7%. The correlation coefficient between the two methods was R(2) = 0.97. The mean percentage variation using the imaging software was 0.68%, while it was 6.36% with the graph paper. The mean time taken to measure using the image analyzer and graph paper was 1.9 +/- 0.8 minutes and 4.5 +/- 1.08 minutes, respectively (P < 0.001)nnnCONCLUSIONnThe imaging program is accurate, fast, and highly reproducible in estimating two-dimensional stone surface area from radiographs compared with manual measurements using graph paper.

Renal Deterioration Index: Preoperative Prognostic Model for Renal Functional Outcome After Treatment of Bilateral Obstructive Urolithiasis in Patients with Chronic Kidney Disease

BACKGROUND AND PURPOSEnPatients who present with varying severity of obstructive urolithiasis behave differently after the treatment. Some patients recover with improved renal function while others progress to renal failure. Our objective was to objectively quantify which patients would progress to renal failure after treatment for obstructive urolithiasis.nnnPATIENTS AND METHODSnA prospective analysis of 167 patients with renal failure from bilateral obstructive urolithiasis who were treated and subsequently followed for at least 1 year was performed. Failure was defined as glomerular filtration rate (GFR) values less than 15 mL/min at 1 year follow-up. All patients had preoperative placement of a percutaneous nephrostomy tube for at least 5 days before treatment with either ureteroscopy or percutaneous nephrolithotomy. Multiple logistic regression analysis of affecting parameters was performed. A renal deterioration index (RDI) was constructed based on scores assigned to varying severity of multivariate significant factors and the receiver operating characteristic (ROC) curve was analyzed.nnnRESULTSnThere were 48(28.7%) patients who progressed to CKD stage V at 1-year follow-up. Combined cortical width (≤ 0.001), proteinuria (0.01), positive urine culture (0.004), and nadir preoperative GFR postbilateral percutaneous nephrostomy (0.016) were statistically significant factors affecting renal deterioration on multivariate analysis. RDI has a high ROC curve (AUC=0.90) for predicting renal functional outcome. Combining these parameters in a prediction table yielded a RDI score ≥ 12 being associated with high odds risk (odds ratio=11.2) of treatment failure.nnnCONCLUSIONnRDI ≥ 12 is associated with renal deterioration after appropriate treatment of bilateral obstructive urolithiasis.

Face and content validity of transurethral resection of prostate on Uro Trainer: is the simulation training useful?

BACKGROUNDnUro Trainer (UT; Karl Storz GmbH, Tuttlingen, Germany), a virtual reality simulator for transurethral resection of prostate (TURP), has been infrequently validated. To ascertain the utility of such a trainer, we performed a basic face and content validity study.nnnMATERIALS AND METHODSnTen experts and nine novices (done more than 50 and less than 3 TURPs, respectively) performed a TURP on UT and rated simulator usefulness (seven items), realism (five items), and overall score (one item) on a Likerts 10-point scale. Scores of < 6.0, 6.0 to 8.0, and > 8.0 on the Likert scale 1 to 10 were considered not, slightly, and highly acceptable, respectively.nnnRESULTSnNovices rated UT as more helpful than experts in the following aspects of face and content validity: usefulness general (p = 0.0001, statistically significant), hand-eye coordination (p = 0.04, statistically significant), material knowledge and skills (p = 0.02, statistically significant), spatial skills (p = 0.003, statistically significant), cystoscopy (p = 0.002, statistically significant), TURP (0.002, statistically significant), visual aspects (p = 0.003, statistically significant), and overall score (p = 0.007, statistically significant). One item of usefulness (coagulation) and three items of realism (tissue feel, depth feel, and capsule identification) failed to impress both novice and experts. UT usefulness domain was highly acceptable for 77.7% and slightly acceptable for 100% of the novices and experts, respectively. The general realism domain was highly and slightly acceptable for 33.3% and 66.6% of the novices while slightly acceptable for 100% of the experts.nnnCONCLUSIONnNovice group found UT more useful than the experts group. Further modification is advisable to increase the realism of the UT.

Management of acute anastomotic transplant renal artery stenosis in orthotopic renal transplantation by percutaneous angioplasty and stenting in the early post-operative period

Despite recent advances, post-renal transplant vascular complication rate remains stable. We report a case of a 55-year-old male, chronic smoker with extensive atherosclerotic disease who underwent right orthotopic live related renal transplantation. On 6th post-operative day, the patient had sudden drop in urine output and graft site pain and found to have acute anastomotic transplant renal artery stenosis (TRAS), which was managed successfully with percutaneous angioplasty (PA) and stenting. His post-operative course was uneventful and has normal renal functions at 6 months post-transplant period.