Rahul Janak Sinha

A Prospective Randomized Study Comparing Percutaneous Nephrolithotomy under Combined Spinal-Epidural Anesthesia with Percutaneous Nephrolithotomy under General Anesthesia

Objective: A prospective randomized study was executed to compare the surgical parameters and stone clearance in patients who underwent percutaneous nephrolithotomy (PNL) under combined spinal-epidural anesthesia (CSEA) versus those who underwent PNL under general anesthesia (GA). Methods: Between January 2008 to December 2009, 64 patients with renal calculi were randomized into 2 groups and evaluated for the purpose of this study. Group 1 consisted of patients who underwent PNL under CSEA and Group 2 consisted of patients who underwent PNL under GA. The operative time, stone clearance rate, visual pain analog score, mean analgesic dose and mean hospital stay were compared amongst other parameters. Results: The difference between visual pain analog score after the operation and the dose of analgesic requirement was significant on statistical analysis between both groups. Conclusion: PNL under CSEA is as effective and safe as PNL under GA. Patients who undergo PNL under CESA require lesser analgesic dose and have a shorter hospital stay.

Prospective evaluation of complications using the modified Clavien grading system, and of success rates of percutaneous nephrolithotomy using Guy's Stone Score: A single-center experience

Introduction and Objectives: To prospectively document the perioperative complications of percutaneous nephrolithotomy (PCNL) using the modified Clavien grading system. Evaluation of complications and clearance rates according to stone complexity using the validated Guys Stone Score (GSS) was also done. Materials and Methods: A total of 221 renal units underwent 278 PCNL procedures at a urology resident training center between September 2010 and September 2011 and data were recorded prospectively in our registry. Patients with co-morbidities like diabetes, renal failure, hypertension and cardiopulmonary diseases were excluded. Stone complexity was classified according to the GSS while peri-operative complications were recorded using the modified Clavien grading system. Results: Two hundred and forty-five complications were encountered in 278 PCNL procedures involving 116 renal units (41.72%). Complications of Grades 1, 2, 3a, 3b, 4a, 4b and 5 were seen in 52 (18.7%), 122 (43.8%), 42 (15.1%), 18 (6.4%), 6 (2.1%), 4 (1.4%) and 1 (0.3%) renal units respectively. There were 68, 98, 50 and 5 renal units in GSS I, II, III and IV groups, respectively. All grades of complications were more common in GSS III and IV (P<0.05). For GSS I, II, III and IV 100%, 74%, 56% and 0% of renal units, respectively, were stone-free after one session and 0%, 24%, 44% and 60% respectively needed two sessions to be stone-free. Conclusion: Although the complication rates were higher most were of low grade and self-limiting. Complications were significantly more common with higher GSS and the GSS effectively predicted stone-free rates.

Prospective comparison of quality‐of‐life outcomes between ileal conduit urinary diversion and orthotopic neobladder reconstruction after radical cystectomy: a statistical model

To conduct a prospective comparison of quality‐of‐life (QoL) outcomes in patients who underwent ileal conduit (IC) urinary diversion with those who underwent orthotopic neobladder (ONB) reconstruction after radical cystectomy for invasive bladder cancers.

Clavien Classification of Semirigid Ureteroscopy Complications: A Prospective Study

OBJECTIVE To prospectively report and grade the perioperative complications of ureteroscopy (URS) for stone removal using a semirigid ureteroscope with the modified Clavien classification system and to identify the determinants of the complications. METHODS From August 2010 to November 2011, the prospective data from 120 consecutive patients (71 men and 49 women) who had undergone primary unstented URS at a resident training center were analyzed. Patients with renal failure, pyonephrosis, diabetes mellitus, hypertension, and congenital ureteral abnormalities were excluded (n = 29). The data recorded included patient demographics, stone size and location, and complications according to the modified Clavien classification system. RESULTS Of the 120 patients, 36 (30%) experienced 79 complications. The stone size was ≤ 10 mm in 56 and >10 mm in 64 patients. The stone location was the lower, mid-, and upper ureter in 62, 58, and 3 patients, respectively. The latter 3 were excluded because of the small sample size. Grade 1, 2, 3a, 3b, 4a, and 4b complications were encountered in 46 (38.3%), 18 (15%), 3 (2.5%), 10 (8.3%), 1 (0.8%), and 1 (0.8%) patient, respectively. The incidence of complications was greater for stones >10 mm, a mid- versus distal ureteral location, impacted stones, and surgery performed by a resident. The incidence was not affected by patient sex, stone laterality, or lithotripter type. The patients with complications had a longer operative time (75 vs 46.5 minutes), longer hospitalization (4.8 vs 1.5 days), and lower stone-free rate (64% vs 97%). CONCLUSION Most complications were grade 1-3 (98%), and grade 4 complications were rare (<2%) with URS. The present study is probably the first to prospectively study the complications of URS using the modified Clavien classification system.

Reconstructive Surgery for Penoscrotal Filarial Lymphedema: A Decade of Experience and Follow-up

OBJECTIVES To present our experience of reconstructive surgery in patients with penoscrotal filarial lymphedema. METHODS From January 2000 to December 2009, we treated 48 patients with penile and penoscrotal filarial lymphedema using reconstructive surgery. Isolated penile involvement was seen in 14 patients, and 34 patients had penoscrotal involvement. All the patients had taken multiple courses of antifilarial drug before surgery. For isolated penile involvement, the diseased penile skin was excised and covered with a split-thickness skin graft. In some patients, the inner prepucial skin was preserved and used to cover the penile shaft. For those with penoscrotal involvement, scrotoplasty was performed, after excising the diseased scrotal skin and underlying soft tissue, while sparing the testes and spermatic cords. RESULTS The mean patient age was 38 years (range 25-52), and the median follow-up time was 48 months (range 10-120). All 48 patients reported a satisfactory cosmetic appearance after the procedure and noted improvement in their ability to void while standing. Also, all of them could ambulate better and resumed sexual activity. Local groin infection was present in 12 patients; all were cured after proper management. CONCLUSIONS In filarial lymphedema of penis and/or scrotum, excision of the diseased tissue and covering with a split-thickness skin graft provided good results. If the inner prepucial skin is healthy, it should be used to cover the distal penile shaft. If the scrotum is involved, scrotoplasty with lateral and posterior mobilized flaps provides satisfactory results.

Transperitoneal versus retroperitoneal laparoscopic ureterolithotomy: a prospective randomized comparison study.

PURPOSE We compared laparoscopic transperitoneal and retroperitoneal ureterolithotomy approaches, and determined whether one technique is superior to the other. MATERIALS AND METHODS In this prospective randomized study from January 2009 to May 2012, 48 patients with proximal or mid ureteral stones underwent transperitoneal laparoscopic ureterolithotomy or retroperitoneal laparoscopic ureterolithotomy. The randomization occurred on a 1:1 basis. Groups 1 and 2 consisted of patients who underwent transperitoneal laparoscopic ureterolithotomy and retroperitoneal laparoscopic ureterolithotomy, respectively. Demographic and clinical characteristics as well as postoperative data were collected and analyzed. Statistical analysis was performed with SPSS® version 15.0 using the Fisher exact and Mann-Whitney U tests with p <0.05 considered statistically significant. RESULTS The difference in visual pain analog score and mean tramadol requirement on days 1 and 2 between the 2 groups was statistically significant, and was higher in group 1 (p <0.05). Postoperative hospital stay and paralytic ileus rates were significantly higher in group 1 (p <0.05). The differences in total operative time and intracorporeal suturing time between the 2 groups were not statistically significant. However, successful stone removal was equal in the 2 groups. CONCLUSIONS For proximal or mid ureteral large and impacted stones, transperitoneal laparoscopic ureterolithotomy is significantly associated with pain, greater tramadol requirement, ileus and longer hospital stay than retroperitoneal laparoscopic ureterolithotomy. However, successful stone removal remains the same in both groups.

A critical appraisal of complications of percutaneous nephrolithotomy in paediatric patients using adult instruments

To evaluate the complications (using the CROES Clavien scoring system) and various factors affecting them in children undergoing percutaneous nephrolithotomy (PCNL).

Squamous Cell Carcinoma of the Kidney â Rarity Redefined: Case Series with Review of Literature

Squamous cell carcinoma of the renal pelvis and ureter is a rare malignancy, having an incidence of 6% to 15% (of all urothelial tumors). Few cases of primary squamous cell carcinoma of kidney have been reported in the world literature. The insidious onset of symptom and lack of any pathognomonic sign, leads to delay in the diagnosis and subsequent treatment, resulting in grave prognosis for these patients. Herein, we report 5 cases (three males and two females) of advanced primary squamous cell carcinoma of kidney that were treated at our centre during the last 6 years. The average age was 57 years (range 50-65 years). Three of the patients had history of long standing renal calculus disease while 3 had history of smoking and 1 patient had history of analgesic abuse. These cases were unique because in few of them; all the calyces were involved by the tumor - a field change type of pattern normally seen in transitional cell carcinoma of the kidney. In one patient, thrombus of the inferior vena cava was also present along with infi ltration of the duodenum by the tumor. Despite prompt nephroureterectomy, 4 out of 5 patients died within 6 months of treatment. Only one patient was surviving at 5 months of follow up. Nephrectomy with or without ureterectomy is the treatment of choice in patients suffering from squamous cell carcinoma of the kidney. There is lack of evidence of survival benefi ts of chemo-radiation following surgery but is advocated by some with the hope that it might increase survival. Biopsy from the renal pelvis or calyceal wall is advocated at the time of stone removal in patients having long-standing history of large renal calculi or staghorn calculus since such patients are capable of harboring occult or overt malignancy.

Transvaginal repair of complex and complicated vesicovaginal fistulae

To document the experience at a tertiary referral hospital in India with managing complex and complicated vesicovaginal fistulae (VVF) by the transvaginal route, and to document the complications and the long‐term outcome of the patients.

Prospective randomized comparison of retroperitoneoscopic pyelolithotomy versus percutaneous nephrolithotomy for solitary large pelvic kidney stones.

Objectives: We performed a prospective randomized comparison of retroperitoneoscopic pyelolithotomy (RP) versus percutaneous nephrolithotomy (PNL) for solitary pelvic stones >3 cm and assessed the outcome results. Methods: From 2010 to 2012, 44 patients with a solitary pelvic stone >3 cm without any anatomical abnormality were randomized to either RP or PNL on a 1:1 ratio. Stone-free rate, number of procedures per patient and complications were recorded. Results: The stone-free rate on the first postoperative day was 95.5% in the RP group versus 72.7% in the PNL group (p = 0.04). The stone-free rates at 3 months were similar between the two groups. Blood loss, visual pain analog score and analgesic requirement on the first postoperative day were significantly higher in the PNL group whereas the mean operative time and overall complications were similar between the two groups. Conclusion: In patients with solitary large pelvic stones, RP is associated with lesser blood loss, postoperative pain and analgesia as well as with a higher stone-free rate in the immediate postoperative period in comparison to PNL. However, the stone clearance rate remains the same at 3 months in both groups.