Rajiv Goel

Multi-tract percutaneous nephrolithotomy for large complete staghorn calculi.

Introduction: The treatment of large complete staghorn calculi requires a sandwich combination of percutaneous nephrolithotomy (PCNL) and shockwave lithotripsy (SWL) or sometimes open surgery. Many urologists hesitate to place more than 2–3 tracts during PCNL because of the belief that this may increase complications. We present data to support multi-tract PCNL for large (surface area >3,000 mm2) complete staghorn calculi. Patients and Methods: From July 1998 to October 2003, 121 renal units (103 patients) with large complete staghorn renal calculi were treated with PCNL. All procedures were performed in the prone position after retrograde ureteral catheterization. Fluoroscopy-guided punctures were made by the urologist followed by track dilation to 34 french. When multiple tracts were anticipated all punctures were usually made at the outset and preplaced wires were put into the collecting system or down the ureter. Stones were fragmented and removed using a combination of pneumatic lithotripsy and suction. Postoperative stone clearance was documented on X-ray KUB. Results: 121 renal units of 103 patients (15 women and 88 men, mean age 43 years) were treated. Six patients had associated bladder calculi that were treated simultaneously. The stone surface area was 3,089–6,012 (mean 4,800) mm2. 10 patients (9.7%) had renal insufficiency with a mean (range) serum creatinine of 3.0 (1.5–5.5) mg/dl. The number of tracts required per patient were 2 tracts in 11, 3 tracts in 68, 4 tracts in 39, and 5 tracts in 3, giving a total of 397 tracts in 121 renal units, over a total of 140 procedures (including second-look procedures in 19 renal units). The points of entry of these tracts were 121 upper calyx (30.4%), 178 middle calyx (44.8%), and 98 lower calyx (24.6%). All 121 units had one upper polar access tract of which 92 (76%) were supracostal. Complications were blood transfusion (n = 18), pseudoaneurysm (n = 2), fever (n = 22), septic shock (n = 1) and hydrothorax (n = 3). PCNL monotherapy achieved an 84% complete clearance rate that improved to 94% with SWL in 8 renal units with small residual fragments. Stone compositions were calcium oxalate (91%), uric acid (2%) and mixed (7%). Conclusion: Aggressive PCNL monotherapy using multiple tracts is safe and effective, and should be the first option for massive renal staghorn calculi.

Minimally Invasive Retroperitoneoscopic Ureterolithotomy

PURPOSE We assessed the efficacy of modified technique of retroperitoneal ureterolithotomy for managing ureteral stones. MATERIALS AND METHODS Between December 1999 and March 2002, 31 patients underwent retroperitoneal ureterolithotomy. In most cases only 3 ports (a 10 mm., 2 5 mm. and in a few 2, 3 mm.) were used without any ureteral stent or catheter. The stone was removed from the primary port site, while visualizing retrieval through the 3/5 mm. port using fine laparoscope. Ureterotomy closure was performed by intracorporeal interrupted sutures of 4-zero polyglactin. RESULTS The 20 males and 11 females had a mean age of 38.5 years. Mean operative time was 67 minutes and mean hospital stay was 2.4 days. The mean analgesic requirement was 42.2 mg. meperidine. Mean followup was 8 months. There were no significant postoperative complications except persistent urine leakage in 2 patients 48 hours after surgery. An internal stent was placed and leakage subsided without any consequences. CONCLUSIONS The modified, minimally invasive technique of retroperitoneal ureterolithotomy is highly effective and efficient without an associated increase in the complication rate.

Upper pole access for complex lower pole renal calculi

Authors from New Delhi assessed the efficacy of superior pole access for complex lower pole calyceal calculi; they found this to be the best way of approaching such complex stones, allowing faster and better clearance with a single puncture.

Cost‐effective laparoscopic pyeloplasty: Single center experience

Objective:  Laparoscopic pyeloplasty (LPP) is a minimally invasive treatment option for ureteropelvic junction (UPJ) obstruction. We report here our experience of performing cost‐effective LPP on 24 patients at a single center.

Cooled lignocaine gel: does it reduce urethral discomfort during instillation?

Introduction: Topical urethral analgesia with 2%lignocaine gel for office procedures is anaccepted practice in contemporary urology.However, instillation of 2% lignocaine gelinto the urethra is associated with discomfort insome patients.Material and Methods: Forty consentingmen reporting for cystoscopy under localanesthesia were randomized to receive 10 ml of2% lignocaine hydrochloride gel at 4 °Cand 22 °C. After instillation of the gel thepatients were immediately asked to score thepain using a nongraphical visual analogue scale.Results: The pain scores were analyzedusing the paired Students t-test. There wassignificant reduction in pain scores in thegroup receiving gel at 4 °C compared with thegroup at 22 °C (P < 0.05).Conclusion: Refrigerating the gel to 4 °Ccan significantly reduce the initial discomfortassociated with instillation of 2% lignocainehydrochloride into the male urethra.

Laparoscopic Assisted Percutaneous Nephrolithotomy (PCNL) in Ectopic Kidneys: Two Different Techniques

Two patients presented with calculi in ectopic kidneys. Complete clearance of calculi was achieved by laparoscopic assisted percutaneous nephrolithotomy (PCNL), by different but related techniques. In one patient with prior history of open pyelolithotomy, the anterior surface of the kidney was exposed by mobilizing the overlying sigmoid colon laparoscopically and the percutaneous tract was established into the desired calyx under combined laparoscopic and fluoroscopic control. In the second patient, the tract was established between the major mesenteric vessels without any mobilization of the bowel. Herein, we outline the nuances of these two related techniques, and the indications and contraindications for their use for laparoscopic assisted PCNL in ectopic kidneys.

Tubeless Percutaneous Nephrolithotomy

Introduction: To assess the efficacy, safety and morbidity of tubeless percutaneous nephrolithotomy. Materials and Methods: One hundred and fifty-two patients with renal and upper ureteric calculi were included in this study. Sixty-nine patients (71 renal units; group 1) in whom no nephrostomy tube was placed at the conclusion of the procedure was compared with a similar control group of 83 patients (group 2) in whom a nephrostomy tube was placed. Operating time, blood loss, analgesia requirement, puncture site urinary leakage, hospital stay and mean convalescence period were compared in both groups. Results: Both groups were similar with respect to age, sex distribution and stone size. Operating time and blood loss were less in group 1 although they did not reach statistical significance. The mean analgesic requirement, puncture site urinary leakage and hospital stay were significantly less in group 1. Conclusion: Tubeless percutaneous nephrolithotomy is a safe and effective procedure in this selected group of patients.

Laparoscopic Repair of Vesicovaginal Fistula

Vesicovaginal fistula (VVF) may be a complication of prolonged repair or urogynecologic surgery. Failing conservative management, it may be repaired using an abdominal or vaginal approach. We herein report laparoscopic repair of VVF following vaginal hysterectomy and detail the operative steps.

Hemostasis in Tubeless PNL: Point of Technique

Introduction: Tubeless PNL (percutaneous nephrolithotomy), in a highly selected group of patients, is a modification aimed at reducing the morbidity of PNL. We present a simple technique of achieving tract hemostasis as an adjunct to the safe performance of a tubeless PNL. Materials and Methods: Charts of 40 consecutive patients who underwent tubeless PNL at our center were reviewed. In the latter 20 consecutive patients, diathermy coagulation of the intrarenal bleeders and tract was done and these patients were compared with the earlier 20 patients in whom fulguration was not done. Drop in hemoglobin, postoperative analgesic requirement, operating time, length of hospitalization and postoperative complications were compared. Results: No statistical difference was found between the operative times and drop in hemoglobin for both the groups. The length of hospitalization and postoperative analgesic requirement were significantly less in the fulguration group. No significant complications were noted in either of the two groups. Conclusions: Fulguration of visible intrarenal and tract bleeders is a simple, safe and effective hemostatic adjunct in patients undergoing tubeless PNL.

Squamous cell carcinoma of the renal pelvis manifesting after percutaneous nephrolithotomy for long standing calculus

Squamous cell carcinoma of the renal pelvis is a rare neoplasm and is usually associated with long standing stone disease. The disease is aggressive in nature and usually has a poor prognosis. We report a case of renal lithiasis who underwent successful percutaneous nephrolithotomy (PCNL) for renal pelvic calculus, and eight months later presented with a large invasive squamous cell carcinoma in the same location.