Rohit Kathpalia

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.

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.

Comparison of Extracorporeal Shock Wave Lithotripsy for Inferior Caliceal Calculus Between Children and Adults: A Retrospective Analysis—Why Do Results Vary?

OBJECTIVE To retrospectively evaluate the effectiveness of extracorporeal shock wave lithotripsy (ESWL) for inferior caliceal calculi ≤ 20 mm in size and compare the results between children and adults. MATERIALS AND METHODS From January 2004 to January 2012, ESWL was performed for inferior caliceal calculi in 230 children and 1006 adults. The Dornier compact alpha-K1025163 (Dornier Med Tech) was used. The success rates, number of ESWL sessions required, and auxiliary procedures used were evaluated in a comparative manner. RESULTS The overall stone-free rate (for both stone sizes) was 82.2% for children and 40% for the adults. Of the children, 17% had a residual stone compared with 47.8% of the adults. ESWL was unsuccessful in 0.8% of children and 12.2% of adults. The mean number of ESWL sessions required in children and adults was 1.43 (range 1-4) and 2.13 (range 1-4), respectively. Repeat treatment was required in 31% of the children and 65% of the adults. Auxiliary procedures were required in 5.2% of the children and 16.2% of the adults. Complications were seen in 5.6% of the children and 15% of the adults. CONCLUSION The results of ESWL for inferior caliceal calculi ≤ 20 mm in adults remains poor but not so in children. Children can achieve high stone-free rates, require a fewer number of ESWL sessions than adults to be stone free, and have a lower need for repeat treatment and auxiliary procedures, and have fewer complications.

Comment to Lira-Dale et al.: Effect of intraprostatic epinephrine on intraoperative blood loss reduction during transurethral resection of the prostate

We appreciate the authors for conducting this study on the effect of intraprostatic epinephrine on intraoperative blood loss reduction during transurethral resection of the prostate, but few points need clarification [1]. The authors have shown the benefits on intraoperative blood loss but do not mention whether intraprostatic epinephrine had any benefit in postoperative period. We assume that the vasoconstrictive effect of epinephrine can conceal the bleeding vessels intraoperatively that could have been coagulated and postoperatively as the effect weans off, these patients may have reactionary hemorrhage [2]. Is there any reason why the resected prostatic tissue was less in epinephrine group than the placebo group, despite larger gland volume in the former? This can bias the results as the intraoperative blood loss is proportional to the resected tissue [3]. Finally, the amount of epinephrine injected into the prostate was fixed, that is, 20 ml. Probably, the effect may vary based on prostate volume, where smaller glands may require lesser dose in comparison with larger ones. We would like to have author’s opinion in this context.

Urethral skip metastasis from cancer penis or a second malignancy? A dilemma!

A 76-year old man presented with stricture of bulbar urethra for which he underwent urethral dilatation and was advised to perform self urethral dilatation. Four months later he noticed an ulcerative lesion over glans penis and its biopsy revealed a verrucous carcinoma. This was managed by partial penectomy. The resection margins were free of tumor. Two months following surgery, the patient again developed poor urinary stream. Physical examination revealed normal urethral meatus and there was a hard swelling in midperineal area suggestive of urethral calculus. Retrograde urethrogram showed an irregular filling defect in peno-bulbar urethra (Figure-1). Cystoscopy was inconclusive as only one surface of the lesion was visible and that too was covered by slough. In view of advance age and localized excisable disease, the patient underwent wide excision of the mass with permanent perineal urethrostomy. The histopathological examination of the mass showed hyperkeratinised stratified squamous epithelium showing acanthosis and papillomatosis suggestive of verrucous carcinoma (stage T2). COMMENTS

Scrotal calcinosis: pathogenetic link with epidermal cyst.

Scrotal calcinosis is a rare entity characterised by multiple calcified nodules in the scrotal skin. Various pathogenetic mechanisms have been postulated in the literature to explain the origin of these nodules; however, debate continues among variable opinions and evidence. We report two cases of scrotal calcinosis developing from an epidermoid cyst with demonstration of pathology at various stages, thereby suggesting calcification of epidermal cysts as an initiating event in the pathogenesis of the disease, at least in a few cases.

Preventing inadvertent placement of foley catheter into prostatic urethra during suprapubic trocar cystostomy: A simple face-saver trick

During suprapubic cystostomy using standard technique, there always remains a chance of accidental migration of foley catheter through bladder neck into prostatic urethra. We herein present a point of technique in which by keeping the direction of cannula slot toward umbilicus and making it vertical or slightly tilting its tip toward umbilicus during foley placement, prevents the inadvertent migration of catheter into prostatic urethra and further complications.

Re: Ozden et al.: Long-term outcomes of percutaneous nephrolithotomy in patients with chronic kidney disease: a single-center experience. (Urology 2012:79:990-995).

o 2. Morris DL. Pre-operative albendazole therapy for hydatid cyst. Br J Surg. 1987;74(9):805-806. 3. Stamatakos M, Sargedi C, Stefanaki Ch, et al. Anthelminthic treatment: an adjuvant therapeutic strategy against Echinococcus granulosus. Parasitol Int. 2009;58:115-120. 4. Junghanss T, Menezes da Silva AM, Horton J, et al. Clinical management of cystic echinococcosis: state of the art, problems, and perspectives. Am J Trop Med Hyg. 2008;79(3):301-311. 5. Cotting J, Zeugin T, Steiger U, et al. Albendazole kinetics in patients with echinococcosis: delayed absorption and impaired elimination in cholestasis. Eur J Clin Pharmacol. 1990;38:605-608.

Re: Elkoushy et al.: pulsed fluoroscopy in ureteroscopy and percutaneous nephrolithotomy (urology 2012;79:1230-1235).

We read this report with great interest and congratulate the authors for successfully performing this quality improvement project to assess the effect of using pulsed fluoroscopy (PF) compared with standard fluoroscopy on the total fluoroscopy time during ureteroscopic (URS) holmium laser lithotripsy and percutaneous nephrolithotomy to reduce radiation exposure. The conclusion of their study seems very straightforward. The authors concluded that the use of PF during URS holmium laser lithotripsy and percutaneous nephrolithotomy led to significant reductions in fluoroscopy time. This, in turn, led to a decrease in radiation exposure for both patients and operating room personnel without a loss of diagnostic information. However, we believe that the message of their study has not been highlighted properly. Expressing the “reduction in the time of radiation exposure” by PF in percentages rather than in terms of the absolute time reduction would probably be more appealing and informative. That is, rather than reporting a 65-second reduction in radiation duration in the URS cohort, it would be better to report the 60% (65/110 100) reduction in fluoroscopic time using PF compared with standard fluoroscopy. This is important because the percentage of reduction in fluoroscopy time would translate into a similar reduction in the radiation dose. Thus, it could be concluded that PF decreased the duration of radiation (and, hence, the dose of radiation) by 60% during URS and by 65% during percutaneous nephrolithotomy compared with standard fluoroscopy. The authors do not mention whether they used overthe-table or under-the-table fluoroscopy sources. This is important for 2 reasons. First, under-the-table systems have lead curtains that reduce the scatter radiation by a factor of 30-70. However, the over-the-table systems do not because the lead curtains are impractical for endourologic interventions, which require sterile conditions. n

Bulbous urethral stricture: a rare and grave complication of suprapubic catheterisation

We report a very rare complication of bulbous urethral stricture following suprapubic catheterisation (SPC). A 67-year-old paraplegic man underwent SPC for urethral trauma. During SPC, the catheter slipped across the bladder neck into the bulbous urethra where the balloon was inflated. Follow-up retrograde urethrograms showed the gradual evolution of stricture at the same site. This report highlights yet another pitfall of the SPC procedure. We also describe the ways to avoid this complication.