Samit Chaturvedi

Percutaneous Nephrolithotomy in Ectopically Located Kidneys and in Patients with Musculoskeletal Deformities

Objective: To assess the feasibility, safety and results of percutaneous nephrolithotomy (PNL) in ectopically located kidneys and in patients with musculoskeletal deformities. Patients and Methods: Thirteen such patients underwent PNL between June 2005 and May 2008. Mean stone size was 27.4 mm (16–37 mm). Six patients had severe kyphoscoliosis, 2 patients each had achondroplasia, cross-fused ectopia and pelvic ectopic kidney, and 1 patient had thoracic kidney. All had a preoperative CT scan of the abdomen. Preoperative ultrasound- or CT-guided percutaneous nephrostomy (PCN) was done in 10 patients. Three patients underwent laparoscopic-assisted PNL. All underwent standard PNL. The stone-free rate, complication rate and need for secondary intervention were evaluated. Results: PNL was successfully completed in all. A second ultrasound-guided intraoperative puncture was required in 2 patients. Re-look PNL was required in 1 patient and the same patient later required shock wave lithotripsy for complete stone clearance. The remaining 12 patients (92.3%) were rendered stone-free in a single sitting. Conclusion: PNL is a feasible and effective modality in anomalous kidneys. Preoperative planning with CT and image-guided PCN is helpful in these situations. Laparoscopic-assisted PNL can be safely performed in patients where access to a renal collecting system by fluoroscopy or image-guided assistance (ultrasound or CT scan) is not possible.

Is port site metastasis a result of systemic involvement

Aims: Port site metastasis (PSM) is an unwelcome consequence of laparoscopy for oncological procedures with uncertain etiology. We present the clinical evidence to prove that PSM is likely to be due to the hematogenous spread of tumor cells. Materials and Methods: Six cases of port site metastasis, four following laparoscopic radical nephrectomy for localized renal cell carcinoma (RCC), one after laparoscopic radical prostatectomy done in two patients and one after laparoscopic partial cystectomy for tumor at bladder dome done in two were studied. One case of metastatic RCC with bilateral gluteal masses and two cases of open radical nephrectomy, with recurrence at the drain and incision site were also studied. Results: During the median follow up of 59 months (range 24–120), 4/136 patients with RCC (1.47%) developed port site metastasis between 7–36 months after surgery. All six cases of PSM had advanced disease and recurrences at other sites, that is, peritoneum, omentum, bones, and lungs. None of the patients had isolated PSM. One patient of metastatic RCC, who did not have any intervention but repeated intramuscular injections of analgesics-developed bilateral gluteal masses, confirmed to be RCC on fine needle aspiration cytology. Two patients had metastasis at the incision site (one at the drain site) with distance, including cutaneous metastases. Conclusions: Port site metastasis did not develop in isolation. There could be a likely existence of circulating tumor cells at the time of surgical trauma of penetrating nature, that is, port site or injection site, which manifest in some patients depending upon their immune response.

Managing disorder of sexual development surgically: A single center experience

Introduction: Ambiguous genitalia are a major cause of parental anxiety and create psychological and social problems to patient, if not managed properly. Here we present our experience in managing patients with ambiguous genitalia. Material and Methods: We retrospectively reviewed clinical records of all patients with ambiguous genitalia managed surgically at out institute between December 1989 and January 2011. Relevant history, clinical examination, investigations and surgical procedures performed were analyzed and results were evaluated in terms of anatomical, functional and psychosexual outcomes. Results: Female pseudohermaphroditism was the most common cause of genital ambiguity in our patients. Male and female genitoplasty was done according to gender of rearing, genital anatomy and parental choice. Twenty six patients (86.6%) reported satisfactory cosmetic outcome and 22 (73.3%) satisfactory functional outcome on long term follow-up. Among the 24 patients diagnosed as male pseudohermaphroditism 14 (82.3%) patient have reported satisfactory cosmetic outcome and 13 (76.4%) have reported satisfactory functional outcome. In patients with mixed gonadal dysgenesis and true hermaphroditism satisfactory cosmetic and functional outcome was seen in 70% patient. Conclusion: Managing patients of genital ambiguity according to gender of rearing, genital anatomy and parental choice carries good prognosis in terms of anatomical, functional and psychosexual outcome.

Laparoscopic live donor nephrectomy: comparison of outcomes right versus left

OBJECTIVE To compare outcomes between right- and left-sided laparoscopic live donor nephrectomy (LDN). Left LDN (LLDN) remains the side of choice whenever possible because the left renal vein is longer; however, there are some donors in whom the right kidney is taken for donation due to anatomical or functional reasons. Right LDN (RLDN) is perceived to be difficult due to anatomical factors. Therefore, many surgeons have a bias for left kidney donation or will do right side donation as an open donor nephrectomy. At our institution, we routinely perform RLDN when indicated and herein compare the outcomes between right- and left-sided LDN. METHODS From January 2007 to January 2017, 1850 laparoscopic donor nephrectomies were conducted at the Max Super Speciality Hospital. Of these, 168 were right-sided donor nephrectomies and 1682 were left-sided donor nephrectomies. All the donor case records were retrospectively reviewed; the operative time, warm ischemia time, intraoperative events, blood loss, and postoperative parameters were recorded. The kidney recipient data were also recorded. RESULTS The donor demographic characteristics were comparable between 2 groups. Among other variables, operating time was significantly less in RLDN (120 minutes) versus the LLDN group (146 minutes). Intraoperative estimated blood loss (118 mL in RLDN; 126 mL in LLDN), warm ischemia time (4.8 minutes in RLDN; 5.2 minutes in LLDN) and hospital stay (4.2 days in RLDN; 4.3 days in LLDN) was comparable. Vascular complications occurred in four patients in the RLDN group and six cases in the LLDN group. Recipient outcomes were comparable. CONCLUSIONS With adequate experience, RLDN can be accomplished in a safe manner with comparable outcomes to LLDN.

Standard vs Modified Technique of Laparoscopic Donor Nephrectomy

Introduction Laparoscopic donor nephrectomy (LDN) has now become a standard procedure to retrieve the kidney. We present a modified technique of laparoscopic trans-peritoneal donor nephrectomy, which reduces total surgery time, chances of vascular spasm and post-operative lymphatic leak. Materials and Methods We started doing LDN in standard fashion from the year 1998. Donor was placed in kidney position. Standard port placement was done and colon was mobilised medially. Ureter-gonadal vein complex was identified and followed cranially till renal vein. Dissection of lymphatic vessels was carried out around the renal pedicle and renal fat was dissected free with baring of the kidney. Graft was retrieved through preplaced Pfannensteil incision. There were a number of cases with renal artery spasm and occasional acute tubular necrosis (ATN), lymphorrhoea and prolonged drainage from drain in situ. We modified this technique from 2010 with minimal dissection around renal vessels and mobilization of kidney along with renal fat. Lymphatic vessels were clipped and cut after clipping and cutting renal vessels. Removal of perinephric fat and lymphatics was done on the bench. (Video of the techniques to be demonstrated during oral presentation). Results We performed around 1200 LDN with standard technique vs. 800 cases with modified technique. Mean operative time in modified technique was 104 min vs. 136 min in standard technique. Mean duration of drain in situ was 4.2 days for standard technique vs. 2.3 days in modified technique. Renal artery spasm requiring papaverine instillation was in 112 cases of standard technique vs. nil in modified technique. Post operative ATN was seen in 24 cases of standard technique vs. 6 cases of modified technique. Minor renal trauma was seen in 86 cases of standard technique vs. in 12 cases of modified technique. Conclusions Our modified technique of LDN reduces chances of arterial spasm and subsequent ATN, total surgery time and incidence of post-operative lymphatic leak. Chances of renal injury (hematoma/tear) are also minimized.

Prospective Comparison Between Open and Robot Assisted Kidney Transplant: Our Initial Results

Introduction Herein, we compare our first 30 consecutive robot assisted kidney transplant (RAKT) with 30 open kidney transplants (OKT) done during the same period. Materials and Methods All eligible patients were explained about both procedures. Patients were divided into the two groups based on their preference. Right sided grafts and grafts with more than two arteries were excluded. After bench preparation, graft was placed in gauze jacket and placed inside peritoneal cavity using Gel-port or Pfannenstiel incision. Da Vinci surgical system was docked; graft vein and artery were consecutively anastomosed with external iliac vein and artery using end-to-side fashion with Gor-tex® 6-0 suture. Modified Lich-Gregoir ureteroneocystostomy was done. Data was prospectively maintained and analyzed. The comparison was done using Levens’s test for equality of variances and student’s t-test for equality of means. Results All patients were live related, either first degree or second-degree relatives. The two groups were comparable in terms of age, sex, duration on hemodialysis (HD) and warm ischemia time (WIT). Recipients in RAKT group were having higher body mass index (BMI). Re-warm ischemia time was longer and fall of creatinine was slower in RAKT as compared OKT, but were not statistically significant. There was statistically significant less requirement of perioperative analgesic dose in RAKT group. One patient in RAKT expired on 25th day due to massive brain haemorrhage. She was a case of juvenile diabetes with diabetic nephropathy and was on HD for 36 months prior to presenting for transplant. Two patients with morbid obesity (BMI – 42 and 47) developed hospital acquired respiratory infection and required ventilator support and colistin. Both recovered completely and their creatinine at 1-year follow up is 1.6 and 2.2 mg/dL respectively. Rest all patients did very well Figure. No caption available. Conclusions This is our initial experience of RAKT, which is comparable to our vast experience in OKT. After 10 cases, our anastomosis time and re-warm ischemia time has steadily improved and is presently in well-selected cases, the results are similar. RAKT a very good modality especially in morbidly obese patients, where wound related complications are minimum.

Trans-vaginal total pelvic floor repair using customized prolene mesh: A safe and cost-effective approach for high-grade pelvic organ prolapse.

Aims: To assess safety, efficacy, and cost-effectiveness of trans-vaginal total pelvic floor repair with customized prolene mesh in patients with high-grade pelvic organ prolapse. Materials and Methods: A total of 32 patients, who underwent trans-vaginal total pelvic floor repair using a customized prolene mesh from January 2007 to June 2010 for grade III and IV pelvic organ prolapse, were analyzed retrospectively. Prolapse was graded using Pelvic Organ Prolapse Quantification system of International Continence Society. Patients were evaluated for symptoms associated with prolapse pre- and postoperatively. Results: Of the 32 patients, 18 were grade IV uterine prolapse, 10 were grade III uterine prolapse, and 4 were grade IV vault prolapse. Twenty-eight patients underwent vaginal hysterectomy at the time of repair. All the patients had associated anterior and posterior prolapse of varying degree. Follow-up ranged from 6 to 42 months. All patients had symptomatic relief after surgery. There were no intraoperative rectal or bladder injuries. Early complications were perineal pain (30), de novo urgency (4), vaginal discharge (3), vaginal wall hematoma (2), and failure to void (2). Two patients had vaginal erosion of mesh. Conclusions: Trans-vaginal total pelvic floor repair using a customized prolene mesh is safe and effective treatment for comprehensive repair of high-grade pelvic organ prolapse. The use of this custom-made prolene mesh makes the procedure very cost-effective and affordable. The reduction in cost is about 25-30 times with the use of this mesh when compared with commercially available variety.

081 LAPAROSCOPIC LIVE DONOR NEPHRECTOMY: A SINGLE CENTRE EXPERIENCE

Discussion: Acute Humoral Rejection has been described rarely to occur with de novo production of DSAs. Usually less than 10% of C4D positive biopsy samples show features suggestive of ATN. Conventional regimes for treatment of AMR include IVIG + Plasmapharesis +/Rituximab. We are reporting this case for the unexpected nature of the clinical setting in which he developed Antibody mediated rejection and for the use of Plasmapharesis with rATG as an economically viable and efficacious alternative treatment regimen for Acute Antibody-mediated rejection.