Shivanshu Singh

Robot-assisted heminephrectomy for chromophobe renal cell carcinoma in L-shaped fused crossed ectopia: Surgical challenge

Renal cell carcinoma associated with fused ectopic kidneys has rarely been reported in the literature. Here we report the first case of robot-assisted heminephrectomy for chromophobe renal cell carcinoma in an L-shaped fused ectopic kidney. The present case report highlights the importance of three-dimensional vision and enhanced maneuverability with the EndoWrist technology of the robotic surgical system for precise dissection. This report also highlights the importance of preoperative contrast-enhanced computed tomography with three-dimensional arterial reconstruction for surgical planning.

Giant Abdominoperineal Malignant Schwannoma: An Unusual Presentation and Surgical Challenge

Schwannoma is a benign tumor arising from the Schwann cells of peripheral nerves. These are usually benign but malignant transformation can occur in larger lesions. The definitive diagnosis of malignancy can only be made after final histopathological report. The literature reports large pelvic and perineal schwannomas with few being malignant. We report the first case of such giant malignant abdominoperineal schwannoma which was benign on initial biopsy but final histopathology revealed it to be malignant. In view of proximity of perineal and pelvic tumors to urogenital organs and pelvic nerves, such cases represent a challenge to surgical excision. This case brings to highlight another atypical presentation of such tumors.

Day care PNL using 'Santosh-PGI hemostatic seal' versus standard PNL: A randomized controlled study.

Introduction To compare the outcomes of tubeless day care PNL using hemostatic seal in the access tract versus standard PNL. Material and methods It was a prospective randomized controlled study. Cases were randomized to either the day care group with hemostatic seal (DCS) or the control group where patients were admitted and a nephrostomy tube was placed at the conclusion of surgery. Results A total of 180 cases were screened and out of these, 113 were included in the final analysis. The stone clearance rates were comparable in both the groups. The mean drop in hemoglobin was significantly lower in DCS group than the control group (1.05 ±0.68 vs. 1.30 ±0.58 gm/dl, p = 0.038).Mean postoperative pain score, analgesic requirement (paracetamol) and duration of hospital stay were also significantly lower in the DCS group (3.79 ±1.23 vs. 6.12 ±0.96, 1.48 ±0.50 vs. 4.09 ±1.11 grams and 0.48 ±0.26 vs. 4.74 ±1.53 days respectively; p <0.05). The incidence of urine leakage through the access tract site was significantly lower in the DCS subgroup when compared to the controls (3.6% vs. 21.1%, p <0.05). Cases in the DCS group resumed their normal activities in a significantly shorter time (8.05 ±3.05 vs.18.42 ±4.42 days; p <0.05). Higher proportion of cases in the DCS group got re-admitted, although it was not a statistically significant number (7.1% vs. 1.8%; p = 0.21). Conclusions Tubeless day care PNL with composite hemostatic tract seal is considered safe. It resulted in a significant reduction of blood loss and analgesic requirement with significantly reduced hospital stay, nephrostomy tube site morbidity and time required to resume normal activity when compared to the standard PNL. However, patients must be compliant with the given instructions and should have access to a health care facility, as few of them may need re-admission.

Genitourinary Hydatid Disease

Genitourinary echinococcosis is an uncommon cyclo-zoonotic disease. It is caused by Echinococcus species. Kidneys are the common target organs in the genitourinary tract. Clinical presentation is usually non-specific. Pre-operative diagnosis requires a high index of suspicion. It should be considered in differential diagnosis of cystic mass of genitourinary tract, especially in endemic regions. Computed tomography, ultrasonography, and antibody testing aid in diagnosing and classifying the stage of the cyst. Although a number of operative techniques have been described, complete removal of germinal layer with daughter cysts without spillage of viable cyst contents with perioperative medical therapy provides an optimum chance of cure with minimal morbidity. Considering the benign nature of the disease, organ preservation is feasible in majority of the cases. The conventional open surgical treatment has evolved into minimally invasive laparoscopic, endoscopic, and even robotic techni‐ ques with concomitant improvement in postoperative and cosmetic outcome. Given the rarity of the disease, no randomized control trial comparing the treatment modalities for genitourinary hydatid exists. Moreover, long-term follow up in many cases is unavailable. Overall, the incidence of local and systemic recurrence is low.

PD63-03 RECOVERY OF THE FUNCTION OF THE KIDNEY FOLLOWING RENAL TRAUMA AND CONSERVATIVE MANAGEMENT

INTRODUCTION AND OBJECTIVES: The majority of patients with renal trauma are managed conservatively regardless of grade of injury once they are stable with resuscitation. However, it is not known what happens to the function of the affected kidney following initial loss due to trauma. METHODS: In this prospective study conducted from July 2014 to December 2015 patients with unilateral renal injury and contra-lateral normal kidney were included. Their renal injury was graded according to American Association for the Surgery of Trauma. They underwent first DMSA renal scan within 7 days and second DMSA scan 3 months after trauma for assessment of early and delayed relative function of injured kidney respectively. Patients requiring any surgical and radiological intervention were excluded from the study. RESULTS: Total 32 patients fulfilled the inclusion and exclusion criteria and completed the study. The mean early relative function of the injured kidney (35.7 15.8 %) improved significantly at 3 months (39.6 17.7%, p < 0.001). When we considered grade I to grade III as low grade we observed that the improvement was significant in kidneys with low grade injury (from 46.1 3.2% to 50.4 2.7%, p < 0.01) and grade IV injury. There was no improvement of function of kidney with grade V injury (Table I). The preserved function and improvement of function was associated with low grade injury, low degree of parenchymal loss and no vascular injury (p<0.01, Table 2). On multivariate analysis only vascular injury was associated with no significant improvement in function. The relative renal function improved in 25 patient remained almost the same in 3 patients and decreased in 4 patients. Significantly a high proportion of kidney with high grade injury, more than 50% of parenchyma loss and vascular injury had loss of relative function more than 5 %. CONCLUSIONS: Retained renal function following conservative management depends on grade of renal injury, degree of parenchymal loss and vascular injury. The improvement of function of injured kidney occurs with passage of time in the majority except those with vascular injury. Source of Funding: none

Robot-assisted "Santosh-Post Graduate Institute tubularized flap pyelovesicostomy" in a solitary functioning kidney with giant hydronephrosis: A minimally invasive salvage procedure.

We describe a case of a solitary functioning kidney with giant hydronephrosis secondary to ureteropelvic junction obstruction in a young girl who underwent successful robot-assisted tubularized flap pyelovesicostomy. The aim of this report was to highlight the feasibility and efficacy of this technique in salvaging such renal moieties and to present a brief review of the surgical options available for the management of giant hydronephrosis.

Organ Preservation in a Case of Retroperitoneal Ganglioneuroma: A Case Report and Review of Literature

The retroperitoneum is a closed space harbouring vital organs including the great vessels, kidneys and adrenal glands, ureters, and the ascending and descending colon. Surgical management of retroperitoneal pathologies may need multiorgan resection in order to achieve complete surgical resection while preservation of surrounding organs should be attempted, especially in case of benign tumors. We present a case of 15-year-old girl with an 11 × 6 × 5 cm retroperitoneal ganglioneuroma displacing the right kidney, renal vein, and ureter and abutting the IVC which was excised in toto preserving the right kidney and ureter with careful dissection around the great vessels. We also attempt to review the various surgical options available while dealing with these benign retroperitoneal tumors which are often detected incidentally and usually surround important retroperitoneal organs and vessels.

Pelvic pheochromocytoma mimicking as urinary bladder pheochromocytoma: looking beyond the obvious.

Pheochromocytomas located outside the adrenal glands are called paragangliomas. A pelvic location is rare, the most common location for a paraganglioma being the retroperitoneal space. Paragangliomas arise from neural crest cells. Pelvic pheochromocytomas may mimic urinary bladder pheochromocytomas on imaging studies. Patients may present with hypertensive crisis during micturition. We present a 26-year-old female who presented to us with accelerated hypertension with episodes of severe headache and palpitation during micturition. Based on imaging studies, she was diagnosed to have a urinary bladder pheochromocytoma. However, on exploration, the patient was found to have an extravesical pheochromocytoma arising from the left posterolateral pelvic wall, which was excised while preserving the bladder. We present this case report as pelvic pheochromocytomas can mimic bladder pheochromocytomas and are difficult to differentiate on radiological imaging and can lead to inadvertent cystectomy.

Robot assisted calycovesicostomy in solitary giant hydronephrotic kidney: safe and feasible surgical procedure

Ureteropelvic junction obstruction is a common congenital anomaly with an incidence of 1 in 1500 population [1]. While in developed countries most cases present in paediatric age group, in developing countries most patients present in adulthood. Alsoit is not uncommon to find cases of giant hydronephrosis occurring due to congenital UPJO. Giant HDN per se offer a surgical challenge in treating these complex entities even with open surgical procedures. A variety of surgical procedures are described in literature ranging from reduction pyeloplasty to complex surgical procedures like pyelovesicostomy or calycovesicostomy. The advent of robotic surgery has allowed us to manage such cases with minimally invasive approach. We report a case of solitary functioning kidney with giant hydronephrosis who successfully underwent robot assisted calycovesicostomy and is probably the first reported case in the literature.

Instrument malfunction during robotic surgery: A case report.

Robotic assistance is the new dimension of minimally invasive surgery. Despite being the state-of-the-art technology, newer technical problems still occur during robotic surgeries which are not addressed in the trouble shooting manual. We report one such problem being encountered with the tip cover accessory of monopolar scissors. In the current report, we discuss the technical fault and its correction. We feel that this problem needs to be registered into the trouble-shooting manual to prevent such incidents in future.