Siddharth Yadav

Systemic Inflammatory Response Syndrome Following Percutaneous Nephrolithotomy: Assessment of Risk Factors and Their Impact on Patient Outcomes

Objectives: To identify perioperative risk factors for postoperative systemic inflammatory response syndrome (SIRS) and suggest possible modifications to reduce morbidity. Material and Methods: We prospectively analysed perioperative data such as history of pervious stone surgery, number and configuration of stones, presence of stent or nephrostomy, any previous positive urine culture, intraoperative renal pelvic urine and stone culture, aspiration of turbid urine on initial puncture, number of tracts required and clearance of stones, operative time and intraoperative hypotension and tachycardia of all patients who underwent percutaneous nephrolithotomy over a period of 15 months. Results: A total of 182 patients were included, average stone size was 2.8 cm, 36.2% had staghorn stones and 15.9% had an indwelling stent or nephrostomy. Despite sterile preoperative urine culture, renal pelvic urine culture (RPUC) was positive in 14.8% (27 patients) and stone culture was positive in 21.9% (40 patients). SIRS developed in 17.5% (32 patients) and septic shock in 1.09% (2 patients). On analysis younger age, positive RPUC and stone culture, longer operative time and intraoperative tachycardia correlated significantly with the development of SIRS. Conclusion: Intra-operative cultures are only therapy-guiding cultures during SIRS, as preoperative urine cultures seldom accurately depict bacteriological status of upper tracts and thus should be obtained in all patients.

Lymphangioma of the urethra.

We report a case of urethral lymphangioma presenting with frank, painless hemaluria as the only symptom. Such a case has not been described in the literature to our knowledge.

Serum microRNA Expression Profiling: Potential Diagnostic Implications of a Panel of Serum microRNAs for Clear Cell Renal Cell Cancer

OBJECTIVE To study the expression profiles of 5 microRNAs in tissue and serum of patients with clear cell renal cell cancer (ccRCC) and evaluate their diagnostic and prognostic potential. MATERIALS AND METHODS We prospectively analyzed 30 patients of histologically proven ccRCC and collected 3 mL of serum preoperatively and small pieces of tumor and adjacent non-tumor renal tissue intraoperatively. Control serum samples were obtained from 15 patients of non-renal benign diseases. We analyzed 5 miRNAs-miR-34a, miR-141, miR-200c, miR-1233, and miR-21-2. Freshly collected samples were immediately frozen in liquid nitrogen and total RNA was extracted. cDNA was synthesized by reverse transcription, and quantitative polymerase chain reaction was performed to determine relative miRNA expression. RESULTS In the renal tissue and serum samples, 3 out of 5 miRNAs were differentially expressed; that is, the expression levels of miR-34a and miR-141 were significantly decreased, whereas that of miR-1233 was significantly increased. Serum miR-34a, miR-141, and miR-1233 were able to diagnose ccRCC with a sensitivity of 80.76%, 75%, and 93.33%, and specificity of 80%, 73.33%, and 100%, respectively, as compared to histopathology. Using a panel of 2 serum miRNAs (miR-141 and miR-1233) ccRCC can be diagnosed with 100% sensitivity and 73.3% specificity. CONCLUSION miRNAs are differentially expressed in serum of patients with ccRCC and can be used to diagnose ccRCC with high sensitivity and specificity. Diagnostic sensitivity can be further improved by using a panel of miRNAs and has the potential to serve as novel diagnostic markers of ccRCC.

Outcomes of Pyeloplasty in Very Poorly Functioning Kidneys: Examining the Myths

OBJECTIVE To assess the perioperative complications and functional midterm outcomes after pyeloplasty for poorly functioning kidneys due to ureteropelvic junction obstruction. PATIENTS AND METHODS We retrospectively analyzed patients who underwent pyeloplasty for primary ureteropelvic junction obstruction in very poorly functioning kidneys in terms of split renal function of ≤20% or estimated glomerular filteration rate of ≤20 mL/minute. Perioperative complications and postoperative outcomes in terms of symptomatic improvement and functional stabilization or recovery were assessed. RESULTS A total of 32 patients with estimated glomerular filteration rate ≤20 mL/minute or split function ≤20% underwent pyeloplasty since January 2010. All patients were followed for a mean period of 26.8 months and none required reintervention for obstructive drainage, deteriorating function, or intractable pain. One patient had persistent pain requiring analgesics and overall success rate (defined as nonobstructive pattern, no deterioration in split function, and no persistent symptoms) was 93.7%. Thirteen patients (40.6%) showed significant improvement in renal function (>5% over preoperative), and in all except 1 (3.1%) case there was no further deterioration of function. CONCLUSION Pyeloplasty provides high rates of morphological and functional success even in very poorly functioning renal units. There is a possibility of functional recovery in one-third of patients, and in most of the rest, there is no further deterioration.

Fine Needle Aspiration Cytology Diagnosis of an Urachal Adenocarcinoma.

Urachal Carcinoma (UC) is a rare malignancy of urinary bladder. It is usually found in adults in advanced stages because the tumour often grows outside the bladder without producing clinical symptoms. Most of the cases are mucinous, intestinal or signet ring cell adenocarcinoma and the diagnosis is usually made on biopsy. Radiographic images of this tumour may show characteristic features with a midline solid or cystic mass in the anterior wall of bladder associated with small calcification, which is considered as a pathognomonic sign for the diagnosis of UC. We report a case of UC in an adult, whose radiographic images suggested an urachal tumour and Fine Needle Aspiration (FNA) cytology revealed an adenocarcinoma. Laparoscopic partial cystectomy with umbilectomy and pelvic node dissection was done without further histopathological confirmation. Surgical intervention of UC on the basis of FNA diagnosis has not been reported in the literature.

Solitary second metatarsal metastasis as the first site of distant spread in TCC urinary bladder: A case report.

Metastasis to the skeleton is uncommon in muscle-invasive carcinoma of the urinary bladder. When present, it most commonly involves the axial and proximal appendicular skeleton, and acrometastasis (metastasis to hand and foot) is very rare. We report a patient who developed a solitary metastatic lesion of the left metatarsal 2 weeks after radical cystectomy. The lack of suspicion and magnetic resonance imaging findings suggestive of inflammation led to a diagnosis of tubercular osteomyelitis and antitubercular therapy was started. The patient developed nodal metastasis and, because the foot lesion did not respond to treatment, fine needle aspiration cytology from it revealed poorly differentiated metastatic cancer.

Genital tuberculosis: current status of diagnosis and management

Genitourinary Tuberculosis (GUTB) is the second most common extra-pulmonary manifestation of tuberculosis (Tb) and an isolated involvement of genital organs is reported in 5–30% of the cases. Genital involvement results from primary reactivation of latent bacilli either in the epididymis or the prostate or by secondary spread from the already infected urinary organs. The epididymis are the commonest involved organs affected primarily by a hematogenous mode of spread. Tb is characterized by extensive destruction and fibrosis, thus an early diagnosis may prevent function and organ loss. The gold standard for diagnosis is the isolation and culture of mycobacterium tuberculosis bacilli and in the cases of suspected GUTB, it is commonly looked for in the urinary samples. All body fluid specimens from possible sites of infection and aspirates from nodules must also be subjected to examination. Radiologic investigations including ultrasonography and contrast imaging may provide supportive evidence. Anti-tubercular chemotherapy is the first line of management for all forms of genital Tb and a 6 months course is the standard of care. Most patients with tubercular epididymo-orchitis respond to antitubercular therapy but may require open or percutaneous drainage. Infertility resulting from the tubercular affliction of the genitalia is multifactorial in origin and may persist even after successful chemotherapy. Multiple organ involvement with obstruction at several sites is characteristic and most of these cases are not amenable to surgical reconstruction. Thus, assisted reproduction is usually required. Post treatment, regular annual follow up is recommended even though, with the current multi drug therapy, the chances of relapse are low.

Sequential unusual site metastases in renal cell cancer: Saga of repeated tumor implantation and prolonged survival without systemic therapy

Renal cell cancer (RCC) is known to produce metastasis to unusual sites both synchronously and metachronously several years after the primary treatment. We report a rare case of RCC with three different, sequential, and each time isolated rare site metastasis to ureteric stump, surgical site, and urinary bladder over a period of 6 years after radical nephrectomy. At each recurrence, metastasectomy was carried out and no systemic therapy was administered. Eleven years after radical nephrectomy and 5 years after last resection, the patient remains disease free. Multiple recurrences can occur in RCC and complete surgical resection results in disease free survival.

Outcomes following retroperitoneal lymph node dissection in postchemotherapy residual masses in advanced testicular germ cell tumors

Introduction: We aimed to study the outcomes of retroperitoneal lymph node dissection (RPLND) in postchemotherapy residual masses in advanced testicular germ cell tumor (GCT) in the Indian population. Patients and Methods: We retrospectively analyzed 35 patients who underwent postchemotherapy RPLND at our institute after primary (29 patients) or salvage (6 patients) chemotherapy over a period of 9 years (June 2003 to July 2012). Results: The mean age of our patients was 26.8 years. 18 (51.42%) presented with primary tumor in the right testis and 3 (8.51%) had bilateral tumors. Mixed GCT was the most common histology among 19 (54.3%) patients. 14 (40%) patients had the residual mass in para-aortic location, which was the most common site. 14 (40%) patients required an adjunctive procedure, most commonly nephrectomy which was required in 9 out of 14 (25.7%). We recorded 25 complications, mostly Clavien-Dindo grade II. Histopathology of residual mass was necrosis in 17 (48.57%), teratoma in 12 (34.28%), and viable tumor in 6 (17.14%) patients. Conclusion: Nearly half of the patients had either teratoma or viable tumor, thus justifying the surgical resection of postchemotherapy residual mass. Although nearly half of the patients had complications, they were adequately managed and there was no mortality. Thus, postchemotherapy RPLND can be a useful procedure in multimodality approach to GCT in carefully selected patients.

Pregnancy with a ruptured renal artery aneurysm: management concerns and endovascular management

Renal artery aneurysm (RAA) affects <0.01% of the general population. Rupture of RAA is a rare catastrophe that can complicate pregnancy and is associated with high maternal and fetal mortality. Presentation is usually acute with severe flank pain, with or without haematuria, and haemodynamic instability requiring exploration and nephrectomy. A 26-year-old pregnant woman had sudden onset of gross haematuria and on evaluation was found to have a left RAA with an intrapelvic rupture and thinned out renal parenchyma. In view of the high risk of surgery, she was managed with endovascular placement of an Amplatzer type II vascular plug. Immediate and complete occlusion of blood flow was achieved and nephrectomy was avoided. Follow-up Doppler ultrasound revealed a reduced 5 cm mass in the left renal fossa with no internal flow and plug in position. She is currently on follow-up with 3–6 monthly ultrasonography not requiring any intervention.