Sudheer K. Devana

Renal vein leiomyoma: a rare entity with review of literature.

Tumors of vascular origin are unusual. These tumors are predominantly malignant and commonly arise from the inferior vena cava. Benign smooth muscle tumors arising from renal vein are very rare. We present a case of leiomyoma of renal vein in a post-menopausal woman that clinically resembled a retroperitoneal paraganglioma.

Delayed Migration of Embolized Coil with Large Renal Stone Formation: A Rare Presentation

Delayed bleeding following percutaneous nephrolithotomy (PCNL) usually occurs due to development of the pseudoaneurysm which can be successfully managed with coil embolization. However very few cases of such complications have been reported in the literature. Here we are reporting a case of delayed post-PCNL bleeding that occurred in a 53-year-old diabetic patient operated on for renal stone. Computed tomography scan revealed a presence of the pseudoaneurysm in the segmental branch of right renal artery, which was successfully managed with coiling. Patient remained asymptomatic for the next 9 years after which he again presented with similar complaints. X-ray KUB was done which revealed a 2.7 cms renal pelvic calculus with the migrated coil in its center and a left upper ureteric calculus. His routine haemogram, coagulogram, serum electrolytes, and liver function tests, renal function tests, vitamin D3, and PTH (parathyroid hormone) were within normal limits. He underwent left laparoscopic ureterolithotomy and right percutaneous nephrolithotomy (PCNL). Intraoperatively the migrated stainless steel embolization coil was seen engulfed all around by the multiple stones in the right renal pelvis. Postoperative period was uneventful. Later he was followed in the outpatient department and was doing well. To conclude, this is the only case report of development of a large calculus around a migrated embolization coil which was successfully managed with PCNL. PCNL offers better stone clearance in cases of stones being formed over foreign bodies like fragmented double J stents, fragmented nephrostomies, or migrated embolization coil.

Scratch to state-of-the-art: setting up a new robotic facility in a developing country

The potential challenges encountered for setting up a robotic assisted surgical facility in developing country like India are many. We describe the initial hurdles and troubleshooting in establishing a facility of such kind. This experience might help to decrease initial hiccups in setting up such an innovative technology at other institutes.

Ureteric injury after lumbosacral microdiscectomy: A case report and review of literature

Microdiscectomy is considered a very safe procedure with few serious complications. Ureteric injury following microdiscectomy is rarely reported in the literature. We report a rare case of iatrogenic ureteric injury following L5-S1 microdiscectomy for prolapsed intervertebral disc which was detected early and managed in time.

Post chemotherapy retroperitoneal lymph node dissection in germ cell tumor: robotic way

Post chemotherapy residual masses are considered extremely challenging to remove even by the most experienced laparoscopic surgeons. Robotic technology has added a new dimension to the management of such cases and has lessened the fear and discomfort associated with such challenging surgery but is still evolving. We present our experience of management of post chemotherapy residual mass with robotic assistance along with tips and tricks required to perform such procedure.

Bladder paraganglioma: safe and feasible management with robot assisted surgery

Pheochromocytomas of extra-adrenal origin are known as paragangliomas. Urinary bladder is the most common site of genitourinary paragangliomas. The variable functional status of these tumors presents a surgical challenge in their management by minimally invasive surgery. Robot-assisted partial cystectomy offers the advantage of minimal handling of tumor, early ligation of feeding vessels and easy suturing. We hereby report the feasibility and safety of robot-assisted surgery in the management of one such case.

Pelvic Pheochromocytoma: A Rare Lethal Tumor Initially Presenting as Tuboovarian Mass to Gynaecologist

Extra-adrenal pheochromocytomas are rare, but potentially lethal, tumors which may initially present to gynecologists masquerading as a tuboovarian mass leading to a potentially dangerous exploration in an unprepared patient. We present a case of a large extra-adrenal pheochromocytoma which was diagnosed intraoperatively because of sudden hypertension.

Single-incision multiport laparoendoscopic technique to repair retrocaval ureter using the Santosh PGI ureteric tacking fixation technique.

A retrocaval ureter is a rare congenital anomaly associated with upper urinary tract obstruction. It can cause varying degrees of ureteral obstruction, and surgical intervention is often necessary. Here, we present a case of a retrocaval ureter repaired with the single‐incision multiport laparoendoscopic technique. We used a new fixation technique, Santosh PGI (Postgraduate Institute) ureteric tacking fixation technique, on both ureteric ends for easy ureteroureteric anastomosis.

Complete obliteration of post percutaneous nephrolithotomy (PCNL) pseudoaneurysm following administration of tranexamic acid.

A 45 year old male with no known comorbidities presented to our institute with history of bilateral flank pain since 2 years. He was a known case of bilateral renal stone disease who underwent pyelolithotomy on right side 28 years back. Extracorporeal shock wave lithotripsy (ESWL) was done for left side renal stone in our institute. Post ESWL patient had graveluria and complete clearance of the stones on left side. On evaluation NCCT KUB done showed multiple inferior calyceal stones in right kidney (Fig. 1). His hemogram and biochemistry were all within normal limits. He underwent right tubeless PCNL (percutaneous nephrolithotomy) for multiple inferior calyceal stones. It was a posterior inferior calyceal puncture and the procedure was uneventful. On postoperative day 2, patient had sudden onset of gross hematuria associated with clots and hypovolemic shock. Clot evacuation was done and continuous bladder irrigation was started. His hemoglobin dropped from 10.3 to 7.4 g % and he was given 2 Units of blood transfusion. CT angiography was done immediately and showed a pseudoaneurysm involving the posterior segmental branch of right renal artery (Fig. 2). Patient was planned for embolization but it was delayed for 24 h due to heavy rush in the angiography suite. During this waiting period patient was hemodynamically stabilized. He was given 1 gram intravenous tranexamic acid 8th hourly. When once the patient was taken up for embolization in the angiography suite (after 24 h), surprisingly no pseudoaneurysm was found on angiography (Fig. 3), so the embolization was abandoned as there was no definite pseudoaneurysm seen. Patient was conservatively managed with tranexamic acid for 72 h. Hematuria was settled and he had an uneventful recovery after that. Again before discharging the patient CT angiography done showed no evidence of pseudoaneurysm (Fig. 4). So we feel that this was an interesting case of post PCNL bleed due to pseudoaneurysm which got completely thrombosed, organized and obliterated due to tranexamic acid. Our experience in this case shows that conservative management of post PCNL bleed with tranexamic acid can be successful in at least some cases.

Complex pelvic–ureteric junction obstruction (PUJO): successful management with robotic assistance

The management of complex pelvic–ureteric junction obstruction (PUJO) is challenging. The traditional open surgical approach used large incisions with prolonged post-operative recovery. Laparoscopic reconstruction in complex PUJO requires surgical expertise and is challenging to master. Robotic assistance has provided a viable minimally invasive alternative replicating the open surgical approach for such complex cases. In the present study, we evaluated the feasibility and success of robot-assisted reconstructive procedures in such situations.