Surendra B. Kolla

Multi-tract percutaneous nephrolithotomy for large complete staghorn calculi.

Introduction: The treatment of large complete staghorn calculi requires a sandwich combination of percutaneous nephrolithotomy (PCNL) and shockwave lithotripsy (SWL) or sometimes open surgery. Many urologists hesitate to place more than 2–3 tracts during PCNL because of the belief that this may increase complications. We present data to support multi-tract PCNL for large (surface area >3,000 mm2) complete staghorn calculi. Patients and Methods: From July 1998 to October 2003, 121 renal units (103 patients) with large complete staghorn renal calculi were treated with PCNL. All procedures were performed in the prone position after retrograde ureteral catheterization. Fluoroscopy-guided punctures were made by the urologist followed by track dilation to 34 french. When multiple tracts were anticipated all punctures were usually made at the outset and preplaced wires were put into the collecting system or down the ureter. Stones were fragmented and removed using a combination of pneumatic lithotripsy and suction. Postoperative stone clearance was documented on X-ray KUB. Results: 121 renal units of 103 patients (15 women and 88 men, mean age 43 years) were treated. Six patients had associated bladder calculi that were treated simultaneously. The stone surface area was 3,089–6,012 (mean 4,800) mm2. 10 patients (9.7%) had renal insufficiency with a mean (range) serum creatinine of 3.0 (1.5–5.5) mg/dl. The number of tracts required per patient were 2 tracts in 11, 3 tracts in 68, 4 tracts in 39, and 5 tracts in 3, giving a total of 397 tracts in 121 renal units, over a total of 140 procedures (including second-look procedures in 19 renal units). The points of entry of these tracts were 121 upper calyx (30.4%), 178 middle calyx (44.8%), and 98 lower calyx (24.6%). All 121 units had one upper polar access tract of which 92 (76%) were supracostal. Complications were blood transfusion (n = 18), pseudoaneurysm (n = 2), fever (n = 22), septic shock (n = 1) and hydrothorax (n = 3). PCNL monotherapy achieved an 84% complete clearance rate that improved to 94% with SWL in 8 renal units with small residual fragments. Stone compositions were calcium oxalate (91%), uric acid (2%) and mixed (7%). Conclusion: Aggressive PCNL monotherapy using multiple tracts is safe and effective, and should be the first option for massive renal staghorn calculi.

Robotic Reconstruction for Recurrent Supratrigonal Vesicovaginal Fistulas

PURPOSEnWe report our experience with robotic reconstruction for recurrent supratrigonal vesicovaginal fistulas and its outcome.nnnMATERIALS AND METHODSnFrom August 2006 to October 2007 we treated 7 cases of recurrent supratrigonal vesicovaginal fistula. Salient features of our technique are 1) vaginoscopy and cystoscopy with bilateral Double-J stent or ureteral catheter placement and placement of a catheter through the fistula from vagina to bladder, 2) patient positioning in a low lithotomy position with a 60-degree Trendelenburg tilt and a 5-port transperitoneal approach, 3) peritoneoscopy and adhesiolysis with minimal posterior cystotomy encircling the fistulous opening, 4) mobilization of the bladder and vaginal flaps to allow tension-free closure, 5) excision of the fistulous rim, 6) bladder and vaginal edge freshening, 7) bladder and vaginal closure, 8) omental, peritoneal or sigmoid epiploic tissue interposition and 9) insertion of a Foley catheter and drain. Difficulty was primarily noted with regard to the safe establishment of pneumoperitoneum, the need for extensive adhesiolysis, dissection of the fistula from perifistulous fibrosis in close vicinity to the ureteral opening, tension-free closure of the larger defect and occasional absence of omentum for use as interposition tissue.nnnRESULTSnThe average size of supratrigonal fistulas was 3.0 cm. Mean operative time was 141 minutes (range 110 to 160). Mean blood loss was 90 cc. No significant intraoperative or postoperative complications were observed. Mean hospital stay was 3 days. The catheter was removed 14 days postoperatively. All patients had a successful outcome.nnnCONCLUSIONSnOur experience suggests that robotic repair for recurrent vesicovaginal fistulas is feasible, results in low morbidity and provides outstanding results. It provides an attractive option for vesicovaginal fistula repair by a minimally invasive approach for the surgeon and the patient alike.

Laparoscopic Radical Cystectomy and Extracorporeal Urinary Diversion: A Single Center Experience of 48 Cases with Three Years of Follow-up

OBJECTIVESnTo report our experience with laparoscopic radical cystectomy and extracorporeal urinary diversion for high-grade muscle invasive bladder cancer in a consecutive series of 48 patients with 3 years of follow-up.nnnMETHODSnFrom June 1999 to April 2006, 48 patients (42 men and 6 women; mean age 59 years, range 24 to 80) with bladder cancer underwent laparoscopic radical cystectomy and bilateral pelvic lymph node dissection at our institution. Urinary diversion was done extracorporeally through the specimen extraction incision.nnnRESULTSnThe mean operating time was 310 minutes, and the mean blood loss was 456 mL. In 1 patient, conversion to open surgery was required because of severe hypercarbia. Three major complications were observed intraoperatively (rectal injury in 2 and external iliac vein injury in 1 patient). However, all these complications were managed laparoscopically, with completion of the procedure laparoscopically. The mean hospital stay was 10.2 days (range 7 to 25). One patient died in the postoperative period of severe lower respiratory tract infection and septicemia. Histologic examination showed organ-confined tumors (Stage pT1/pT2/pT3a) in 34 patients (71%) and extravesical disease (pT3b/pT4) in 14 (29%). Of the 48 patients, 12 (25%) had lymph node involvement. The mean number of nodes removed was 14 (range 4 to 24). At a mean follow-up period of 38 months (range 10 to 72), 35 patients were alive with no evidence of disease (disease-free survival rate 73%).nnnCONCLUSIONSnThe results of our study have shown that laparoscopic radical cystectomy is a safe, feasible, and effective alternative to open radical cystectomy. Extracorporeal urinary diversion through a small incision decreases the operating time, while maintaining the benefits of laparoscopic surgery. The 3-year oncologic efficacy was comparable to that of open radical cystectomy.

Interobserver reliability of the RENAL nephrometry scoring system.

OBJECTIVEnTo determine the reliability of the RENAL nephrometry scoring system by studying its reproducibility among different observers.nnnMETHODSnWe reviewed computed tomography or magnetic resonance imaging scans from 51 patients who underwent partial nephrectomy at our cancer center. Digitized axial and coronal images were available for all patients. Three surgeons independently scored the renal tumors using the RENAL nephrometry system. The scoring system had 5 components: R (tumor diameter), E (exophytic/endophytic), N (nearness to collecting system), A (anterior/posterior), and L (location in relation to polar lines). Interobserver variability was calculated for each of the 5 components using a frequency procedure and Kappa statistics.nnnRESULTSnThe reliability assessed by frequency procedure showed concordance among 3 observers in 94%, 76%, 66%, 80%, and 54% for the R, E, N, A, and L components, respectively. The corresponding kappa values for each of these 5 components were 0.95, 0.86, 0.76, 0.84, and 0.73, respectively.nnnCONCLUSIONnThe RENAL nephrometry scoring system has good interobserver reliability. Quantifying the tumor location (L) was more challenging and the least reliable of the 5 components. This variation might affect the total nephrometry score and should be considered when using the system to compare different series of patients undergoing partial nephrectomy.

Preliminary Study of Virtual Reality and Model Simulation for Learning Laparoscopic Suturing Skills

PURPOSEnRepetitive practice of laparoscopic suturing and knot tying can facilitate surgeon proficiency in performing this reconstructive technique. We compared a silicone model and pelvic trainer to a virtual reality simulator in the learning of laparoscopic suturing and knot tying by laparoscopically naïve medical students, and evaluated the subsequent performance of porcine laparoscopic cystorrhaphy.nnnMATERIALS AND METHODSnA total of 20 medical students underwent a 1-hour didactic session with video demonstration of laparoscopic suturing and knot tying by an expert laparoscopic surgeon. The students were randomized to a pelvic trainer (10) or virtual reality simulator (10) for a minimum of 2 hours of laparoscopic suturing and knot tying training. Within 1 week of the training session the medical students performed laparoscopic closure of a 2 cm cystotomy in a porcine model. Objective structured assessment of technical skills for laparoscopic cystorrhaphy was performed at the procedure by laparoscopic surgeons blinded to the medical student training format. A video of the procedure was evaluated with an objective structured assessment of technical skills by an expert laparoscopic surgeon blinded to medical student identity and training format. The medical students completed an evaluation questionnaire regarding the training format after the laparoscopic cystorrhaphy.nnnRESULTSnAll students were able to complete the laparoscopic cystorrhaphy. There was no difference between the pelvic trainer and virtual reality groups in mean +/- SD time to perform the porcine cystorrhaphy at 40 +/- 15 vs 41 +/- 10 minutes (p = 0.87) or the objective structured assessment of technical skills score of 8.8 +/- 2.3 vs 8.2 +/- 2.2 (p = 0.24), respectively. Bladder leak occurred in 3 (30%) of the pelvic trainer trained and 6 (60%) of the virtual reality trained medical student laparoscopic cystorrhaphy procedures (Fisher exact test p = 0.37). The only significant difference between the 2 groups was that 4 virtual reality trained medical students considered the training session too short compared to none of those trained on the pelvic trainer (p = 0.04).nnnCONCLUSIONSnThere is no significant difference between the pelvic trainer and virtual reality trained medical students in proficiency to perform laparoscopic cystorrhaphy in a pig model, although both groups require considerably more training before performing this procedure clinically. The pelvic trainer training may be more user-friendly for the novice surgeon to begin learning these challenging laparoscopic skills.

Prognostic significance of Her2/neu overexpression in patients with muscle invasive urinary bladder cancer treated with radical cystectomy

IntroductionThe aim of the study was to evaluate the status of Her2/neu protein expression in patients with muscle-invasive urothelial carcinomas of the bladder treated with radical cystectomy and to determine its prognostic significance.Material and methodsWe retrospectively analyzed the data of 90 patients who had undergone cystectomy for invasive transitional cell carcinoma of the urinary bladder. Immunohistochemical analysis for Her2/neu was done on paraffin-fixed tissues with CB11 antibodies (BioGenex, San Ramon, CA, USA). Sections with gradexa02 and gradexa03 staining were considered positive for Her2/neu.ResultsOver a median follow-up period of 46xa0months (24–96xa0months) 46 patients are living without disease recurrence and six with recurrent disease either at the local site or with distant metastases. The remaining 38 patients have died. The median overall survival time was 50xa0months, and median disease-free survival time was 40xa0months. The Her2/neu status was significantly related to the tumor stage (Pxa0=xa00.001), lymph node involvement (77% in N+ vs 23% in N0; Pxa0=xa00.001) and the grade of the disease (32% of gradexa02 vs 71% of gradexa03; Pxa0=xa00.037). Kaplan–Meier curves showed a significantly worse disease-related survival period (log rank Pxa0=xa00.011) for patients with Her2 overexpressing tumors than for those without overexpression. In addition to tumor stage [Pxa0=xa00.001; relative risk (RR)xa0=xa02.62] and lymph node status (Pxa0=xa00.0001; RRxa0=xa02.95), Her2 status (Pxa0=xa00.020; RRxa0=xa02.22) was identified as an independent predictor for disease-related survival in a multivariate analysis.ConclusionThese results suggest that Her2 expression might provide additional prognostic information for patients with muscle-invasive bladder cancer. Future studies on Her2 expression with chemosensitivity and the efficacy of Her2-targeted therapies in urothelial carcinomas are warranted.

Safety of supracostal punctures for percutaneous renal surgery

Aim: Supracostal superior calyceal access has been shown to be the most suitable approach for staghorn calculi, calculi in the upper ureter and complex inferior calyceal calculi, as well as for antegrade endopyelotomy. However, many urologists hesitate in using this approach because of the potential for chest complications. The aim of this study was to analyze one institution’s data regarding the safety and efficacy of this approach for percutaneous renal surgery.

Interobserver Reliability and Reproducibility of S.T.O.N.E. Nephrolithometry for Renal Calculi

PURPOSEnTo assess the reliability of the S.T.O.N.E. (stone size [S], tract length [T], obstruction [O], number of involved calices [N], and essence or stone density [E]) nephrolithometry scoring system by testing its reproducibility between different observers.nnnPATIENTS AND METHODSnPreoperative images of 58 patients who underwent percutaneous nephrolithotomy (PCNL) were reviewed. Medical students, urology residents, one fellow, and a urology attending independently reviewed all images and scored the renal stones. Interobserver reliabilities of the total score for all categories and each component were evaluated by the intraclass correlation (ICC) and a κ coefficient.nnnRESULTSnThe interobserver reliability for the total score demonstrated high correlations for all components and total score (ICC=S, T, O, N, E and total 0.80, 0.97, 0.89, 0.84, 0.91, and 0.87, respectively). κ rates for individual components between two medical students were 0.36, 1, 0.31, 0.45, 0.33, and 0.30 for the S, T, O, N, E components and total score, respectively. κ values between the two urology residents were 0.71, 1, 0.92, 0.79, 0.93, and 0.67 for S, T, O, N, E components and total score, respectively. κ values between the urology fellow and an attending physician were 0.95, 1, 0.88, 0.94, 0.89, and 0.87 for S, T, O, N, E components and total score, respectively. P value for all the scoring components was <0.05, indicating that the estimated κ was not a result of chance.nnnCONCLUSIONSnThe S.T.O.N.E. nephrolithometry has excellent interobserver reliability. Quantifying the S and N metrics was the most challenging and least reliable. Standardized protocols to measure these components should be considered to improve accuracy and reproducibility of the scoring system.

In Vitro, Ex Vivo and In Vivo Isotherms for Renal Cryotherapy

PURPOSEnPreoperative planning for renal cryotherapy is based on isotherms established in gel. We replicated gel isotherms and correlated them with ex vivo and in vivo isotherms in a porcine model.nnnMATERIALS AND METHODSnPERC-17 CryoProbes (1.7 mm) and IceRods (1.47 mm) underwent trials in gel, ex vivo and in vivo porcine kidneys. Temperatures were recorded at 13 predetermined locations with multipoint thermal sensors.nnnRESULTSnAt the cryoprobe temperatures were not significantly different along the probe in any medium for either system (p = 0.0947 to 0.9609). However, away from the probe ex vivo and in vivo trials showed warmer temperatures toward the cryoprobe tip for each system (p = 0.0003 to 0.2141). Mean +/- SE temperature 5 mm distal to the cryoprobe tip in vivo was 19.2C +/- 16.1C for CryoProbes and 27.3C +/- 11.2C for IceRods. Temperatures were consistently colder with CryoProbes than with IceRods in gel (p <0.00005), ex vivo (p <0.00005) and in vivo (p = 0.0014). At almost all sites temperatures were significantly colder in gel and in ex vivo kidney than in in vivo kidney for CryoProbes (p = 0.0107 and 0.0008, respectively) and for IceRods (each p <0.00005).nnnCONCLUSIONSnGel and ex vivo isotherms do not predict the in vivo pattern of freezing. Thus, they should not be used for preoperative planning. The cryoprobe should be passed 5 mm beyond the tumor border to achieve suitably cold temperatures. Multipoint thermal sensor probes are recommended to record actual temperature during renal cryotherapy.

Screening rectal culture to identify fluoroquinolone-resistant organisms before transrectal prostate biopsy: do the culture results between office visit and biopsy correlate?

OBJECTIVEnTo investigate the performance of screening rectal cultures obtained 2 weeks before transrectal prostate biopsy to detect fluoroquinolone-resistant organisms and again at transrectal prostate biopsy.nnnMATERIALS AND METHODSnAfter institutional review board approval for observational study, we obtained a rectal culture on patients identified for a prostate biopsy but before antibiotic prophylaxis from September 12, 2011 to April 23, 2012. The specimen was cultured onto MacConkey agar with and without 1 μg/mL ciprofloxacin. We then obtained a second rectal culture immediately before prostate biopsy after 24 hours of ciprofloxacin prophylaxis. All cultures were blinded to the practitioner until the end of the study.nnnRESULTSnOf 108 patients enrolled, 58 patients had both rectal cultures for comparison. The median time duration between cultures was 14 (6-119) days. There were 54 of 58 concordant pairs (93%), which included 47 negative cultures and 7 positive cultures; 2 patients (3%) who were culture negative from the first screening culture became positive at biopsy. Sensitivity, specificity, negative, positive predictive values, and area under the operator curve were 95.9%, 77.8%, 95.9%, 77.8%, and 0.868, respectively. When Pseudomonas spp. are removed from the analysis, the area under the curve is increased to 0.927.nnnCONCLUSIONnScreening rectal cultures 2 weeks before prostate biopsy has favorable test performance, suggesting screening cultures give an accurate estimate of fluoroquinolone-resistant colonization.