Swarnendu Mandal

Prospective evaluation of complications using the modified Clavien grading system, and of success rates of percutaneous nephrolithotomy using Guy's Stone Score: A single-center experience

Introduction and Objectives: To prospectively document the perioperative complications of percutaneous nephrolithotomy (PCNL) using the modified Clavien grading system. Evaluation of complications and clearance rates according to stone complexity using the validated Guys Stone Score (GSS) was also done. Materials and Methods: A total of 221 renal units underwent 278 PCNL procedures at a urology resident training center between September 2010 and September 2011 and data were recorded prospectively in our registry. Patients with co-morbidities like diabetes, renal failure, hypertension and cardiopulmonary diseases were excluded. Stone complexity was classified according to the GSS while peri-operative complications were recorded using the modified Clavien grading system. Results: Two hundred and forty-five complications were encountered in 278 PCNL procedures involving 116 renal units (41.72%). Complications of Grades 1, 2, 3a, 3b, 4a, 4b and 5 were seen in 52 (18.7%), 122 (43.8%), 42 (15.1%), 18 (6.4%), 6 (2.1%), 4 (1.4%) and 1 (0.3%) renal units respectively. There were 68, 98, 50 and 5 renal units in GSS I, II, III and IV groups, respectively. All grades of complications were more common in GSS III and IV (P<0.05). For GSS I, II, III and IV 100%, 74%, 56% and 0% of renal units, respectively, were stone-free after one session and 0%, 24%, 44% and 60% respectively needed two sessions to be stone-free. Conclusion: Although the complication rates were higher most were of low grade and self-limiting. Complications were significantly more common with higher GSS and the GSS effectively predicted stone-free rates.

Clavien Classification of Semirigid Ureteroscopy Complications: A Prospective Study

OBJECTIVE To prospectively report and grade the perioperative complications of ureteroscopy (URS) for stone removal using a semirigid ureteroscope with the modified Clavien classification system and to identify the determinants of the complications. METHODS From August 2010 to November 2011, the prospective data from 120 consecutive patients (71 men and 49 women) who had undergone primary unstented URS at a resident training center were analyzed. Patients with renal failure, pyonephrosis, diabetes mellitus, hypertension, and congenital ureteral abnormalities were excluded (n = 29). The data recorded included patient demographics, stone size and location, and complications according to the modified Clavien classification system. RESULTS Of the 120 patients, 36 (30%) experienced 79 complications. The stone size was ≤ 10 mm in 56 and >10 mm in 64 patients. The stone location was the lower, mid-, and upper ureter in 62, 58, and 3 patients, respectively. The latter 3 were excluded because of the small sample size. Grade 1, 2, 3a, 3b, 4a, and 4b complications were encountered in 46 (38.3%), 18 (15%), 3 (2.5%), 10 (8.3%), 1 (0.8%), and 1 (0.8%) patient, respectively. The incidence of complications was greater for stones >10 mm, a mid- versus distal ureteral location, impacted stones, and surgery performed by a resident. The incidence was not affected by patient sex, stone laterality, or lithotripter type. The patients with complications had a longer operative time (75 vs 46.5 minutes), longer hospitalization (4.8 vs 1.5 days), and lower stone-free rate (64% vs 97%). CONCLUSION Most complications were grade 1-3 (98%), and grade 4 complications were rare (<2%) with URS. The present study is probably the first to prospectively study the complications of URS using the modified Clavien classification system.

Comparison of Extracorporeal Shock Wave Lithotripsy for Inferior Caliceal Calculus Between Children and Adults: A Retrospective Analysis—Why Do Results Vary?

OBJECTIVE To retrospectively evaluate the effectiveness of extracorporeal shock wave lithotripsy (ESWL) for inferior caliceal calculi ≤ 20 mm in size and compare the results between children and adults. MATERIALS AND METHODS From January 2004 to January 2012, ESWL was performed for inferior caliceal calculi in 230 children and 1006 adults. The Dornier compact alpha-K1025163 (Dornier Med Tech) was used. The success rates, number of ESWL sessions required, and auxiliary procedures used were evaluated in a comparative manner. RESULTS The overall stone-free rate (for both stone sizes) was 82.2% for children and 40% for the adults. Of the children, 17% had a residual stone compared with 47.8% of the adults. ESWL was unsuccessful in 0.8% of children and 12.2% of adults. The mean number of ESWL sessions required in children and adults was 1.43 (range 1-4) and 2.13 (range 1-4), respectively. Repeat treatment was required in 31% of the children and 65% of the adults. Auxiliary procedures were required in 5.2% of the children and 16.2% of the adults. Complications were seen in 5.6% of the children and 15% of the adults. CONCLUSION The results of ESWL for inferior caliceal calculi ≤ 20 mm in adults remains poor but not so in children. Children can achieve high stone-free rates, require a fewer number of ESWL sessions than adults to be stone free, and have a lower need for repeat treatment and auxiliary procedures, and have fewer complications.

Cheek metastasis from a bladder tumor: unusual presentation of an aggressive disease

Transitional cell carcinoma (TCC) has been well described for its propensity to metastasize to distant sites. Metastases to the soft tissues of the oral cavity from a bladder cancer are extremely rare. We present the case of a 65-year-old man who presented with history of hematuria for 1 month and was found to have high-grade TCC of the bladder. He developed a cheek lesion after 3 weeks, which was diagnosed as metastatic nodule along with pulmonary metastases from high-grade bladder TCC. The patient received chemotherapy followed by the radiotherapy of the cheek lesion, but he succumbed after 3 months due widespread metastatic disease. We also presented a review of the literature regarding this rare presentation.

Re: Jens J. Rassweiler, Michael Müller, Markus Fangerau, et al. iPad-assisted percutaneous access to the kidney using marker-based navigation: initial clinical experience. Eur Urol 2012;61:628-31.

We congratulate the authors for this innovative technique in which they demonstrate the feasibility of iPad-assisted augmented reality to achieve accurate access for percutaneous nephrolithotomy (PCNL) [1]. PCNL is considered the gold standard for the management of renal calculus because it is easy to learn, easy to teach, inexpensive, easily available worldwide, and safe and gives good results. We are apprehensive about the introduction of expensive software to obtain access in PCNL for several reasons. This approach would defeat the purpose of PCNL as the gold standard because (1) it would be difficult to introduce the software to most centers around the world, and thus it would be restricted to a few centers; (2) it would translate into a significant increase in expenditure; (3) it would decrease hospital turnover; and (4) it would create less need for acquiring surgical skill. However, it is expected that the expense of computed tomography scan, navigation aids, iPad, WiFi, and control-room establishment would

Urodynamic and continence assessment of orthotropic neobladder reconstruction following radical cystectomy in bladder cancer; a prospective, blinded North Indian tertiary care experience

Aim: The aim of this study is to compare urodynamic and continence parameters among patients undergoing orthotropic neo-bladder substitution with sigmoid or ileal segments. Variations in the Urodynamic parameter between the continent and incontinent patients were also evaluated. Patients and Methods: From January 2008 to March 2012, 44 patients underwent ileal neobladder (IN) reconstruction and 36 patients underwent sigmoid neobladder (SN) reconstruction. Evaluation of Urodynamic and Continence parameters was performed at 12 months after surgery. Results: The average capacity of IN and SN was 510 ml and 532 ml respectively. The voiding pressure, mean peak flow rates and post void residual urine (PVRU) for IN and SN were 27.5 cm H2O versus 37 cm H2O, 15ml/s versus 17ml/s and 36 ml versus 25 ml respectively. Daytime continence for IN and SN was 93% (41/44) and 89% (32/36), and night-time continence was 91% (40/44) and 78% (28/36) respectively. The compliance, maximum cystometric capacity and PVRU in the daytime continent (versus incontinent) were 61 (versus 41), 471 (versus 651) and 22 (versus 124) and in the night-time continent (versus incontinent) were 57 (versus 43), 437 (versus 654) and 18 (versus 105) respectively. Conclusion: A neobladder constructed from detubularized ileum or sigmoid achieves urodynamically proven adequate capacity and compliance with 89-93% daytime and 78-91% night time continence. Continent men when compared with incontinent (both daytime and night time) were more likely to have comparatively higher compliance, lower maximum cystometric capacity and lower PVRU. Urodynamic study could predict which incontinent men would improve with pelvic floor exercises and clean intermittent catheterization (CIC).

Spontaneous Erosion of Ureterocele Wall by Stone: Rare Images

The incidence of ureterocele at autopsy is estimated to be in 1/500 to 1/4000. A solitary stone in a single ureterocele is common, with a prevalence of 4%-39%. However, spontaneous rupture of the ureterocele wall by a stone has not been reported, to the best of our knowledge. We report the case of a 35-year-old man with right-side ureterocele, complicated by a stone that spontaneously eroded the ureterocele wall.

Comment to Lira-Dale et al.: Effect of intraprostatic epinephrine on intraoperative blood loss reduction during transurethral resection of the prostate

We appreciate the authors for conducting this study on the effect of intraprostatic epinephrine on intraoperative blood loss reduction during transurethral resection of the prostate, but few points need clarification [1]. The authors have shown the benefits on intraoperative blood loss but do not mention whether intraprostatic epinephrine had any benefit in postoperative period. We assume that the vasoconstrictive effect of epinephrine can conceal the bleeding vessels intraoperatively that could have been coagulated and postoperatively as the effect weans off, these patients may have reactionary hemorrhage [2]. Is there any reason why the resected prostatic tissue was less in epinephrine group than the placebo group, despite larger gland volume in the former? This can bias the results as the intraoperative blood loss is proportional to the resected tissue [3]. Finally, the amount of epinephrine injected into the prostate was fixed, that is, 20 ml. Probably, the effect may vary based on prostate volume, where smaller glands may require lesser dose in comparison with larger ones. We would like to have author’s opinion in this context.

Cystadenoma Of The Seminal Vesicle: A Case Report Of Rare Seminal Vesical Tumour and review of literature

Although the secondary involvement of the seminal vesicles by prostate cancer is relatively common, seminal vesicle as a primary site for neoplastic disease is uncommon.1 There are a wide variety of tumors among primary seminal vesicle tumors that are derived from both the epithelium and stroma. Hence, they have been classified as mixed epithelial-stromal tumors. This report describes a 32-year-old man who presented with a retrovesical cystic mass that was initially thought to be a prostatic tumor but demonstrated pathologically to be a cystadenoma of the seminal vesicles.

Re: Gender and body mass index as risk factors for bladder perforation during primary transurethral resection of bladder tumors: K. Herkommer, C. Hofer, J. E. Gschwend, M. Kron and U. Treiber J Urol 2012; 187: 1566-1570.

To the Editor: We congratulate the authors for demonstrating that gender and body mass index are risk factors for bladder perforation during primary transurethral resection of bladder tumor (TURBT). We have a few questions. The type of anesthesia (general/spinal) was not mentioned. At our center most TURBTs are performed with the patient under spinal anesthesia. In our experience perforation is more common for laterally placed tumors due to obturator jerk at resection. Given the conflicting data in the literature regarding tumor location at the dome as a risk factor for bladder perforation (as discussed by the authors), a mention in the present study about the tumor location in 49 patients who had bladder perforation would have given further insight into this debate. Also the impact of surgeon experience (consultant vs resident) on complication rate would have been useful. Elderly patients also have a thin bladder wall. Did the authors note a higher perforation rate in this subgroup?