Varun Mittal

Transcutaneous posterior tibial nerve stimulation in pediatric overactive bladder: A preliminary report

BACKGROUND Non-neurogenic overactive bladder (OAB) is a common problem in children that may affect their quality of life. Various methods of neuromodulation have been reported to treat refractory lower urinary tract dysfunction. Since most of these techniques are invasive, they are less applicable in children. OBJECTIVE To evaluate the efficacy of transcutaneous PTNS in treatment of OAB in children, in a randomized clinical setting. STUDY DESIGN This study was single-blinded, prospective, sham controlled randomized trial. 40 children with non-neurogenic OAB refractory to behavioural and anticholinergic therapy were randomized either to test group or sham group. Neuromodulation was performed using two self-adhesive electrodes cephalad to medial malleolus. In test group the stimulation was given with voltage pulse intensity of 0 to 10 mA, pulse width of 200 μs and frequency of 20 Hz. In sham group patch electrodes were applied to simulate the test group but no stimulation was given. In both groups, weekly session of 30 min was given for a period of 12 weeks. The OAB symptoms, severity of incontinence, number of voids daily (NV), average voided volume (AVV) and maximum voided volume (MVV) were evaluated before and after treatment. RESULTS On assessment of subjective improvement of OAB symptoms, 66.66% patients reported cure and 23.81% patients reported significant improvement of symptoms in test group whereas in sham group only 6.25% patients reported significant improvement. In test group 71.42% patients reported complete improvement in incontinence whereas in sham group only 12.5% patient reported complete improvement. The AVV, MVV and NV improved significantly in test group (p <0.001) as compared to sham group (Table). DISCUSSION The present study is unique as none of the earlier studies in children were sham controlled. It is also first PTNS study in which patch electrodes were used; therefore it is completely noninvasive. This technique provides better patient acceptability and compliance. This study proved that, there is a definite effect of PTNS as compared to placebo because when patients from sham group were treated actively, they responded well. The present study has few limitations as it has relatively short follow-up period of 12 weeks. Relapse of OAB symptoms and maintenance schedule of PTNS need to be assessed further. CONCLUSION Transcutaneous PTNS is superior to placebo in treatment of non-neurogenic overactive bladder in children. In view of its effectiveness and acceptability we believe that transcutaneous PTNS should be part of pediatric urology armamentarium for treatment of OAB.

Spiral laminar flow, the earliest predictor for maturation of arteriovenous fistula for hemodialysis access.

Introduction: Arteriovenous fistula (AVF) is the gold standard vascular access for hemodialysis (HD). A thrill or murmur immediately after creation of AVF is considered a predictive sign of success. However, this does not ensure final maturation for successful HD. Our objective was to determine different clinical and duplex parameters within AVF to predict maturation and subsequent successful HD. Materials and Methods: A prospective observational study was conducted on 187 patients who had AVF formation from July 2012 to May 2013. Following surgery, all patients had Doppler ultrasound (DU) on Days 0 and 7. Doppler parameters noted in the outflow vein were: Thrill, broadening of spectral waveform with increased peak systolic velocity (PSV) and spiral laminar flow (SLF). Patients with at least one positive parameter at Day 0 were followed-up serially and underwent repeat Doppler imaging on Day 7. Patients with the absence of all three parameters on Day 0 were excluded from the study. Endpoint was maturation of AVF, i.e. successful HD. Statistical analysis was performed with binary logistic regression, to find out the strongest and earliest predictor for maturation of AVF using SPSS version 20. Results: SLF and broadening of spectral waveform with increased PSV were found to have a significant association with maturation (P = 0.0001). Presence of SLF on Day 0 most strongly predicted maturation. Presence of thrill or murmur could not predict the maturation. Conclusions: SLF pattern in AVF is the most important and the earliest predictor of maturation.

Prevention of Orchialgia After Left-Sided Laparoscopic Donor Nephrectomy—A Prospective Study

BACKGROUND AND PURPOSE Etiology of orchialgia or testicular pain after laparoscopic donor nephrectomy (LDN) has been found to be related to injury of the spermatic plexus during gonadal (testicular) vein (GV) or ureteral ligation. This study aimed to evaluate and validate the impact of the level of ligation of GV and ureter in relation to the crossing of iliac vessels (CIV) on incidence of orchialgia. PATIENTS AND METHODS A prospective study was conducted on 70 males who underwent left LDN from January 2008 to December 2010 (group A) to determine the correlation between orchialgia and level of ligation of the GV and ureter with respect to CIV; this revealed that the ligation of the GV and/or ureter above the level of the CIV (level 1, n=40) is less likely to cause orchialgia than ligating them at or below (level 2, n=30). Subsequently, in 45 male patients (group B) for left LDN from January 2011 to June 2013, we ensured that clipping of the ureter and GV be performed above the CIV to validate the above findings. Patients with a history of scrotal pathology or surgical procedure were excluded. One-sided Z-test with pooled variance was used to calculate the sample size. RESULTS In group A, orchialgia was seen in 10 (14.3%) patients. The clipping of the ureter and GV at level 2 (orchialgia, n=9) was associated with a significantly higher incidence of orchialgia than clipping them at level 1 (orchialgia, n=1) (P=0.001,95% confidence interval=0.0707 to 0.2471). In group B, 43 patients were finally analyzed, and none had orchialgia. CONCLUSION The level of ligation of the GV and ureter has significant impact on the incidence of orchialgia. Ipsilateral testicular pain in patients with left-sided LDN is preventable, if the ureter and GV are ligated or clipped above the level of iliac vessels bifurcation.

Importance of lower pole nephrectomy during ureterocalicostomy

Ureterocalicostomy is usually a salvage procedure for recurrent pelvi-ureteric junction (PUJ) stricture or upper ureteric injury. It requires meticulous dissection of the upper ureter, and lower pole nephrectomy is considered an essential step to achieve a wide funneled and dependent ureterocaliceal anastomosis. We, hereby, highlight the importance of guillotine lower pole nephrectomy through a case report of recurrent PUJ stricture managed with ureterocalicostomy that failed due to the omission of lower pole nephrectomy.

An audit of early complications of radical cystectomy using Clavien-Dindo classification

Introduction: Despite the major improvements in surgical technique and perioperative care, radical cystectomy (RC) remains a major operative procedure with a significant morbidity and mortality. The present study analyzes the early complications of RC and urinary diversion using a standardized reporting system. Materials and Methods: Modified Clavien-Dindo classification was used to retrospectively assess the peri-operative course of 212 patients who had RC with urinary diversion between October 2003 and October 2014 at a single institution. The indications for surgery were muscle invasive urothelial carcinoma, high-grade nonmuscle invasive bladder cancer (BC), and Bacillus Calmette-Guerin-resistant nonmuscle invasive BCs. Data on age, sex, comorbidities, smoking history, American Society of Anaesthesiologists score, and peri-operative complications (up to 90 days) were captured. Statistical analysis was performed using SPSS 20.0 software (Chicago, USA). Results: The mean age was 56.15 ΁ 10.82. Orthotopic neobladder was created in 113 patients, ileal conduit in 88 patients, and cutaneous ureterostomy in 11 patients. A total of 292 complications were recorded in 136/212 patients. 242 complications (81.16%) occurred in the first 30 days, with the remaining 50 complications (18.83%) occurring thereafter. The rates for overall complication were 64.1%. The most common complications were hematologic (21.6%). Most of the complications were of Grade I and II (22.9% and 48.9%, respectively). Grade IIIa, IIIb, IVa, IVb, and V complications were observed in 10.2%, 8.9%, 3.4%, 2.7%, and 2.7% of the patients, respectively. Conclusions: RC and urinary diversion are associated with significant morbidity. This audit would help in setting a benchmark for further improvement in the outcome.

Standardized Grading of Shock Wave Lithotripsy Complications with Modified Clavien System.

Introduction: Definitive consensus on grading of complications of shock wave lithotripsy (SWL) does not exist. The objective of this study was to grade complications of SWL in relation to different stone and shock wave parameters, according to the modified Clavien system. Materials and Methods: Complications observed in 2,648 patients who underwent SWL between January 2003 and May 2014 were evaluated statistically and stratified into 5 grades by the modified Clavien system focusing on stone and shock wave parameters. Results: Statistically significant association (p ≤ 0.05) was found between SWL outcome, Clavien grade of complications and stone and shock wave parameters. According to the modified Clavien system, grades I, II, IIIa, IIIb, IV and V complications were observed in 1,811 (68.39%), 619 (23.37%), 183 (6.91%), 34 (1.28%), nil (0.00%) and 1 (0.03%) patients, respectively. The overall success rate at 3 months was 87.72%. Conclusions: The modified Clavien system provides a standardized grading of SWL complications and can be used to standardize procedural errors and maintain quality, thereby preventing associated complications and improving the overall management and hence outcome of SWL.

Follow-up imaging after pediatric pyeloplasty

Introduction: The duration, methods and frequency of radiographic follow-up after pediatric pyeloplasty is not well-defined. We prospectively evaluated a cohort of children undergoing pyeloplasty to determine the method for follow-up. Methods: Between 2000 and 2008, children undergoing pyeloplasty for unilateral ureteropelvic junction obstruction were evaluated for this study. All patients were evaluated preoperatively with protocol ultrasound (USG) and diuretic renal scan (RS). On the basis of preoperative split renal function (SRF), these patients were divided into four groups - Group I: SRF > 40%, Group II: SRF 30–39%, Group III: SRF 20–29%, and Group IV: SRF 10–19%. In follow-up, USG and RS were done at 3 months and repeated at 6 months, 1 year, and then yearly after surgery for a minimum period of 5 years. Improvement, stability, or worsening of hydronephrosis was based on the changes in anteroposterior (AP) diameter of pelvis and caliectasis on USG. Absolute increase in split renal function (SRF) >5% was considered significant. Failure was defined as increase in AP diameter of pelvis and decrease in cortical thickness on 3 consecutive USG, t½ >20 min with obstructive drainage on RS and/or symptomatic patient. Results: 145 children were included in the study. Their mean age was 3.26 years and mean follow-up was 7.5 years. Pre- and post-operative SRF remain unchanged within 5% range in 35 of 41 patients (85%) in Group I. While 9 of 20 patients (45%) in Group II, 23 of 50 patients (46%) in Group III, and 14 of 34 patients (41%) in Group IV exhibited changes >5% after surgery. 5 patients failed, 2 in Group III, and 3 in Group IV. None of the patients deteriorated in Group I and II. Conclusion: After pyeloplasty in children with a baseline split GFR >30%, if a diuretic renogram and USG performed 3 months postoperatively shows nonobstructive drainage with t½ <20 min and decreased hydronephrosis, no further follow-up is required.

Trans-vaginal anterior vaginal wall prolapse repair using a customized tension-free bell-shaped prolene mesh: A single-center experience with long-term functional analysis.

Introduction: The existing literature shows that mesh reinforcement improves the anatomical success rate of cystocele repair. We report the long-term results of a custom bell-shaped mesh with simultaneous urethral support for the repair of cystocele. Materials and Methods: The present study was a single-center, single-surgeon case series of 36 patients. Only patients with Pelvic Organ Prolapse Quantification system (POP-Q) stage 2 and above were included in the study. Patients having rectocele or uterine/vault prolapse were excluded. Body of the mesh was used for reinforcement of the cystocele repair and two limbs were left tension free in the retropubic space. Patients were followed 3 monthly for the first year and yearly thereafter. Recurrence was defined as cystocele ≥stage 2 (Aa or Ba 0) any time after the first follow-up. Results: Mean patient age was 58.5 ± 6.2 years. The mean parity was 3.2 ± 1.6. Of 36 patients, 11 (30.5%) of the patients were POPQ stage 2, 15 (41.7%) were stage 3 and 10 (27.7%) were stage 4 cystocele. The mean follow-up period was 53.4 months, with 32 patients reporting for follow-up till date (88.9%). There was no bladder injury, no mesh erosion or infection. No patient required CIC (clean intermittent catheterization) or had stress urinary incontinence post-operatively at 5 years of follow-up. Conclusion: The bell-shaped mesh is a simple, effective and safe procedure in the surgical management of cystocele with excellent long-term outcome.