Vascular injuries during laparoscopic donor nephrectomy and proposed risk reduction strategies

ABSTRACT Introduction: Laparoscopic donor nephrectomy (LDN) has become the standard of care and popular among most of the transplant centres across the globe. Objective of this video is to report different vascular injuries, their management during LDNs and propose risk reduction strategies. Patient and methods: This was a retrospective analysis of all the LDNs performed between January 2011 and March 2016. All donor nephrectomies were performed laparoscopically by transperitoneal route, under ideal operative conditions by expert laparoscopic surgeons and by novice surgeons. Results: 858 LDNs (left, n = 797; right, n = 61) were performed during the study period with 5 cases of vascular injuries. Mean (SD) donor age was 45.5 (± 10.76) years and the operative time was 165 (± 44.4) min. Of these five cases, two had renal vein injury, while the three others had renal artery, inferior vena cava and aortic injury (one each). Four injuries occurred during left LDN and only one during a right LDN. Vascular injuries were managed using the Rescue stitch or metallic clips as indicated. Risk reduction strategy was developed to avoid vascular injuries during LDN, which include - meticulous attention to port placement, addition of fourth port, complete dissection of upper pole and pedicle before clipping, and judicious use of ultrasonic diathermy. Conclusions: Careful evaluation of computed tomography angiography just before surgery will act like a global positioning system (GPS) for the operating surgeon. Rescue stitch is a saviour. Not to panic and being well versed with the risk reduction strategies of laparoscopy and rescue measures is of paramount importance.

Immunomodulatory effects of fruits of Barringtonia racemosa Linn.

Background: Barringtonia racemosa (B. racemosa) is used medicinally in treatment of diarrhoea, asthma, coughs, jaundice. It is also used as an analgesic and antipyretic. This plant has also significant anti-tumor activity. However, systematic evaluation of its immunomodulatory effects has not been reported. In present study the hydroalcoholic extract of fruits of B. racemosa has been evaluated for its immunomodulatory properties in animal models. Methods: Extract of Fruits of B. racemosa was prepared from fruit powder and methanol by macerations and filtration. Healthy albino Wistar rats of either sex having 110-160 g body weight were used for this study. 1. Delayed type hypersensitivity reaction (DTH) using Sheep red blood cells (SRBCs): After immunization with SRBC effect of cyclophosphamide and hydroalcoholic extract of B. racemosa was seen on paw volume changes in rats challenged with SRBC by using digital Plethysmometer. 2. Humoral antibody response to SRBC: Animas were immunized with SRBC and treated with cyclophosphamide and hydroalcoholic extract of B. racemosa. Serum of these animals was observed for haemagglutination titer. Results: Fruits extract at the dose of 5 mg/kg i.p. showed significant decrease in DTH response as compared to that of control group animals. However, the effect of extract was less potent as compared to that of cyclophosphamide treated group. In haemagglutination titer assay, antibody titer in case naïve control, SRBC treated, cyclophosphamide treated and extract treated groups was 1:1, 1:32, 1:8 and 1:16 respectively. Conclusions: The hydroalcoholic extract of this fruits was found to inhibit SRBCs induced DTH in rats. Similarly, SRBCs induced antibody titer was also reduced.

Balloon dilatation for male urethral strictures "revisited"

To analyze the results of balloon dilatation for short segment male urethral strictures. Retrospective analysis was done on 120 patients undergoing urethral balloon dilatation since January 2004 to January 2012. The inclusion criteria for analysis was a short segment [less than 1.5 cm] stricture, exclusion criteria were pediatric, long [more than 1.5 cm], traumatic, malignant strictures. The parameters analyzed included presentation of patients, ascending urethrogram [AUG] and descending urethrogram findings, pre- and postoperative International prostate symptoms score [IPSS], uroflowmetry [Q max], and post-void residue [PVR]. Need for self calibration/ancillary procedures were assessed. Failure was defined as requirement for a subsequent endoscopic or open surgery. A urethral balloon catheter [Cook Urological, Spencer, Indiana] is passed over a guide wire after on table AUG and inflated till 180 psi for 5 minutes under fluoroscopy till waist disappears. Dilatation is followed by insertion of a Foley catheter. Patients were followed up at 1, 3, and 6 months. Mean age was 49.86 years. Mean follow-up was 6 [2-60] months. IPSS improved from 21.6 preoperative to 5.6 postoperatively. Q[max] increased from 5.7 to 19.1 and PVR decreased from 90.2 to 28.8 [P < 0.0001*] postoperatively. At 1, 3, and at 6 monthly follow-up, 69.2% [n = 82] patients were asymptomatic. Balloon dilation is a safe, well-tolerated procedure with minimal complications. Further randomized studies comparing balloon dilatation with direct internal visual urethrotomy are warranted

Management of nephrolithiasis in autosomal dominant polycystic kidney disease - a single center experience

To evaluate available options for the management of nephrolithiasis in patients with autosomal dominant polycystic kidney disease [ADPKD]. Case files of all the patients with ADPKD treated in our hospital in the last 18 years were evaluated. Their demographic details, clinical presentations, investigations, treatments, and outcomes were critically analyzed. There were a total of 19 patients [23 renal units] with nephrolithiasis among 452 consecutive cases of ADPKD. Male-to-female ratio was 3.75:1. The mean age of the patients was 43.3 years [range 23 to 60 years]. The most common presentations were pain and hematuria [27.7% each]. Mean serum creatinine was 7.2 mg/ dl [range 0.8-18.1 mg/dl] at presentation. The mean stone size was 115 mm[2] [range 36 to 980 mm[2]]. The majority of the stones were calyceal [n = 10]. Ten renal units [nine patients] required intervention, while the rest were treated conservatively. Treatment offered included open nephrectomy for non-functioning infected kidney [n = 1], extracorporeal shock wave lithotripsy [ESWL, n = 3], ureterorenoscopy [URS, n = 3], and percutaneous nephrolithotomy [PCNL, n = 3]. All patients undergoing URS and PCNL had complete clearance, while those undergoing ESWL had a residual stone. Two failed ESWL patients required an auxiliary procedure [retrograde intrarenal surgery, RIRS] and the other was kept under observation. Mean follow-up after treatment was 4.2 years [one month to six years]. None of the patients had major complications. Careful selection of the endourological procedure can give good results in patients of ADPKD with nephrolithiasis

Spontaneous subcapsular renal hematoma: a case report and review of literature

Spontaneous subcapsular renal hematoma is not a common entity. We report a 38-year-old lady presenting with sudden onset right flank pain with uncontrolled hypertension and she was found to have subcapsular collection in the right kidney on ultrasonography. Finding was confirmed on computed tomography. Except hypertension, no particular cause for the condition could be found. Symptoms and size of the collection decreased on conservative treatment. They completely disappeared on ultrasonography at 6 months follow-up. She was asymptomatic at 18 months follow-up

Urological manifestations of Chikungunya fever: a single centre experience

Chikungunya is a viral infection often associated with lower urinary tract dysfunction. This study evaluates the urological squeal of Chikungunya fever in a single centre after an epidemic in 2006-2007 in India. Retrospective analysis of medical records of 13 patients with lower urinary tract symptoms after Chikungunya fever was evaluated and outcome following intervention assessed. A total of 13 patients [M:F=9:4], with age ranging from 30 to 72 years, were included in the study. They presented with chronic urinary retention [n=9, 69.23%] of which two had paraparesis, voiding symptoms alone [n=7, 53.8%], storage symptoms alone [n=3, 23%], and acute urinary retention [n=1, 7.6%]. Presentation with lower urinary tract symptoms after an episode of Chikungunya fever was after a mean period of 163 days [range 30-360 days]. Mean serum creatinine on presentation was 1.8 mg/dl [0.6-6.5 mg/dl]. Evaluation revealed dilated upper tract in four [30.7%] patients. Cystometrography showed acontractile detrusor [n=3, 37.5%], hypocontractile detrusor [n=3, 37.5%], overactive detrusor [n=1, 12.5%] and normal study [n=1, 12.5%]. At the mean follow up of 11 months, 11 patients [84.6%] had satisfactory functional outcome after intervention, namely supra pubic diversion and bladder training [n=5, 38.4%], alpha blocker [n=3, 23%], timed frequent voiding [n=2, 15.3%], clean intermittent catheterization [n=2, 15.3%], trial void with alpha blocker [n=1, 7.6%] while two are on continuing supra pubic diversion due to persistent neurological deficit. Chikungunya fever is an uncommon entity in urological practice, often associated with urinary symptoms. An accurate assessment of the symptoms and timely intervention prevents upper tract deterioration and improves the quality of life

Solitary renal actinomycosis

A 53-year-old man, who was a recurrent stone former and diabetic, presented with left flank pain, pyuria, and fever. He had undergone multiple interventions for removal of the left kidney stones and retained ureteral double-J stent. All blood and urine investigations were unremarkable and negative for fungus and tuberculosis. Computed tomography scan revealed an edematous left kidney with poorly enhancing upper pole having dilated calyces with hyperdense contents suggestive of abscess [Figure 1]. Ultrasonography-guided aspiration of left renal abscess grew Pseudomona Aeruginosa. Thereafter, patient underwent left laparoscopic nephrectomy. On gross examination, yellow sulfur granules in the dilated upper pole calyceal system were seen [Figure 2]. Microscopic examination of the sulfur granules demonstrated homogenous eosinophilic hyaline material coating actinomyces colonies surrounded by a dense lymphoplasmacytic infiltrate [Splendore-Hoeppli phenomenon] with concomitant pyelonephritis [Figure 3]. The patient was discharged on long-term doxycycline as he was allergic to penicillin. Solitary renal actinomycosis can present as pyelonephritis, renal/perinephric abscess, or renal mass. [1] Multiple interventions, recurrent urinary tract infection, retained double-J stent, uncontrolled diabetes mellitus, and untreated dental caries are predisposing factors for this disease. With development of effective antibiotics, the challenge now lies in the clinician's ability to make the correct diagnosis, thus, ensuring timely recognition and renal salvage if possible[2]

Trans-esophageal echocardiography for tricuspid and pulmonary valves.

Transesophageal echocardiography has been shown to provide unique information about cardiac anatomy, function, hemodynamics and blood flow and is relatively easy to perform with a low risk of complications. Echocardiographic evaluation of the tricuspid and pulmonary valves can be achieved with two-dimensional and Doppler imaging. Transesophageal echocardiography of these valves is more challenging because of their complex structure and their relative distance from the esophagus. Two-dimensional echocardiography allows an accurate visualization of the cardiac chambers and valves and their motion during the cardiac cycle. Doppler echocardiography is the most commonly used diagnostic technique for detecting and evaluating valvular regurgitation. The lack of good quality evidence makes it difficult to recommend a validated quantitative approach but expert consensus recommends a clinically useful qualitative approach. This review ennumerates probe placement, recommended cross-sectional views, flow patterns, quantitative equations including the clinical approach to the noninvasive quantification of both stenotic and regurgitant lesions.

Azathioprine versus betamethasone for the treatment of parthenium dermatitis: a randomized controlled study.

BACKGROUND: Parthenium hysterophorus is the commonest cause of airborne contact dermatitis in India. Azathioprine has been shown to be effective and safe in parthenium dermatitis, but there are no reports of comparison of steroids and azathioprine in this condition. AIMS: To study the therapeutic efficacy of azathioprine versus betamethasone in patients having contact dermatitis to parthenium and compare the side effects of the drugs. METHODS: Fifty-five patients of airborne contact dermatitis to parthenium were randomly assigned to treatment with azathioprine 100 mg daily (group A) or betamethasone 2 mg daily (group B), for 6 months in a blinded manner. The patients were evaluated every month for 6 months to determine the response to treatment and side effects and then further followed up for another 6 months to determine any relapse. RESULTS: There were 26 patients in group A and 29 in group B, of which 20 patients of group A and 21 of group B completed the study. Nineteen (95%) patients in group A and all 21 (100%) patients in group B had an excellent response (complete remission) to treatment (P=0.0156 vs. 0.0005). The patients in group B, however, had more adverse effects (Fisher exact, P<or=0.05). Nine (45%) patients in group A and 14 (67%) patients in group B relapsed during the post-treatment follow-up. CONCLUSIONS: Azathioprine and betamethasone appear to be almost equally effective (P=0.0156 vs. 0.0005) in the treatment of parthenium dermatitis. However, adverse effects and relapses were observed to be more frequent in patients treated with betamethasone.

Laparoscopic partial cystectomy for urachal and bladder cancer

PURPOSE: To report our initial experiences with laparoscopic partial cystectomy for urachal and bladder malignancy. MATERIALS AND METHODS: Between March 2002 and October 2004, laparoscopic partial cystectomy was performed in 6 cases at 3 institutions; 3 cases were urachal adenocarcinomas and the remaining 3 cases were bladder transitional cell carcinomas. All patients were male, with a median age of 55 years (45-72 years). Gross hematuria was the presenting symptom in all patients, and diagnosis was established with trans-urethral resection bladder tumor in 2 patients and by means of cystoscopic biopsy in the remaining 4 patients. Laparoscopic partial cystectomy was performed using the transperitoneal approach under cystoscopic guidance. In each case, the surgical specimen was removed intact entrapped in an impermeable bag. One patient with para-ureteral diverticulum transitional cell carcinoma required concomitant ureteral reimplantation. RESULTS: All six procedures were completed laparoscopically without open conversion. The median operating time was 110 minutes (90-220) with a median estimated blood loss of 70 mL (50-100). Frozen section evaluations of bladder margins were routinely obtained and were negative for cancer in all cases. The median hospital stay was 2.5 days (2-4) and the duration of catheterization was 7 days. There were no intraoperative or postoperative complications. Final histopathology confirmed urachal adenocarcinoma in 3 cases and bladder transitional cell carcinoma in 3 cases. At a median follow-up of 28.5 months (range: 26 to 44 months), there was no evidence of recurrent disease as evidenced by radiologic or cystoscopic evaluation. CONCLUSIONS: Laparoscopic partial cystectomy in carefully selected patients with urachal and bladder cancer is feasible and safe, offering a promising and minimally invasive alternative for these patients.

Effect of Aerva lanata on calcium oxalate urolithiasis in rats.

Calcium oxalate (CaOx) stone was induced in rats using 0.75% of ethylene glycol in drinking water for 28 days. Ethylene glycol treated rats showed significant increase in the activities of oxalate synthesizing enzymes such as glycolic acid oxidase (GAO) in liver and lactate dehydrogenase (LDH) in liver and kidney. CaOx crystal deposition, as indicated by increased excretion of stone-forming constituents in urine, such as calcium, oxalate, uric acid, phosphorus and protein and decreased concentration of inhibitors, such as citrate and magnesium was observed in ethylene glycol induced urolithic rats. Histopathological studies also confirmed the deposition of CaOx crystals. Administration of Aerva lanata aqueous suspension (2g/kg body wt/dose/day for 28 days) to CaOx urolithic rats had reduced the oxalate synthesizing enzymes, diminished the markers of crystal deposition in the kidney. The results of the present study confirmed that A. lanata can be used as an curative agent for urolithiasis.