Laparoendoscopic Single-Site Urologic Surgery in Children Less Than 5 Years of Age

PURPOSE: We report our experience with laparoendoscopic single-site (LESS) urological procedures in children less than 5 years of age. MATERIALS AND METHODS: Ten patients (11 procedures) underwent LESS through the umbilicus. Seven patients underwent nephrectomy and three patients underwent pyeloplasty (one simultaneous bilateral). R-port port (Advanced Surgical Concepts, Ireland) was used in nine cases, in one case, the Gelpoint access port (Applied Medical, Rancho Santa Margarita, CA, USA) was used. The Olympus Endoeye camera with coaxial light cable was used. The hilum was secured in all cases with Hem-o-Lok clips (Teleflex Medical, Research Triangle Park, NC, USA) except in one case in which an Endo GIA stapler (Covidien Surgical, Norwalk, CT, USA) was used. RESULTS: All procedures were technically successful. Accessory port (3 mm) was used in 3 patients. Mean age in nephrectomized patients was 3.14+/-1.7 years, the mean operative room time (ORT) was 97.5+/-12.54 minutes. In the pyeloplasty group, mean ORT was 192+/-47.16 minutes and mean age was 2.43+/-2.3 years. Bilateral pyeloplasty was done in a 4-month-old infant. The ORT in this case was 180 minutes. A follow-up renogram done in the pyeloplasty patients (n=2) showed good drainage. Mean length of stay was 3.6 days (range, 3 to 6 days).The analgesic requirement was 23.86 mg (range, 12.5 to 50 mg) of diclofenac sodium. CONCLUSIONS: LESS is technically feasible in patients as young as 4 months of age. It has the potential to offer better cosmesis. This needs to be proved in further comparative studies. Development of miniature instruments will further the growth of LESS in this age group.

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

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]