Which is the best option to treat large (>1.5 cm) midureteric calculi?

INTRODUCTION: Before the 1980s, ureteric stones were managed by open ureterolithotomy. Since the introduction of shock-wave lithotripsy (SWL) and ureteroscopy, the use of an open surgical approach for the removal of ureteric stones has rapidly declined. Open surgery, which is currently being replicated by laparoscopic techniques, is generally indicated for failed endourologic procedures, particularly in centers that do not have flexible ureteroscopy or laser lithotripter, and in patients with larger stones. Considering this, we conducted a retrospective study to compare the different modalities for the management of midureteric calculi of more than 1.5 cm. MATERIALS AND METHODS: Between August 2000 and July 2005, a total of 71 patients with large midureteric calculi (>1.5 cm in size) were treated with the three different modalities; SWL, ureteroscopic pneumatic lithotripsy (URS), and laparoscopic ureterolithotomy at AMAI Trust's Institute of Urology. Data were collected and all the patients were analyzed for stone-free rate, intraoperative and immediate postoperative complications, and the results were calculated. RESULTS: Stone clearance was 39.1% with SWL (group 1), 79.2% with ureteroscopic pneumatic lithotripsy (group 2), and 100% with the laparoscopic method (group 3), with a statistically significant difference between groups 1 and three and groups 1 and 2, but there was no statistical significance in groups 2 and three. However, hospital stay and hence morbidity was significantly greater in group 3, when compared to the other two groups. CONCLUSION: SWL gives the least clearance for large midureteric calculi. Statistically, URS and laparoscopic ureterolithotomy give equal results; hence, URS still remains the treatment of choice for the treatment of large midureteric calculi considering the low morbidity and acceptable stone-free rate of the procedure. Though laparoscopic ureterolithotomy can be considered as a treatment option, prospective, randomized trials are needed to confirm the efficacy of one modality of treatment over the other.

Management of large (>60 g) prostate gland: PlasmaKinetic Superpulse (bipolar) versus conventional (monopolar) transurethral resection of the prostate.

BACKGROUND AND PURPOSE: Today, urologists around the world are encountering greater numbers of larger prostate glands, probably because of an initial trial of pharmacotherapy. The present study was performed to assess the safety and efficacy of bipolar transurethral resection of large prostate glands using the PlasmaKinetic (PK) Superpulse System. PATIENTS AND METHODS: This single-blind, randomized study included 70 patients with prostate gland >60 g seen on three-dimensional transrectal ultrasonography. Patients were randomized 1:1 using envelopes into either a PK Superpulse transurethral resection of the prostate (TURP) group or conventional TURP group, and underwent the procedure accordingly. Perioperative and postoperative parameters included operative time, blood loss, need for blood transfusion, clinical transurethral resection (TUR) syndrome, and duration of catheterization and hospitalization. Of 70 patients, 67 were followed for a minimum of 9 months, and data were analyzed using SPSS software. RESULTS: Both groups were comparable in terms of preoperative parameters, which included American Urological Association Symptom Score, Qmax, gland size, and postvoid residual. A statistically significant difference between the two groups was found in terms of perioperative blood loss, change in serum sodium, and duration of catheterization. These complications were significantly less in the PK Superpulse group, with an obvious reduction in the duration of hospitalization in that group. CONCLUSION: The PK Superpulse System can be used as safely and effectively in the resection of the large gland (>60 g) as it has been reported to be in the resection of small and medium-sized glands. By using physiologic saline (0.9% NaCl) as irrigation fluid, it eliminates any danger of TUR syndrome and thus eliminates the conventional time limit of resection. PK Superpulse TURP is a promising treatment modality in the management of large prostate glands. It has all the features of gold-standard monopolar TURP, along with added safety and efficacy. It is ready to be included in the urologist's armamentarium.

A prospective, randomized, controlled study to evaluate the efficacy and tolerability of Ayurvedic formulation "varuna and banana stem" in the management of urinary stones.

BACKGROUND: Medical management of urinary calculus disease is a challange for modern science. In the present trial Ayurvedic drug "Herbmed," which is made up of varuna (Crataeva nurvala) and banana stem (Musa paradisiaca) was assessed to see reduction and/or expulsion of urinary calculi and also to assess the role of these drugs to reduce pain during expulsion. MATERIALS AND METHODS: In this prospective randomized, double-blind, placebo control trial, total 77 patients with calculi more than 5 mm were included. All patients were evaluated either by X-ray KUB or USG KUB for 3 months. All patients were divided into two groups: group A included patients with calculi 5-10 mm (n = 31) and group B with calculi > 10 mm (n = 30) with either active treatment or placebo in both the groups. All patients were asked to keep a record of number of pain episodes, while severity of pain was measured on a visual analogue scale (VAS). RESULTS: In group A, there was 33.04% reduction in the size of calculi in the active arm while there was a 5.13% increase in the same group in the placebo arm (p = 0.017). In the other group B, there was an 11.25% reduction in the active arm and a 1.41% reduction in the same group with placebo. In the active arm there was statistically significant lower VAS as compared to the placebo arm in the form of the highest VAS (p = 0.008), average VAS (p = 0.001) and VAS at the first episode of pain (p < 0.0001). CONCLUSIONS: Our preliminary experience suggests that the Ayurvedic formulation "varuna and banana stem" has promise for the management of upper urinary-tract calculi, especially renal calculi. It helps to dissolve renal calculi and facilitate their passage. In addition, it also helps in reduction of pain due to renal/ureteric calculus disease. A larger phase III study with a longer follow-up is required.

Case report: laparoscopic heminephrectomy in a horseshoe kidney using bipolar energy.

Aberrant vasculature, functional parenchyma in the isthmus, and abnormal location are all unique features of horseshoe kidney that present technical challenges to laparoscopic management of disease. A 52-year-old man presented with a large renal calculus in a poorly functioning left moiety of a horseshoe kidney and underwent laparoscopic heminephrectomy. The ismthus, which had 2.5 to 3.0 cm of functioning parenchyma, was divided using the PlasmaKinetic Superpulse Generator (Gyrus). No additional hemostatic measure was required. The total operative time was 140 minutes with an estimated blood loss of 160 mL. At follow-up, the right moiety and remaining isthmus exhibited normal function with no extravasation.

Vesicovaginal fistula with secondary vaginal stones.

PURPOSE: We report a rare case of a vesicovaginal fistula associated with secondary vaginal stones that was managed totally endoscopically. MATERIALS AND METHODS: A 52-year-old woman presented with urinary incontinence and perineal pain. On subsequent evaluation, we found a vesicovaginal fistula associated with secondary vaginal stones caused by a retained gauze. Management involved vaginoscopy, intracorporeal shock wave lithotripsy for vaginal stones, and removing retained medical gauze. We performed cystoscopy, laparoscopic cystotomy, transabdominal Foley catheterization of the vesicovaginal fistula for traction, injection of diluted adrenaline-saline solution for better dissection, dissection of the bladder from the vagina, tension-free closure of the bladder and vaginal defects, and closure of the cystotomy. RESULTS: Operative time was 155 minutes and blood loss was 60 mL. The patient was discharged on postoperative day 3, and catheterization time was 14 days. At 3-month follow-up, the patient was fully continent. CONCLUSION: To our knowledge, this is the first reported case of a vesicovaginal fistula associated with secondary vaginal stones which was managed totally endoscopically. We believe that this is a feasible and efficacious approach for the management of such cases.

Laparoscopic management of a retained heavily encrusted ureteral stent.

The indwelling ureteral stent is a fundamental part of today's urologic practice. Since its introduction in 1978, many improvements have been made in stent design and composition to minimize patient discomfort. As a consequence, the patient can forget about the stent. A known and well-documented complication of this situation is encrustations of the ureteral stent which causes significant morbidity to the patient, and at times, they are very difficult to manage. Reports in the literature describe techniques that require several procedures and anaesthetic sessions to effect stent extraction. Here, we report the one-sitting laparoscopic management of a heavily encrusted and stuck DJ stent, with minimal morbidity and very short hospital stay. Laparoscopic management of this common urologic problem has not been reported before. A comprehensive discussion is also presented regarding the management of such problems and their prevention.

Epigastric heteropagus twins: 3 case reports with review of literature.

Conjoined twins are rare, heteropagus conjoined twins are rarer, and epigastric heteropagus conjoined twins are rarer still. It refers to unequal and asymmetrical twinning in which the dependant component (parasite) is smaller and attached to the epigastrium of the dominant component (autosite). We report 3 cases of epigastric heteropagus conjoined twinning. A review of literature is presented along with a discussion of possible etiopathogenesis.

Surgical bypass is still relevant in the palliation of malignant obstructive jaundice.

Malignant tumours of the biliopancreatic system causing obstructive jaundice are not curable in most of the patients, and palliation plays a very important therapeutic role. The role of surgery in palliation of malignant obstructive jaundice has been questioned in the light of availability of endoscopic techniques. In developing countries, however, exploratory laparotomy and palliative surgery (when possible) is the only option available as sophisticated instruments and the expertise to use them is limited to a very few centres. This was a retrospective study of 83 consecutive cases with malignant obstructive jaundice admitted to the Department of Surgery, NSCB Government Medical College, Jabalpur, MP, India from January 1996 to December 2000.