Xanthoma of the urinary bladder - A rare entity.

Xanthomas of the urinary bladder are rare. They may be associated with metabolic disorders. We hereby report a case of bladder xanthoma.

A cost comparison of open versus percutaneous approaches to management of large staghorn calculi.

AIM: This paper compares the cost of open versus percutaneous approaches to the management of large staghorn calculi in a tertiary care hospital in India. MATERIALS AND METHODS: Patients who underwent surgery for staghorn calculi larger than 6 cm between January 1998 and December 2003 were included. Those who had confounding factors in terms of cost such as additional surgical or medical procedures and complications unrelated to the surgery were excluded. The process of costing was done by following the clinical pathway. RESULTS: There were 13 patients who had open stone surgery and 19 patients who underwent percutaneous nephrolithotripsy (PCNL). The major differences in cost were seen in the higher cost of instruments and consumables in the PCNL group. The cost of management of complications widened this gap. Two patients in the PCNL group and none in the residual group required redo surgery. The residual stones in the open and PCNL groups required a mean of 2525 and 3623 shocks per patient respectively. Complete clearance after redo surgery and Shockwave lithotripsy (SWL) was seen in 92% and 58% in the open and PCNL arms respectively. The overall cost per patient was $625 per PCNL and $499 per open surgery. The final mean residual stone size in the PCNL group was 4.84 mm whereas it was 0.38 mm in the open group. The effective cost of achieving complete clearance in one patient was $1078 in the PCNL group and $543 in the open group. CONCLUSION: Open stone surgery is less costly than PCNL in large staghorn calculi.

Shock wave lithotripsy in solitary functioning kidneys: is prophylactic stenting necessary?

OBJECTIVE: To assess the safety of shock wave lithotripsy (SWL) without prophylactic stents in solitary functioning kidneys. PATIENTS AND METHODS: Sixteen solitary functioning kidneys with 23 renal stones with a size of <15 mm were treated with SWL as the primary modality. All patients were counseled about the possibility of obstruction, and treatment was offered to those who consented. The safety of SWL was assessed by the need for interventions and the posttreatment renal function. RESULTS: In 14 patients lithotripsy was uneventful. The duration of treatment ranged from 5 to 35 days. One patient with a 15-mm pelvic calculus presented with anuria which resolved before intervention. In 1 patient fragmentation failed, and percutaneous nephrolithotomy was performed. CONCLUSIONS: In solitary functioning kidneys, SWL is safe without prophylactic stents in properly selected and closely monitored patients. Avoiding stents decreases costs, duration of treatment, and stent-related morbidity without unduly compromising safety.

Bladder-sparing surgery in locally advanced nonurological pelvic malignancy.

INTRODUCTION: The urinary bladder is commonly involved in pelvic malignancy. The incidence of apparent extension into adjacent organs in locally advanced colorectal malignancy is 5-12%. It is not known with other pelvic malignancy. No guidelines are available for its management. Often a dilemma exists between cystectomy and a bladder-sparing procedure. We studied the validity of bladder-sparing surgery (BSS) in locally advanced nonurological pelvic malignancy. METHODS: Hospital records of patients who underwent BSS along with other surgeries (abdomino-perineal resection, anterior resection, anterior exenteration, debulking surgery and total pelvic exenteration) from January 1992 to May 2003 were reviewed. RESULTS: BSS was done in 15 patients. 10 had locally advanced colorectal malignancy, 3 with soft tissue masses of the lateral pelvic wall, 1 had ovarian malignancy and the other had residual mass following radiotherapy and chemotherapy of cancer cervix. In those with locally advanced colorectal malignancy, symptoms suggestive of lower urinary tract involvement were present in 8 (80%). Urine examination and ultrasonography was not helpful in suggesting bladder involvement, unlike CT scan of abdomen and pelvis. Preoperative cystoscopy showed endoscopic evidence of bladder involvement in 7 (87.5%). Bladder was involved supratrigonally in 7. Partial cystectomy was done in 9 patients. The left ureter was involved in 6 patients, and they required ureteric reimplantation. Palliative transurethral resection was done in 1 patient with tumor infiltration at the bladder neck and prostate. 50% patients had bothersome lower urinary tract symptoms at 1 year. One patient died in the immediate postoperative period due to a nonurological cause. Overall 3-year survival rate was 40%. CONCLUSION: Unlike primary bladder cancers these lesions are not multifocal and hence en block conservative bladder-sparing surgery can be offered. Preoperative CT scan or MRI can predict lower urinary tract involvement and help in decision-making by both surgeon and patient. The ultimate decision for bladder sparing is based on intraoperative findings. Sparing the bladder might provide better quality of life by avoiding urinary diversion without altering survival.

Tubercular ureteric strictures.

OBJECTIVE: To review the presentation of tubercular ureteric strictures and assesses the role of balloon dilatation and open surgical repair in their management. METHODS: This was a retrospective review of tubercular ureteric strictures managed between January 1993 and December 2002. The records were analyzed to assess clinical presentation and compare the results of balloon dilatation with open surgical repair. Success was defined as adequate drainage on imaging, no worsening of renal function, no recurrence of symptoms and no requirement of intervention on further follow up. The long term success rates were compared using the t-test for proportion. RESULTS: Of 73 strictures, 88% had lower urinary tract symptoms. Genital abnormalities suggestive of tuberculosis was observed in 40% male patients. Urine examination yielded aseptic pyuria in 85%, positive AFB smears in 36% and positive AFB cultures in 32%. A small capacity bladder and non-functioning renal units were the only consistent findings on intravenous urogram. Nephrectomy was performed in 37% cases due to non salvageable kidneys at presentation. The success rate of stenting fell from 93% on immediate follow up to 59% on a follow-up of 12 months. At 90% success rates on a follow-up of 7 months open surgical repair was superior (p 0.03). Long term success following balloon dilatation in renal units with good function was 78% compared to 25% for poorly functioning units. (p= 0.01) CONCLUSION: Open surgical repair is superior to balloon dilatation in the management of tubercular ureteric strictures. Renal function may predict the success of balloon dilatation.

Does failure to visualize the ureter distal to an impacted calculus constitute an impediment to successful lithotripsy?

BACKGROUND: A severe degree of ureteral obstruction is viewed as a predictor of poor outcome in shockwave lithotripsy (SWL). Impacted stones are often considered a contraindication to in-situ SWL. PATIENTS AND METHODS: Impaction in our study was defined as failure to visualize the ureter distal to the calculus with proximal hold-up of contrast for as long as 3 hours on an intravenous urogram (IVU). We evaluated 30 patients with impacted ureteral calculi, who were compared with a second unimpacted group matched for stone size and stone location. The calculi were reorganized into < or =10-mm and >10-mm groups. The results were compared in terms of clearance rates, number of shockwaves, number of sessions, and number of days between the start of SWL and clearance. RESULTS: Between January 1998 and December 2001, 30 impacted stones were treated with lithotripsy. Complete clearance rates in the impacted as well as the non-impacted group were 76.7%. There was no statistical difference in the number of shockwaves, sessions, or time to clearance. The results were poorer in lower-ureteral than upper-ureteral calculi, but this difference did not reach statistical significance. However, the differences between the < or =10-mm and >10-mm stones were statistically significant. CONCLUSION: Impaction on an IVU does not affect the results of lithotripsy.

Paediatric renal transplantation--a 15 year experience.

OBJECTIVE: To review the outcome of paediatric renal transplantation over a period of 15 years in a developing country. METHODS: This is a retrospective study of 63 children, less than 15 years of age, who underwent living-related renal transplantation in Christian Medical College and Hospital Vellore between 1984 and 1996. RESULTS: The records of 12 patients were not adequate for detailed analysis. Parents were the donors for these children in 84.3% of cases. The most common known cause of end-stage renal disease in these children was reflux nephropathy. Combinations of cyclosporine, azathioprine and prednisolone were used as immunosuppressive drugs. Complications occurred in 16 patients. During the follow-up period, eight patients died and two returned to receiving haemodialysis. Patient survival was 92% at the end of 1 year and 90% at the end of 3 years. Graft survival was 88% and 86% at 1 and 3 years, respectively. CONCLUSION: Our study validates the concept of renal transplantation as optimal therapy with adequate medical, social and functional rehabilitation for children with end-stage renal disease. Our study also indicates that vesicoureteric reflux appears to be underdiagnosed and should be actively pursued to prevent complications.

Transurethral prostatic resection or laser therapy for men with acute urinary retention: the ClasP randomized trial.

PURPOSE: Transurethral resection of the prostate is the standard operation for acute urinary retention, although laser prostatectomy is reportedly effective and safe. The ClasP (conservative management, laser, transurethral resection of the prostate) study compared transurethral prostatic resection and noncontact neodymium (Nd):YAG visual laser assisted prostatectomy for treatment of acute urinary retention. MATERIALS AND METHODS: This study was a multicenter randomized controlled trial, analyses were by intention to treat and followup was at 7.5 months after randomization. Primary outcomes were treatment failure, and included International Prostate Symptom Score, International Prostate Symptom Score quality of life score, residual urine and flow rate. Secondary outcomes included complications, and duration of catheterization and hospitalization. RESULTS: A total of 148 men were randomized to transurethral prostatic resection (74) and laser (74). There were fewer treatment failures after prostatic resection (p = 0.008) and fewer men after resection required secondary surgery for poor results (1 versus 7, p = 0.029). Maximum flow rates after transurethral prostatic resection were better than after laser (mean difference 4.4 ml. per second). Comparison of symptom and quality of life scores demonstrated that any clinically significant advantage for laser could be ruled out. Patients stayed a mean of 2 extra days in the hospital after resection. The duration of catheterization was greater after laser but significantly fewer major treatment complications were found with laser therapy. CONCLUSIONS: Transurethral prostatic resection was more effective, resulted in fewer failures than laser treatment and remains the procedure of choice for men with acute urinary retention.

A prospective randomized trial comparing transurethral resection of the prostate and laser therapy in men with chronic urinary retention: The CLasP study.

PURPOSE: We assessed the effectiveness of laser therapy versus transurethral prostatic resection in men with symptomatic chronic urinary retention secondary to benign prostatic enlargement. MATERIALS AND METHODS: This trial was multicenter, pragmatic and randomized. Analysis was done by intent to treat. Laser therapy involved neodymium:YAG noncontact visual prostate ablation, while transurethral prostatic resection was performed by standard electroresection. Patients were included in our study if they reported moderate to severe lower urinary tract symptoms with an International Prostate Symptom Score (I-PSS) of 8 or more, benign prostatic enlargement and a persistent post-void residual urine volume of more than 300 ml. Followup was 7.5 months. Primary outcome measures included the I-PSS, I-PSS quality of life score, maximum urinary flow and post-void residual urine volume. Secondary outcome measures included treatment failure, complications, hospital stay and catheterization time. RESULTS: A total of 82 patients agreed to be randomized to receive laser therapy (38) or transurethral prostatic resection (44). There were significant improvements in all primary outcomes in each group from randomization to followup. Transurethral prostatic resection was significantly better than laser therapy for I-PSS and maximum urinary flow values (p = 0.035 and 0.029, respectively) but there were no differences in post-void residual urine volume and I-PSS quality of life score between the groups. We noted significantly more treatment failures with laser therapy than resection (8 versus 0, p = 0.0014), although only 3 patients required resection after laser therapy because of persistent symptoms. In addition, hospital stay after resection was 2-fold that after laser therapy (ratio of geometric means 2.01, 95% confidence interval 1.54 to 2.61, p <0.0001). However, time to catheter removal was 9 times longer in the laser therapy group (p <0. 0001). Complication rates were significantly higher for transurethral prostatic resection (chi-square 5.05, 1 df, p = 0.025). CONCLUSIONS: Transurethral prostatic resection is more effective than laser ablation in men with chronic urinary retention in terms of symptom score, maximum urinary flow and failure. However, men who underwent resection had significantly more treatment complications and were hospitalized longer than those who received laser therapy. This finding implies that laser ablation therapy may have a role in patients at higher risk who are willing to accept a lower level of effectiveness in exchange for decreased complication rates and hospital stay.

A randomized trial comparing transurethral resection of the prostate, laser therapy and conservative treatment of men with symptoms associated with benign prostatic enlargement: The CLasP study.

PURPOSE: We evaluated the effectiveness of a new technology (noncontact laser therapy) versus that of standard surgery (transurethral prostatic resection) and conservative management for lower urinary tract symptoms associated with benign prostatic enlargement. MATERIALS AND METHODS: Men with uncomplicated lower urinary tract symptoms, that is no acute or chronic urinary retention, were randomized to receive laser therapy with a noncontact, side firing neodymium:YAG probe, standard transurethral prostatic resection or conservative management, including monitoring without active intervention, in a large multicenter pragmatic randomized controlled trial called the CLasP study. Primary outcomes were International Prostate Symptom Score (I-PSS), maximum urinary flow rate, a composite measure of success based on I-PSS and maximum urinary flow rate categories, I-PSS quality of life score and post-void residual urine volume. Secondary outcomes included treatment failure, hospital stay and major complications. Followup was 7.5 months after randomization. Intent to treat analysis was done using analysis of covariance, proportional odds models and the Newman-Keuls multiple comparisons procedure. RESULTS: Of symptomatic patients 117, 117 and 106 were randomized to receive laser therapy, transurethral prostatic resection and conservative management, respectively. Baseline characteristics were similar. All primary outcomes indicated that transurethral prostatic resection and laser therapy were superior to conservative management, and resection was superior to laser therapy. As measured by combined improved symptoms and maximum urinary flow, a successful outcome was achieved in 81%, 67% and 15% of men who underwent transurethral prostatic resection, laser therapy and conservative management, respectively. Hospital stay was significantly shorter and complications fewer for laser therapy than for resection but catheters were in place significantly longer. Men treated conservatively did not have deterioration or treatment failure. CONCLUSIONS: Laser therapy and transurethral prostatic resection are effective for decreasing lower urinary tract symptoms and post-void residual urine volume as well as improving quality of life and maximum urinary flow in the short term in men presenting with moderate to severe symptoms. Transurethral prostatic resection is superior to laser therapy in terms of effectiveness but some patients may elect laser therapy due to the shorter hospital stay and lower risk of complications. Conservative management may be acceptable and safe in men with lower urinary tract symptoms since we observed no marked deterioration in the short term.

Transplant kidney protection during aortic aneurysm surgery.

PURPOSE: Renal allografts are sensitive to ischemic insult. During aortic cross clamping prevention of ischemic damage to a kidney below an aneurysm is vital. Many maneuvers have been reported. We describe a simple technique of protecting the transplant kidney from ischemic damage during aortic surgery. MATERIALS AND METHODS: During vascular cross clamping a sterile ice slush was placed around the kidney for surface cooling, obviating the need for some of the complicated procedures previously reported. RESULTS: After removal of the ice slush and clamps, urine production resumed and creatinine levels remained unchanged. CONCLUSIONS: External cooling with ice slush provides adequate renal protection during aortic cross clamping and requires no special expertise or equipment.