Development and internal validation of preoperative and postoperative nomograms predicting quadrifecta outcomes following robotic radical prostatectomy.

Introduction: Literature on the factors predicting functional and oncological outcomes following robot-assisted radical prostatectomy (RARP) is sparse for the Indian population. Hence, the primary objective of this study was to develop preoperative and postoperative nomograms predicting these outcomes in patients with prostate cancer undergoing RARP. Methods: This retrospective analysis identified the predictors of quadrifecta outcomes, i.e., the patients who did not have complications, were continent, had negative surgical margins, and were biochemical recurrence free with at least 1 year of follow-up following RARP. We excluded the return of sexual potency as the majority of the patients in our series were sexually inactive preoperatively. We used the backward stepwise logistic regression analysis method to identify the predictors of quadrifecta. Preoperative and postoperative nomograms using these predictors were developed and validated with bootstrapping, goodness of fit, calibration plot, decision curve analysis (DCA), and theits receiver operating characteristic (ROC) analysis. Results: Of the 688 patients who underwent RARP, 399 were included in this study, and 123 (30.8%) of these achieved the quadrifecta outcomes. Preoperative nomogram was developed using four variables, i.e., prostate-specific antigen (PSA), Charlson Comorbidity Index (CCI), biopsy Gleason score, and clinical stage. Postoperative nomogram included PSA, CCI, pathological tumor stage, tumor grade, and positive lymph node. Both the models were internally valid on bootstrapping, calibration plots, and goodness of fit. On the ROC analysis, preoperative and postoperative nomograms had an area under the curve of 0.71 and 0.79, respectively. On the DCA, at a threshold probability of 5%, both the models showed a net benefit. Conclusions: We developed and validated accurate nomograms for predicting quadrifecta outcomes following RARP for the Indian population.

A Cross-Sectional Study of Resident Training in Robotic Surgery in India.

Background The widespread implementation of robotic surgery in the Indian subcontinent has received mixed reactions from residents and mentors alike. To date, however, no study has documented the perception of Indian surgical trainees on the effect of robotic surgery on surgical training. Therefore, we conducted a questionnaire-based study on Indian surgical residents to assess their views about robotic surgery and the effect, they believe, it might have on resident training. Materials and methods Questionnaires were distributed to 300 surgical residents from programs that do not have surgical robots. All other residents, faculty, medical students, and interns were excluded from the study. The responses were collected and analyzed using appropriate statistical methods. Results Overall, 210 surgical residents responded to the survey. A majority of them (57.72%) reported low levels of knowledge regarding robotic surgery. While 88.10% of the study participants reported that the use of robotic surgery will continue to rise in India, an equal proportion (88%) believed that procuring a robot in their program will impair their training in open and laparoscopic surgeries. Conclusions The introduction of robotic surgery into surgical residency programs is seen, by most residents, as a threat to training in traditional surgical methods. This calls for the effective incorporation of robotic training into residency training with equal distribution of resident training cases in programs across the country.

Trigonometric Concept of Fluoroscopy-Guided Percutaneous Renal Access.

Percutaneous nephrolithotomy is the standard surgical management of large renal calculi. Percutaneous renal access using the triangulation method has been an enigma for the endourologist to master and teach. This surgical conundrum is due to the uncertainty in the angle and depth required to puncture the target calyx. We describe a novel trigonometric method of renal access where both the angle and the depth of puncture are easily determined before the puncture.

Acute Presentation of Giant Hydronephrosis in an Adult.

Giant hydronephrosis is defined as a dilated collecting system containing more than one liter of fluid. The diagnosis of giant hydronephrosis is rare due to improved diagnostics and the liberal use of abdominal imaging. Herein we report a 40-year-old woman who presented with acute onset abdominal pain and was diagnosed with giant hydronephrosis. She underwent a simple open nephrectomy and made an unremarkable recovery. Although giant hydronephrosis due to ureteropelvic junction obstruction is common in the pediatric and adolescent age group, it rarely presents in adults. Acute presentations, like abdominal pain, are exceedingly rare. Judicial use of cross-sectional imaging, as in our patient, can confirm the diagnosis and help in successful management.

Acute Presentation of Urachal Cyst: A Case Report.

Urachus is an embryonic organ related to the bladder that degenerates after birth. Defective obliteration of the urachus leads to urachal malformations, the most common of which is a urachal cyst. A urachal cyst is often misdiagnosed due to its myriad presentations. Delay in diagnosis can lead to complications such as sepsis, fistula formation, and rupture of the cyst mimicking peritonitis. Hence, a high index of suspicion is required for the timely diagnosis and management of urachal cysts presenting in the emergency room. We report the case of a 32-year-old woman who presented with clinical features suggestive of an acute abdomen. The judicious use of imaging confirmed the diagnosis of an infected urachal cyst, which was surgically managed.

An Unusual Cause of Vesical Calculi.

Intravesical migration is an uncommon but serious complication of intrauterine contraceptive devices. Calculus formation is common over such migrated intrauterine contraceptive devices. This dreaded complication usually presents with lower urinary tract symptoms such as suprapubic pain, frequency, and nocturia. We present a case of a 50-year-old woman with intravesical migration of copper-T device placed in the immediate postpartum period 25 years ago. She presented with dysuria, which was confirmed by computed tomography. The migrated device was encrusted with a 3.5-cm-sized stone around its vertical limb. Another stone of approximately the same size was present in the bladder. Surprisingly, the patient never had symptoms and hence she never followed up for 25 years. The stones could not be removed endoscopically, and therefore an open vesicolithotomy was performed. This case has been presented to highlight the significance of following up patients with intrauterine contraceptive devices to avoid potentially devastating complications.

A Novel Method of Local Anesthesia for Optical Internal Urethrotomy.

Direct vision internal urethrotomy (DVIU) is the treatment of choice for short anterior urethral strictures. It is performed under spinal or general anesthesia although it can also be done under local anesthesia. We describe a novel method of local anesthesia for internal urethrotomy. The technique described is feasible in morbid patients who are deemed unfit for spinal or general anesthesia and achieves good analgesia.

Atypical Presentation of Renal Leiomyosarcoma: A Case Report.

Primary renal sarcomas are rare comprising from 0.8 to 2.7% of adult renal tumours. They cannot be distinguished clinically or radiologically from the more common renal cell carcinomas. Leiomyosarcoma is the most common histological subtype accounting for around 50-60% of renal sarcomas. Leiomyosarcomas arise from the renal capsule, renal vein or the renal pelvis. They present with nonspecific clinical symptoms and signs and usually have a dismal outcome. Rarely atypical presentations such as acute tumour rupture and hematuria are encountered. We report a 27-year-old woman who presented with malignant hypertension. The hypertension was controlled emergently with antihypertensive agents. In view of the young age, a thorough workup was conducted to identify the cause of hypertension. Imaging studies revealed a solid enhancing renal tumour compressing the renal vasculature. As the staging workup did not reveal any evidence of metastases, the patient underwent right-sided open radical nephrectomy after adequate control of hypertension. The histological examination uncovered the renal tumour to be a leiomyosarcoma. Postoperative period was uneventful and she was doing well on one year follow up. Surprisingly the blood pressure normalised postoperatively and the patient was weaned off of her antihypertensive medications. This case is presented to highlight the atypical acute presentation of primary renal leiomyosarcoma with relatively good prognosis. Timely diagnosis and meticulous surgical resection improved the prognosis of this aggressive renal malignancy.

Study of Knowledge, Attitude, and Practice of Organ Donation Among Medical Students in a Tertiary Care Centre in South India.

Introduction The deceased donor renal transplantation (DDRT) program in India has seen its ups and downs. The Indian state of Tamilnadu runs a successful DDRT program. Future doctors play an important role in continuing with this success and hence educating them on organ donation is of paramount importance. Methods We conducted a cross-sectional questionnaire-based study from June 2015 to December 2017 among 480 medical students to analyse their knowledge, attitude and practice regarding organ donation. The validated questionnaire sheets were distributed during lecture hours and completed sheets were analysed. Results Of the 480 participants, 425 completed the questionnaire which is a response rate of 88.5%. Knowledge scores were uniformly low among all four batches of students (p=0.001). The first and third-year students scored better in practice (p=0.001) and attitude (p=0.001) domains. Females outnumbered males by scoring high in all three domains. Conclusion The poor knowledge score among all the batches of medical students is alarming. This implies the need for urgent changes in the medical curriculum to better educate future doctors of the country. Durable changes in practice can be brought about by changing the attitude of medical students.

Single Session Endoscopic Removal of Bilateral Ureteric Stents Retained for Three Decades: A Case Report.

Forgotten ureteric stents are a devastating complication, which may require a multistage approach necessitating repeated surgeries and may even require removal of the entire renal unit. We report a 59-year-old woman with heavily encrusted bilateral ureteric stents forgotten for 32 years. Successful single-stage endoscopic removal reduced the morbidity and healthcare-related costs. This case report represents the longest indwelling duration of forgotten ureteric stents reported in the literature.

Primary Renal Angiosarcoma Mimicking Renal Cell Carcinoma: A Case Report.

Primary renal angiosarcoma is an exceedingly rare malignancy of the kidney. It usually presents in the elderly with metastatic disease and dismal prognosis. Treatment protocols are not standardized for this very rare renal malignancy. We report the case of a young man who was incidentally diagnosed with primary renal angiosarcoma. Preoperative imaging was suggestive of renal cell carcinoma; however, postoperative histopathological examination confirmed it to be an angiosarcoma. The patient was treated with surgical excision followed by adjuvant chemotherapy and is doing well at one-year follow-up.

Cystic renal oncocytoma mimicking renal cell carcinoma.

Cystic renal lesions are one of the commonly encountered urological conditions. They can be either benign or malignant. The Bosniak classification is employed to differentiate benign cysts from the malignant ones and to recommend treatment options. Bosniak type 4 cysts are mostly malignant. Rarely, benign tumors can be encountered in Bosniak type 4 cysts. We present a 59-year-old female who presented with a hilar Bosniak type 4 cyst in the right kidney. She underwent open exploration of the right renal tumor. The tumor was infiltrating into the renal vessels and could not be separated from the renal vein. In view of preoperative and intraoperative suspicion of malignancy, radical nephrectomy was done. Postoperative histopathological examination revealed the tumor to be an oncocytoma. The benign nature of the cyst could not be conclusively determined by preoperative investigations and intraoperative findings. Postoperative histological examination uncovered the rare cystic presentation of this benign tumor.

Synchronous Triple Malignancies in an Indian Albino: A Case Report.

Oculocutaneous albinism (OCA) is a heterogenous disorder of skin pigmentation characterized by hypopigmentation of the skin, hair, and eyes. The absence of melanin predisposes these individuals to ultraviolet rays induced malignancies. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) in OCA have been rarely reported. Malignant melanoma (MM) of the skin is also very rarely reported. Synchronous BCC, SCC, and MM are exceedingly rare. We report one such case managed successfully with surgical treatment. All the three malignancies were localized cancers and hence the outcome was good. The importance of regular follow up and periodic self-examination in such predisposed individuals are highlighted.

Early Versus Delayed Double J Stent Removal in Deceased Donor Renal Transplant Recipients: A Prospective Comparative Study.

INTRODUCTION: Prophylactic ureteric stents have been commonly employed to reduce the incidence of ureteric obstruction and anastomotic leaks following renal transplantation. There are very few studies on the duration of ureteric stenting in deceased donor renal transplantation (DDRT). We performed a prospective study to compare early and late double J stent removal in DDRT. AIMS AND METHODS: The aim of this study was to compare the early and delayed removal of ureteric stents after DDRT. We performed 80 DDRTs at our center from August 2012 to December 2016, which were included in the study. However, we enrolled 48 patients as the remaining had to be excluded based on the high-risk factors. The recipients were allocated on the 14th postoperative day to two groups. Group 1 underwent early stent removal on the fourteenth postoperative day and in group 2, the stent was removed in the sixth postoperative week. The two groups were followed up for six months and the incidence of urological complications and urinary tract infections (UTI) was compared. RESULTS: The incidence of UTI during the follow-up period of six months was significantly lower in the early stent removal group (two out of 24) than in delayed stent removal group (eight out of 24) (p=0.016). Asymptomatic bacteriuria occurred in six out of 24 (25%) in group 1 and 10 out of 24 (41.6%) in group 2 (p=0.120). There was no significant difference in the incidence of urinary leak, hematuria, or ureteric obstruction between the two groups (p=0.900). However, stent-related symptoms were significantly more in the delayed stent removal group (three in group 1 versus 18 in group 2) (p=0.001). CONCLUSION: Prolonged stenting is associated with an increased risk of UTI and stent-related symptoms in immunosuppressed renal transplant recipients. The early removal of double J stents can be done in carefully selected patients to reduce stent-related complications in DDRT.