Emergency endovascular and percutaneous urological interventions: A pictorial review.

Emergency endovascular and percutaneous urological interventions encompass various diagnostic and therapeutic procedures to address various genitourinary conditions. These urological interventions are life-saving in addressing complications following biopsy, post-nephrectomy, post-transplant, and post-trauma. Compared to other surgical fields, there are relatively fewer urological emergencies. However, they require prompt radiological diagnosis and urgent interventions. This pictorial essay emphasizes various urological emergencies and urgent interventional management.

A Novel Technique for Hand-Assisted Laparoscopy in Difficult Nephrectomies-Is One Hand Better Than Two? A Single-Centre, Single-Surgeon Series.

Laparoscopic radical nephrectomy is the standard of care for T1 renal tumors and nowadays being used for T2 or higher tumors, resulting in higher the conversion rates. To bridge this gap, the hand-assisted laparoscopy (HAL) method was introduced. Even now, in the robotic era, this HAL approach continues to find importance in urology, especially in the most challenging cases, albeit, with a relatively low usage rate due to the cost involved and availability of hand port devices. Here, we report a case series using a novel modification of the HAL nephrectomy (HALN) technique when open conversion is needed. From a prospective database, we retrospectively analyzed the data of Six patients who underwent HALN at the All India Institute of Medical Sciences between January 2019 and December 2022. Indications for surgery included both malignant and benign renal disease. Four surgeries were performed on the right side while two were performed on the left. Five patients underwent a HALN for renal cell carcinoma (RCC) and 1 for a benign non-functioning kidney. In our series, all the cases with RCC had were T2a or higher. Our case series shows that HALN is technically safe, effective, and a great adjunct to conventional laparoscopy. The ingenious use of a surgical glove as a hand port is an easy-to-make-and- use device in such challenging surgeries.

Long-term Sexual Function and Quality of Life in Women Following Substitution Urethroplasty.

PURPOSE: To assess the long-term quality of life (QOL) and sexual function (SF) in women who underwent either dorsal on-lay (DO) or ventral inlay (VI) urethroplasty for urethral stricture disease. METHODOLOGY: Between January 2016 and September 2022, women who underwent either dorsal on-lay (DO) or ventral inlay (VI) urethroplasties and had at least a six-month follow-up been included. Using the Female Sexual Function Index (FSFI) and WHO-QOL bref questionnaires, the QOL and SF were evaluated. Scores were compared between the two groups after being examined for internal validity. A sub-group analysis was carried out based on the procedure's success. RESULTS: With follow-up periods ranging from 6 to 86 months, 25 patients who received VI urethroplasty and 10 patients who underwent DO urethroplasty were included. Both scores demonstrated strong internal consistency. The cumulative QOL and FSFI scores were comparable in both groups (p = 0.53 and p = 0.83, respectively). Significantly high scores were noted in the physical health domain (76.5 ± 9.9 vs 62.33 ± 10.97; p = 0.03; (95% CI = 0.72-24.4)) and the environmental domain (75.75 ± 3.84 vs 66.00 ± 4.24; p = 0.01 (95% CI = 2.64-16.85) in patients with successful VI and DO urethroplasties respectively. Addictions, low socioeconomic status and protracted symptom duration were associated with low QOL scores. Old age was related to low FSFI scores. CONCLUSION: Substitution urethroplasty, despite the approach, showed good QOL and SF scores. Long symptom duration, addictions, and poor socioeconomic status were associated with low QOL whereas old age independently influenced low FSFI scores.

Intraoperative ultrasonography (IOUS)-guided vs conventional laparoscopic nephrectomy: a randomised control trial.

OBJECTIVES: To assess the efficacy of routine use of intraoperative ultrasonography (IOUS) in improving perioperative outcomes in patients undergoing IOUS-guided laparoscopic nephrectomy (IOUS-LN) and conventional laparoscopic nephrectomy (C-LN). PATIENTS AND METHODS: This was a parallel-arm, single-blinded, randomised controlled trial (CTRI/2021/12/038906). All patients undergoing LN, either for benign or malignant causes, were included. Patients undergoing partial/cytoreductive nephrectomy, with venous thrombus were excluded. In the study arm, IOUS-guided renal vascular assessment was performed after colon mobilisation and a standard LN was performed in the control arm. The primary outcome was intraoperative duration. The secondary outcomes were blood loss, need for open conversion, blood transfusion, perioperative complications, duration of Intensive Care Unit (ICU) stay and length of hospitalisation (LOH). The patients were followed for 3 months after surgery. RESULTS: A total of 104 patients were included, with 52 in each arm. Demographic characteristics were comparable in both arms. A significant reduction in the operative duration (mean [sd] 181.69 [40.8] vs 199.7 [41.8] min, P = 0.02) was seen in the IOUS-LN group. The difference in blood loss showed no significant difference when compared between both groups (median [interquartile range] 84.55 [74-105.5] vs 99.95 [78.5-111] mL, P = 0.08). On subgroup analysis, the reduction in the operative duration was significant in patients who underwent laparoscopic simple nephrectomy (LSN; mean [sd] 194.4 [42.5] vs 221.2 [36.4] min, P = 0.01), whereas comparable operative durations were seen in patients undergoing laparoscopic radical nephrectomy (LRN; mean [sd] 168.96 [35.3] vs 178.3 [35.9] min, P = 0.34). Similar conversion rates were seen in both groups (P = 0.98) along with blood transfusions (P = 0.78). The LOH, ICU stay, and complications were similar in both groups. Significantly less blood loss (P = 0.03) was noted with IOUS in patients undergoing LSN. IOUS did not influence any outcomes in patients undergoing LRN. CONCLUSION: Intraoperative ultrasonography significantly reduced the operative duration in LN, but with no significant reduction in the volume of blood loss. Significant reduction in intraoperative duration and blood loss was seen in patients who underwent LSN on subgroup analysis.

Efficacy of Low Dose Intravenous Epinephrine Infusion in Improving Perioperative Outcomes in Patients Undergoing Transurethral Resection of Prostate: A Prospective Parallel Arm Double-Blind Randomized Control Trial.

OBJECTIVE: To determine the efficacy of intraoperative low-dose intravenous epinephrine infusion in improving intraoperative bleeding and perioperative outcomes of transurethral resection of prostate (TURP) surgery. METHODS: This was a double-blinded, randomized control trial in which all patients undergoing bipolar TURP were included. Patients with uncontrolled hypertension, cardiac disease, and on anticoagulants were excluded. The study group received intravenous epinephrine, whereas the control group received normal saline at the same rate (0.05 µg/kg/min) throughout the procedure. Intraoperative blood loss was the primary outcome. The secondary outcomes were incidence of intraoperative hypotension (due to spinal anesthesia), resection time, indwelling catheter time, and length of hospitalization. RESULTS: Thirty-six patients were included in each group. Demographic and clinical profiles were comparable with an overall median prostate size of 41 (34-52) gram in both groups. The primary objective, mean intraoperative blood loss in the study group was lower than the control group but statistically insignificant (67.91+/-18.7 mL vs 75.14 +/-17.1 mL; P = .086). Incidence of intraoperative hypotension was significantly lower in the study group (8.3% vs 33.3%; P = .01). Rest of the secondary outcomes, resection time (83 (64-111.5) minutes vs 86 (68-94.75) minutes; P = .97), mean indwelling catheter time (P = .94), postoperative complications (P = .73), and length of hospitalization (P = .87) were comparable. CONCLUSION: In this first-of-its-kind trial, low-dose epinephrine infusion did not reduce intraoperative blood loss in patients undergoing TURP. However, it significantly reduced intraoperative hypotension, which complicates spinal anesthesia particularly in elderly population.

Pelvic lymph node dissection before or after laparoscopic radical cystectomy: An ambispective study comparing ease of surgery and operative outcomes.

Introduction: It is unclear when pelvic lymph node dissection (PLND) should be performed during laparoscopic radical cystectomy. Proponents of PLND performed before cystectomy claim that early PLND skeletonizes the urinary bladder's vascular pedicles, making cystectomy easy. Others contend that an early cystectomy provides space and flexibility during subsequent PLND. This first-of-its-kind study compared PLND before and after cystectomy for the ease of performing surgery (total operative time, cystectomy time, and PLND time) and the operative outcomes (number of lymph nodes removed, blood loss, and complication rates). Methods: This ambispective cohort study included a predetermined sample size of 44 patients. The first 22 patients underwent PLND after cystectomy (Group 1), and the following 22 underwent PLND before cystectomy (Group 2). The primary outcome was total operative time. Secondary outcomes included cystectomy time, PLND time, number of lymph nodes removed, blood loss, and complication rates. Results: The baseline characteristics were similar in both groups. The total operative time (344.23 ± 41.58 min vs. 326.95 ± 43.63 min, P = 0.19), cystectomy time (119.36 ± 34.44 min vs. 120.91 ± 35.16 min, P = 0.53), PLND time (126.82 ± 18.75 min vs. 119.36 ± 23.34 min, 0.25), number of dissected lymph nodes (13.27 ± 4.86 vs. 14.5 ± 4.76, P = 0.40), and blood loss (620.45 ± 96.23 ml vs. 642.27 ± 131.8 ml, P = 0.20) were similar in the two groups. The complication rates categorized by Clavien-Dindo grading were identical in the two groups. Conclusions: PLND done after cystectomy was comparable to PLND done before cystectomy regarding the ease of surgery and the operative outcomes.

Laparoscopic Radical Nephrectomy in the Current Era: Technical Difficulties, Troubleshoots, a Guide to the Apprentice, and the Current Learning Curve.

Abhishek Pandey, MSObjectives The main aim of this study is to present our experience with laparoscopic radical nephrectomy (LRN) and share practical solutions to various surgical challenges and the learning curve we realized. Materials and Methods We retrospectively analyzed our LRN database for relevant demographic, clinical, imaging, operative, and postoperative data, including operative videos. We described various complications, vascular anomalies, intraoperative difficulties, and our improvisations to improve safety and outcomes. Statistical Analysis We evaluated the learning curve, comparing the initial half cases (group 1) against the latter half (group 2), using the chi-squared test for categorical variables and Student's t -test for continuous variables. Results Of the 106 patients included, LRN was successful in 95% ( n = 101), and five cases converted to open surgical approach. The mean tumor size was 7.4 cm, 42% incidentally detected. The cumulative complication rate was 15%, including five main renal vein injuries. Intraoperative difficulties included ureter identification ( n = 6), venous bleed during hilar dissection ( n = 11), double renal arteries ( n = 23), and venous anomalies ( n = 20). Arterial anatomy had 95% concordance with the imaging findings. We describe various trade tricks to perform hilar dissection, identify and control anomalous vasculature, handle venous bleed, confirm arterial control, and improve decisions using imaging, technology, and guidance of a mentor. No statistically significant difference in the learning curve was observed between the study groups. Conclusion With LRN already established as the current standard of care, our description intends to share the trade tricks and inspire novice urologists, who can assimilate training and reproduce good results under proper guidance. The steep learning curve described in the past may not be apparent in the current era of training and technological advancement.

Inferior Alveolar Plus Buccal Nerve Block Decreases Postoperative Pain Scores at Buccal Mucosal Graft Harvest Site: A Retrospective Analysis.

OBJECTIVE: Postoperative pain at buccal mucosal graft (BMG) harvest site hinders the resumption of food intake. We aim to study the effect of inferior-alveolar nerve block plus buccal nerve block (IANB+BNB) on pain scores. METHODS: This was a retrospective case-control study performed in a single center from July 2021 to July 2022 (ethics committee approval: T/IM-NF/Urology/23/27). We performed IANB+BNB with a mixture of 5 mL each of 1% lignocaine and 0.25% bupivacaine and 4 mg dexamethasone, in addition to local infiltration of 2% lignocaine and (1:100000) epinephrine combination before harvesting BMG. We retrospectively compared the recorded postoperative pain scores using the visual analog scale (VAS) among patients who received and did not receive IANB+BNB. The time for resumption of pain-free diets and postoperative analgesic requirements was compared. RESULTS: The study groups included 20 patients each and were similar in age and graft size. The VAS scores at 0 hours [1.0 (1.25) vs. 2.5 (3.5); P= .043], 6 hours [2.40 (± 0.69) vs. 4.60 (± 0.97); P= .008], 12 hours [2.50 (± 0.97) vs. 4.80 (± 0.92); P= .008], and 24 hours [3.0 (1.25) vs. 4.5 (1.25); P= .002] were better in the intervention arm. However, the pain beyond the second day was similar. The IANB+BNB group resumed solid food quicker, and the cumulative paracetamol dose required was less [8.9 (± 3.03) vs. 16.2 (± 5.06) g; P= .001]. Fewer patients required opioids. CONCLUSION: Patients who received IANB+BNB had better pain scores during the first 24 hours following surgery and tolerated solid diet quicker.

The rhabdoid variant of adrenocortical carcinoma-Report of three cases and literature review.

Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy. Extensive rhabdoid morphology in ACC has been described recently in very few cases. The proportion of rhabdoid morphology and the role of SMARCB1/ INI1 expression in these tumor cells to diagnose the specific variant is not described in the literature. We reviewed the clinicopathological features of nine cases of adrenocortical neoplasm. Out of which, three cases of ACC showed predominant rhabdoid morphology. Large discohesive cells with abundant cytoplasm containing eosinophilic inclusions, eccentric vesicular nucleus, and prominent nucleoli. INI1 immunostain was retained in all cases. We reported the rhabdoid variant of ACC, a novel entity, and its diagnostic approach from their histological mimickers. Identifying more cases of this entity will help to clearly understand the pathogenesis, biologic behaviour, and any specific molecular alterations in the future.

Socio-economic, education, and insurance-related factors associated with the treatment completion rates in patients with nonmetastatic urinary bladder cancer: A Retrospective cohort study.

Introduction: Among urological malignancies, the diagnosis and treatment of urinary bladder cancer (UBC) incurs the highest cost per patient. Our objective was to broaden the current understanding of how demographic, socioeconomic, education, and insurance-related factors influence UBC management. Methods: Between January 2017 and December 2019, all patients with nonmetastatic bladder cancer were included. The demographic, treatment, and follow-up details were retrieved from a prospectively maintained database, and the Modified Kuppuswamy Index was used to evaluate the patients' socioeconomic level. Patients were divided into the completed treatment group, or the incomplete treatment group based on adherence to the initially intended treatment plan. Patients who presented with benign disease or metastases were not included. Results: Eighty-nine patients did not complete the initially intended course of treatment out of 132 patients who needed additional management after the initial transurethral resection. Comparable risk factors and demographic profiles existed in both groups. Patients with intermediate-risk disease are more likely to fail to adhere to the initial intended treatment (odds ratio [OR] = 0.09; 95% confidence interval [CI]: 0.02-0.30). On logistic regression analysis, upper socioeconomic status (OR = 6.8; 95% CI: 0.35-132.1) patients and patients with higher educational status of graduation or above (OR = 3.62; 95% CI: 0.75-17.43) had higher chances of treatment completion. Education status significantly impacted treatment completion on multivariate analysis (P = 0.01). Patients who utilized employer-funded insurance had better treatment compliance (OR = 4.1; 95% CI: 0.90-18.7). The compliance was unaffected by smoking, occupation, or other demographic factors. Conclusion: Patients with low economic status, low levels of education, and who need adjuvant intravesical therapy had considerably greater treatment dropout rates.

A prospective evaluation of patient-reported outcomes during follow-up of ureteral stones managed with medical expulsive treatment (MET).

Patient-reported outcomes (PROs) for ureteral stones predominantly assess the pain. Despite the lack of evidence, multiple trials studying the efficacy of medical expulsive therapy (MET) have used PROs to define spontaneous stone passage (SSP). We aim to objectively evaluate the accuracy of PROs to predict successful SSP and the probability of patient's symptom resolution after stone passage. A single-center, prospective observational study recruiting adults with isolated, uncomplicated, ≤ 10 mm ureteral calculus was conducted. All patients received 4 weeks of MET, and SSP was confirmed by low-dose non-contrast-enhanced computed tomography (NCCT). The accuracy of PROs: "pain cessation," "decreased pain," "stone seen," and "stone capture" to predict successful SSP were evaluated in 1 month. The patient's symptom resolution rate was assessed at 1 and 4-month follow-ups. A total of 171 patients were included, and the overall SSP rate was 66.4% (n = 99). Patient-reported pain cessation, stone visualization, and stone capture were associated with successful SSP, but their accuracy was 59, 53, and 43%, respectively. Moreover, 25% of patients reporting complete pain cessation still harbored ureteral calculus. Pain resolved in 91% of patients after SSP at a 4-month follow-up. While hematuria and nausea resolved in all patients, lower urinary tract symptoms (LUTS) were not resolved in 17% of patients. We concluded that patient-reported pain cessation, stone visualization, and stone capture predict successful SSP, but confirmatory imaging is required due to the poor accuracy of these measures. The significant rates of non-pain-related symptoms indicate their significant contribution to patient morbidity. Clinical Trial Registration: Registered in Clinical Trial Registry of India (CTRI), Registration number: CTRI/2020/10/028777 (29th October 2020).