ABSTRACT
Objective: To compare two retrieval incisions, Pfannenstiel vs iliac fossa incision, in terms of operative technique-related variables and variables related to patient satisfaction postoperatively, in patients undergoing laparoscopic donor nephrectomy (LDN). Patients and methods: This prospective randomised study was conducted between May 2016 and April 2017. All the voluntary kidney donors aged 18-60 years were randomised into two groups. Group 1, comprised patients undergoing graft retrieval via an iliac fossa incision, and Group 2 comprised those undergoing graft retrieval via a Pfannenstiel incision. Intraoperative assessment of the incision by the surgeon was done using a Likert scale-based questionnaire. Other variables studied were the operative time, retrieval time, warm ischaemia time, and length of incision. Postoperatively, visual analogue scale pain scores, analgesia consumption, and hospital stay were compared. During follow-up cosmetic outcome was compared. Results: In all, 108 patients were enrolled in the study with 54 patients in each group. The mean operative time was shorter in Pfannenstiel-incision group, at 155.2 vs 171.67 min (P = 0.01). The retrieval incision length was significantly less in the Pfannenstiel arm, at 9.29 vs 9.85 cm (P < 0.001). In the surgeon Likert scale-based questionnaire, the Pfannenstiel incision scored better than the iliac fossa incision for ease of specimen retrieval (P = 0.015), ease of immediate check laparoscopy (P = 0.002), and ease of incision closure (P < 0.001). The Pfannenstiel-incision group required less postoperative analgesia, at a mean (SD) of 7.03 (8.82) vs 15.55 (11.1) mg nalbuphine (P < 0.001). During follow-up the Manchester Scar Scores were lesser in the Pfannenstiel-incision group (P < 0.001). Conclusion: The Pfannenstiel incision was considered preferable during the critical steps of the LDN and had a smaller retrieval incision, lesser operative time and postoperative analgesia requirement, and better cosmesis than the iliac fossa incision. Abbreviations: BMI: body mass index; LDN: laparoscopic donor nephrectomy; VAS: visual analogue scale; WIT, warm ischaemia time.
ABSTRACT
AIM: To construct and validate a cost-effective indigenously made retrieval system (Modified Nadiad bag) in minimal access urology. METHOD: The components of the modified Nadiad bag are a polyethylene roll, fishnet thread, and a 5 Fr ureteral catheter. The bag is indigenously made in our institute and used for organ retrieval after proper sterilization. The video recordings of entrapments and retrievals done over the past few months were reviewed. The procedures under review in which the bag was used were: Robot Assisted Radical Prostatectomy (50 cases), laparoscopic radical nephrectomy (50 cases), laparoscopic simple nephrectomy (50 cases) and laparoscopic adrenalectomy (18 cases). We also compared the retrieval time with experts and novices. RESULTS: The retrieval times, the organ size (largest dimension) and specimen weight were records for each case. Multivariate analysis of the data was done and we extrapolated the retrieval time with organ size, specimen weight and expertise of the surgeon. There was no significant difference among expert surgeons and novice surgeons with regards to retrieval times (p value = 0.29), with regards to organ size (p value = 0.83) and with regards to specimen weight (p value = 0.99). CONCLUSION: Our design of retrieval system offers a cost-effective option which is easy to make, without the risk of tumor seeding and without the need for separate access sheath. It's a retrieval system which has proved its efficacy in laparoscopic as well as robotic procedures with no bearing on the expertise of the surgeon involved.
ABSTRACT
INTRODUCTION: The challenges in laparoscopic suturing include need to expertise to suture. Laparoscopic needle holder is a" key" instrument to accomplish this arduous task. INSTRUMENT: The objective of this new invention was to develop a laparoscopic needle holder which would be adapted to avoid any wobble (with a shaft diameter same as a 5mm port), ensure accurate and dexterous suturing not just in adult patients but pediatric patients alike (with a short shaft diameter) and finally ensure seamless throw of knots with a narrow tip configuration. VALIDATION: We did an initial evaluation to evaluate the validity of the prototype needle holder and its impact on laparoscopic suturing skills by experienced laparoscopic surgeons and novice laparoscopic Surgeons. Both the groups of surgeons performed two tasks. The first task was to grasp the needle and position it in an angle deemed ideal for suturing. The second task was to pass suture through two fixed points and make a single square knot. At the end of the tasks each participant was asked to complete a 5- point Likert's scale questionnaire (8 items; 4 items of handling and 4 items of suturing) rating each needle holder. In expert group, the mean time to complete task 1 was shorter with prototype 3/5 laparoscopic needle holder (11.8 sec Vs 20.8 sec). The mean time to complete task 2 was also shorter with prototype 3/5 laparoscopic needle holder (103.2 sec Vs 153.2 sec). In novice group, mean time to complete both the task was shorter with prototype 3/5 laparoscopic needle holder. CONCLUSION: The expert laparoscopic surgeons as well as novice laparoscopic surgeons performed laparoscopic suturing faster and with more ease while using the prototype 3/5 laparoscopic needle holder.
ABSTRACT
OBJECTIVE: To determine the overall efficacy and predictors of success of the penile preputial flap in the management of complex urethral strictures >2.5 cm in length. PATIENTS AND METHODS: We performed a retrospective and prospective study of 58 patients undergoing single-stage penile preputial flap urethroplasty for complex long-segment urethral strictures, without lichen sclerosus, repaired between May 2005 and April 2012 at our institution. For obvious reasons circumcised patients were excluded from the study. Results were assessed by univariate analysis of various patient characteristics, preoperative and postoperative patient satisfaction (based on symptoms), and urethral ultrasonography, retrograde urethrography and uroflowmetry. RESULTS: The median (range) follow-up was 42 (6-90) months, the median (range) intra-operative stricture length was 48.5 (26-85) mm and the median (range) operating time was 90 (85-125) min. A total of 87.93% of patients had a satisfactory outcome, with an overall success rate of 81.03%. Diabetes mellitus (relative risk [RR] 5.21, confidence interval [CI] 2.31-64.68, P = 0.003) and smoking (RR 4.19, CI 1.54- 45.0, P = 0.01) were predictors of failure, while postinfective aetiology (RR 2.19), panurethral stricture (RR 2.73), stricture length >70 mm (RR 3.25), previous urethroplasty (RR 2.4) and severe peri-urethral fibrosis (RR 2.37) were also associated with a higher risk of failure. CONCLUSIONS: A urologist should try to gain experience of all the methods of urethroplasty as the techniques may vary according to the circumstances. Single-stage preputial skin flap urethroplasty, in experienced and expert hands, has results equivalent to all other methods of urethroplasty in complex urethral strictures. We prefer this technique in this part of the world where buccal mucosa cannot be used because of dyskeratotic changes as a result of consumption of gutkha, tobacco, pan masala, betel nut.
