A Comprehensive Correlation of Clinicopathologic Prognostic Factors in Malignant Adult Renal Tumors: A Single Institutional Study.

OBJECTIVE: To study the clinicopathologic prognostic parameters of malignant adult renal tumors as these have poor over-all survival (OS) and show frequent metastasis. MATERIAL AND METHODS: This was a retrospective analysis of the clinical and pathologic features of malignant renal tumors in adult patients from January 2011 to December 2020. All the tumors were studied with respect to age, clinical presentation, tumor type/subtype, histologic grade (WHO/ISUP grading system), TNM stage and presence of necrosis. Correlation of histopathologic features and survival analysis was done using Kaplan-Meier survival curves and Cox-regression analysis. RESULTS: A total of 257 cases were included in the study period including 253 renal cell tumors of which clear cell renal cell carcinoma accounted for 69.3%. The age of the patients ranged from 20 to 87 years (median-52 years). The overall survival significantly reduced with increasing histologic grade, stage, and presence of necrosis. The comparison between the histological subtypes was not statistically significant. Univariate Cox-regression analysis found significant hazard ratio with increasing age, size, histologic grade (G4 vs G1), stage, and presence of necrosis. The correlation of OS with histological subtypes was not significant. Multivariate analysis also showed increased hazard ratio with increasing age, size, grade, and stage. However, the P-value was significant only for age. CONCLUSION: Clear cell renal cell carcinoma was the commonest type of adult renal tumor. Older age at presentation, larger tumor size, presence of necrosis, and higher histologic grade and stage were associated with poor prognosis in these patients.

Vaccine-Induced Thrombotic Thrombocytopenia Due to Coronavirus Disease 2019 Vaccine From a Deceased Donor: A Case Report.

With the rapid and massive vaccination campaign against coronavirus disease 2019 (COVID-19) taking place across the globe, there are increasing reports of thrombotic complications with various COVID-19 vaccines such as the Pfizer-BioNTech mRNA, Moderna mRNA, AstraZeneca Oxford (serum institute), and Johnson & Johnson/Janssen vaccines. We report a case of successful organ donation from an 18-year-old woman who presented with cerebral venous thrombosis caused by vaccine-induced thrombotic thrombocytopenia following the first dose of the COVID-19 vaccine (AstraZeneca, University of Oxford, and Serum Institute of India), which caused brain death. Four recipients received 5 organs, kidneys (2), liver (1), and combined heart and lung (1). All 4 recipients had normal graft function without any thrombotic complications after 16 weeks of transplantation. This is first such case being reported from Asian countries.

Effect of pregabalin on postoperative pain and instrumentation-induced dysuria in patients undergoing percutaneous nephrolithotomy: A prospective randomized, double-blinded placebo-controlled study.

Background and Aims: The manipulation of urinary tract, the mandatory requirement of ureteral stenting, and bladder catheterization in patients undergoing percutaneous nephrolithotomy (PCNL) produces significant pain and dysuria postoperatively. The present study compared the efficacy of pregabalin with placebo in attenuation of these symptoms in patients undergoing PCNL. Material and Methods: This randomized controlled study was conducted in 110 patients of either sex, aged 18-65 years undergoing elective PCNL requiring nephrostomy tube under general anesthesia. Group G (n: 53) received pregabalin 150 mg and Group P received placebo (n: 49) orally 1 h before the anesthetic induction. All the patients received standard anesthetic protocol. Pain at the site of nephrostomy, instrumentation-induced dysuria (IID), anxiety, and sedation scores were recorded at 0 min, 15 min, 30 min, 1 h, 2 h, 4 h, 8 h, 12 h, 24 h postoperatively. Hemodynamics, total requirement of rescue analgesia, and incidence of any adverse effects were also noted. Results: Patients were demographically comparable between the two groups. There is no difference in nephrostomy site pain between the groups at different points of measurements. IID was less with pregabalin at 0 min, 15 min, 30 min, 1 h, and 2 h after extubation (P value < 0.05, 43% in Group G vs. 68% in group P). Severe urgency was seen in 4%, moderate in 31%, and mild in 33% of patients in placebo group. No patient in pregabalin had severe grade of instrumentation-induced dysuria score (P < 0.05). Patients in Group P required more rescue analgesic (P: 0.009). Anxiety scores, sedation scores, and hemodynamic parameters were comparable. Conclusion: A single dose of 150 mg pregabalin as oral premedication given 1 h before surgery reduced the incidence and intensity of IID compared to placebo in patients undergoing PCNL without significant adverse effects.

Effect of infraorbital nerve block on postoperative pain and 30-day morbidity at the donor site in buccal mucosal graft urethroplasty.

BACKGROUND AND AIMS: Buccal mucosa harvest for substitution urethroplasty can be painful, and may be associated with long-term complications such as perioral numbness, persistent difficulty with mouth opening, and change in salivary function. This study was designed to evaluate the efficacy of infraorbital nerve block (IOB) in relieving postoperative pain at the donor site of the buccal mucosal graft (BMG) and its associated morbidity at 30 days. MATERIAL AND METHODS: Thirty adults scheduled for BMG urethroplasty were enrolled in this study and were randomized to receive either no block group I (control) and IOB group II intraorally with 1 mL of 0.5% bupivacaine. Pain was assessed by visual analog scale, intraoral morbidity, and patient satisfaction in the immediate postoperative period. All patients were reviewed after 1 month for morbidity such as perioral numbness, pain on mastication, and tightness on mouth opening. Statistical analysis was done using Mann-Whitney's U and Chi-square tests. RESULTS: Median time to pain-free oral intake for liquids (group I: 2-5 days, group II: 1 day, P < 0.001) and solids (group I: 4 days, group II: 2 days, P < 0.001) was earlier in group II. At the follow-up after 1 month, one patient in group II and three patients in group I showed perioral numbness (P = 0.026), and five patients had pain on mastication in group I (P = 0.016). CONCLUSION: IOB is associated with postoperative analgesia and facilitation of early food intake, mitigating the morbidity of the donor site and provides satisfaction.

A comparison of the efficacy of intercostal nerve block and peritubal infiltration of ropivacaine for post-operative analgesia following percutaneous nephrolithotomy: A prospective randomised double-blind study.

BACKGROUND AND AIMS: Intercostal nerve blockade (ICNB) and peritubal infiltration of the nephrostomy tract are well-established regional anaesthetic techniques for alleviating pain after percutaneous nephrolithotomy (PCNL). This prospective study compared the efficacy of ICNB and peritubal local anaesthetic infiltration of the nephrostomy tract in providing post-operative analgesia following PCNL. METHODS: Sixty American Society of Anesthesiologist physical status 1 and II patients scheduled for PCNL requiring nephrostomy tube were randomised to receive either peritubal infiltration or ICNB. At the completion of the procedure, patients in Group P received peritubal infiltration and those in Group I received ICNB at 10, 11, 12th spaces using fluoroscopy guidance. Postoperatively, patients were followed for 24 h for pain using Visual Analogue Scale (VAS) and Dynamic VAS. Rescue analgesia was inj. tramadol 1 mg/kg IV when pain score exceeded 4. Time to first rescue analgesia, number of doses and patient's satisfaction were noted in all patients. RESULTS: Pain scores were lower in the group I at all points of measurement than group P. The mean time to first demand for rescue analgesia was higher in Group I (13.22 ± 4.076 h vs 7.167 ± 3.92 h P - 0.001). The number of demands and the amount of analgesics consumed were less in Group I. CONCLUSION: ICNB provided superior analgesia as evidenced by longer time to first demand of analgesic, reduced number of demands and consumption of rescue analgesic. Peritubal infiltration, although less efficacious, may be a safe and simple alternative technique.

Pharmaco Penile Duplex Ultrasonography in the Evaluation of Erectile Dysfunction.

INTRODUCTION: The National Institute of Health defined 'erectile dysfunction' as the persistent inability to achieve and/or to maintain an erection for a satisfactory sexual performance. In last few years, the concept of erectile dysfunction has evolved from that of a disorder referred to as 'impotence' which used to be considered predominantly psychogenic to that of 'Erectile Dysfunction' (ED), a well understood physiologic result of multiple risk factors, both psychological and organic. The most common cause of organic erectile dysfunction is vasculogenic causes. Doppler evaluation of cavernosal arteries after intracavernosal injection of Papaverine is particularly useful in the evaluation of vasculogenic causes. AIM: To define the role of intracavernosal injection of Papaverine in the evaluation of vasculogenic causes of erectile dysfunction that includes arterial insufficiency and veno occlusive nature. MATERIALS AND METHODS: Pharmaco Penile Duplex Ultrasonography (PPDU) was done using a linear broadband phased array transducer (7-12 MHz) on a E-Saote MyLab 60 ultrasound colour Doppler system on 73 patients over a period of three years. Informed consent was taken from all patients. Visual grading score for erection, Cavernosal Artery Diameter (CAD), PSV (Peak Systolic Velocity), EDV (End Diastolic Velocity), RI (Resistive Index), AT (Acceleration Time) and dorsal vein changes were obtained in all patients following intracavernosal injection of Papaverine. RESULTS: Visual grading for erectile response was E0 in one patient, E1 in 11 patients, E2 in 9 patients, E3 in 7 patients, E4 in 4 patients and E5 in 41 patients. Eighteen patients were diagnosed as having arterial insufficiency, three patients were diagnosed as having venous insufficiency and two patients showed indeterminate results. CONCLUSION: In our study, Papaverine induced PPDU proved to be highly accurate and excellent method for assessing patients with erectile dysfunction.

Role of buprenorphine in prolonging the duration of post-operative analgesia in percutaneous nephrolithotomy: Comparison between bupivacaine versus bupivacaine and buprenorphine combination.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large renal calculi. Pain around the nephrostomy tube is a clinical problem and we have previously reported alleviation of pain by peritubal block with bupivacaine, which lasted for 14 hours. The present study aimed to investigate the role of buprenorphine and bupivacaine combination in prolonging the duration of analgesia in peritubal block. MATERIALS AND METHODS: A prospective, randomized controlled study was undertaken in 40 American Society of Anesthesiologists (ASA) grade I and II patients who were scheduled for PCNL. Group I patients received 20 mL of 0.25% bupivacaine and group II patients received 20 mL of 0.25% bupivacaine with 100 µg of buprenorphine. Peritubal infiltration was given under fluoroscopic guidance along the nephrostomy tube from the renal capsule to the skin. Post-operative pain was assessed by Visual Analog Score (VAS), dynamic VAS (DVAS), sedation score, duration of analgesia and number of rescue analgesic demands. Rescue analgesia was inj tramadol 1 mg/kg IV if pain score exceeded 3. RESULTS: Demographic data were comparable between the groups. Median duration of analgesia was 16 h in group I and 20 h in group II (P = 0.002). The maximum median VAS was 4 in group I and 2 in group II (P = 0.002). The median area under curve (AUC) for VAS was 7 and 5 in groups I and II, respectively (P = 0.047). The median maximum DVAS in group I was 6 and 4 in group II. The median AUC for DVAS in 24 h was 16 in group I and 15 in group II (P = 0.017). CONCLUSIONS: Peritubal infiltration of 0.25% bupivacaine with 100 µg buprenorphine around a nephrostomy tube increased the duration of analgesia following PCNL without any side-effects.

Predictors of nephrectomy in high grade blunt renal trauma patients treated primarily with conservative intent.

INTRODUCTION: There is no consensus on the optimal management of high grade renal trauma. Delayed surgery increases the likelihood of secondary hemorrhage and persistent urinary extravasation, whereas immediate surgery results in high renal loss. Hence, the present study was undertaken to evaluate the predictors of nephrectomy and outcome of high Grade (III-V) renal injury, treated primarily with conservative intent. MATERIALS AND METHODS: The records of 55 patients who were admitted to our institute with varying degrees of blunt renal trauma from January 2005 to December 2012 were retrospectively reviewed. Grade III-V renal injury was defined as high grade blunt renal trauma and was present in 44 patients. The factors analyzed to predict emergency intervention were demographic profile, grade of injury, degree of hemodynamic instability, requirement of blood transfusion, need for intervention, mode of intervention, and duration of intensive care unit stay. RESULTS: Rest of the 40 patients with high grade injury (grade 3 and 4)did not require emergency intervention and underwent a trail of conservative management. 7 of the 40 patients with high grade renal injury (grade 3 and 4), who were managed conservatively experienced complications requiring procedural intervention and three required a delayed nephrectomy. Presence of grade V injuries with hemodynamic instability and requirement of more than 10 packed cell units for resuscitation were predictors of nephrectomy. Predictors of complications were urinary extravasation and hemodynamic instability at presentation. CONCLUSION: Majority of the high grade renal injuries can be successfully managed conservatively. Grade V injuries and the need for more packed cell transfusions during resuscitation predict the need for emergency intervention.

Urethral steinstrasse causing acute urinary retention.

Multiple urethral calculi-forming steinstrasse in the urethra leading to acute urinary retention is a rare event in pediatric urolithiasis. We report a child with urethral steinstrasse that cleared spontaneously with attempted urethral catheterization.

Wunderlich's Syndrome in a Tuberous Sclerosis Patient.

UNLABELLED: Spontaneous non-traumatic renal hemorrhage known as Wunderlich's syndrome is known to occur in renal angiomyolipoma and may be the first manifestation of the disease. Angiomyolipomas in tuberous sclerosis are usually bilateral and multicentric. A 25yr old female, a case of Tuberous sclerosis with bilateral renal angiomyolipomas presented with right loin pain of increasing severity. On evaluation she had acute abdomen with increasing abdominal distension. Investigations revealed large right perinephric hematoma with bilateral renal angiomyolipomas. Exploratory laparotomy and right nephrectomy was done. Spontaneous hemorrhage in renal angiomyolipoma in a case of tuberous sclerosis and management are discussed. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s12262-010-0231-0) contains supplementary material, which is available to authorized users.

Dorsal buccal mucosal graft urethroplasty for anterior urethral stricture by Asopa technique.

BACKGROUND: Buccal mucosal graft (BMG) substitution urethroplasty has become popular in the management of intractable anterior urethral strictures with good results. Excellent long-term results have been reported by both dorsal and ventral onlay techniques. Asopa reported a successful technique for dorsal placement of BMG in long anterior urethral strictures through a ventral sagittal approach. OBJECTIVE: To evaluate prospectively the results and advantages of dorsal BMG urethroplasty for recurrent anterior urethral strictures by a ventral sagittal urethrotomy approach (Asopa technique). DESIGN, SETTING, AND PARTICIPANTS: From December 2002 to December 2007, a total of 58 men underwent dorsal BMG urethroplasty by a ventral sagittal urethrotomy approach for recurrent urethral strictures. Forty-five of these patients with a follow-up period of 12-60 mo were prospectively evaluated, and the results were analysed. INTERVENTION: The urethra was split twice at the site of the stricture both ventrally and dorsally without mobilising it from its bed, and the buccal mucosal graft was secured in the dorsal urethral defect. The urethra was then retubularised in one stage. RESULTS AND LIMITATIONS: The overall results were good (87%), with a mean follow-up period of 42 mo. Seven patients developed minor wound infection, and five patients developed fistulae. There were six recurrences (6:45, 13%) during the follow-up period of 12-60 mo. Two patients with a panurethral stricture and four with bulbar or penobulbar strictures developed recurrences and were managed by optical urethrotomy and self-dilatation. The medium-term results were as good as those reported with the dorsal urethrotomy approach. Long-term results from this and other series are awaited. More randomised trials and meta-analyses are needed to establish this technique as a procedure of choice in future. CONCLUSIONS: The ventral sagittal urethrotomy approach is easier to perform than the dorsal urethrotomy approach, has good results, and is especially useful in long anterior urethral strictures.