First 100 Reported Cases of Supine Percutaneous Nephrolithotomy in Malaysia: An Alternative Effective and Safe Approach to Treat Renal Stones.

Background: Supine percutaneous nephrolithotomy (s-PCNL) offers great benefits from urological and anaesthetic points of view. We present the first evaluation of the outcomes of s-PCNL in Malaysia. Our aim was to explore the safety and efficacy of s-PCNL. Methods: Institutional review board approval was obtained from the National Medical Research Register (NMRR ID-21002225-WLP). We retrospectively reviewed 115 patients with renal pelvis stones who underwent single renal access during s-PCNL between November 2020 and May 2023. Patients who underwent simultaneous ipsilateral or contralateral endourological procedures were included. The data were analysed to determine stone-free rates (SFR), major complication rates, blood transfusion rates, operative times and lengths of hospital stay (LOS). Results: The SFR was higher for the single middle calyceal renal access (MCA) group than for the lower calyceal renal access (LCA) or upper calyceal renal access (UCA) groups (OR: 1.76; 95% confidence interval [CI]: 0.63, 4.92). In total, 0, 1 and 2 patients had major complications in the UCA, MCA and LCA groups, respectively (P = 0.453). One of the 115 patients (0.9%) needed blood transfusion. Subgroup analysis revealed mean operative times of 76.3 min and 78.6 min for patients who underwent sole s-PCNL (PCNL-only group) and those who had simultaneous ipsilateral and contralateral endourological procedures (PCNL-plus group), respectively (P = 0.786). The overall mean LOS was 2.9 days. Conclusion: s-PCNL is a safe and effective alternative treatment for renal stones. We would recommend s-PCNL for patients who require an ipsilateral/contralateral endourological procedure (URS/RIRS) because it is time-efficient. All renal accesses are safe. Single MCA is recommended for complete stone clearance.

Freehand transperineal prostate biopsy with a coaxial needle under local anesthesia: Experience from a single institution in Malaysia.

Background: Freehand transperineal prostate biopsy (TPPBx) using a coaxial needle technique offers an alternative to probe-mounted freehand or template-guided techniques in the diagnosis of prostate cancer (PCa). It only requires the same equipment used for transrectal ultrasound-guided (TRUS) biopsy. Our study is the first in Malaysia to report this experience and its outcomes. We aim to determine PCa detection rate and pain tolerability of freehand TPPBx utilizing a coaxial needle under local anesthesia (LA). Methods: Institutional review board approval was obtained from National Medical Research Register (NMRR ID-21-02052-VIL). We retrospectively reviewed the medical records of patients who underwent TPPBx between August 2020 and April 2022. Records were reviewed for patients' characteristics, prostate volume, prostate-specific antigen (PSA) results, biopsy results and pain tolerability. Data was analyzed to determine PCa and clinically significant prostate cancer (csPCa) detection rate. LA was achieved using perineal skin infiltration and a periprostatic nerve block. The commonly used standard side-firing transrectal ultrasound with its Prostate Biplane Transducer was used as an imaging guide. The principles of the Ginsburg protocol were followed. Pain tolerability was assessed using a visual analog scale. Results: A total of 55 patients with elevated PSA levels underwent freehand TPPBx under LA. The mean age was 67.3 years, the median PSA was 14.2 ng/mL, and the median PSA density (PSAD) was 0.33 ng/mL/cc. The optimal PSAD cutoff for predicting csPCa was 0.35 ng/mL/cc (area under the curve [AUC], 0.792; sensitivity, 87.5%; specificity, 69.2%). PCa was detected in 24 patients (43.6%), of whom 16 (29.1%) had csPCa. The median pain scores during LA infiltration and biopsy were four and two, respectively, which were significant different (P < 0.05). TPPBx exhibited an infection rate of zero. Conclusion: The PCa detection rate and patient tolerability of freehand TPPBx using a coaxial needle are similar to those of a contemporary published series. The use of existing equipment that is used for TRUS biopsy allows for widespread use and transition from TRUS biopsy.

Efficacy and safety of photodynamic therapy for recurrent, high grade nonmuscle invasive bladder cancer refractory or intolerant to bacille Calmette-Guérin immunotherapy.

PURPOSE: We evaluated the effectiveness of photodynamic therapy using Radachlorin in patients with high grade, nonmuscle invasive bladder cancer refractory or intolerant to bacillus Calmette-Guérin therapy who refused radical cystectomy. MATERIALS AND METHODS: Between July 2009 and December 2011 photodynamic therapy was performed in 22 men and 12 women. Radachlorin (0.5 to 0.6 mg/kg) was injected intravenously 2 to 3 hours before photodynamic therapy. After complete transurethral resection, a diffuser using a 22Fr cystoscope was placed in the bladder for irradiation with a 662 nm laser. Output beam power was adjusted to 1.8 W and the light dose was 15 J/cm(2). Photodynamic therapy was performed for 16 to 30 minutes. Recurrence after photodynamic therapy was followed by regular cystoscopy at 1, 2 and 3 months, and at 3-month intervals thereafter for up to 2.8 years. Efficacy was assessed by cystoscopy, cytology and histology, and defined as the number of patients who were tumor free after initial photodynamic therapy. RESULTS: Mean ± SD patient age was 62.94 ± 8.71 years. Average followup was 26.74 ± 6.34 months (median 28.12). As the primary efficacy outcome, the recurrence-free rate was 90.9% at 12 months, 64.4% at 24 months and 60.1% at 30 months. As the secondary efficacy outcome, there was no statistical difference in mass size, carcinoma in situ, number of previous bacillus Calmette-Guérin administrations, number of transurethral bladder resections or tumor multiplicity on Kaplan-Meier analysis (each p >0.05). No evidence of severe adverse effects was detected after photodynamic therapy. CONCLUSIONS: Photodynamic therapy with Radachlorin is a safe, effective treatment for nonmuscle invasive bladder cancer refractory or intolerant to bacillus Calmette-Guérin therapy in select patients.

Robotic single-incision anterior resection for sigmoid colon cancer: access port creation and operative technique.

BACKGROUND: Potential morbidities related to multiport laparoscopic surgeries have led to the current excitement about single-incision laparoscopic techniques. However, multiport laparoscopy is technically demanding and ergonomically challenging. We present our technique of using the Alexis wound retractor and a surgical glove to fashion an access port and the da Vinci surgical robot to perform single-incision anterior resection. METHODS: Through a small transumbilical incision, an Alexis wound retractor and a surgical glove are fashioned as an access port. Appropriate trocars are then inserted through the cut fingertips of the glove and secured. A three-arm da Vinci robot with a 30° up-scope was used. RESULTS: Twenty-two patients (12 males, 10 females) with a mean age of 58.5 years (range = 35-70) underwent robotic single-incision anterior resection for sigmoid colon cancer with this technique. There was no conversion to open surgery and one case was converted to multiport surgery. The mean estimated blood loss was 24.5 ml (range = 5-230), the mean operating time was 167.5 min (range = 112-251), the median skin incision length was 4.7 cm (range = 4.2-8.0), the mean proximal and distal resection margins were 12.9 cm (range = 7.5-25.1) and 12.3 cm (range = 4.5-19.2), respectively, and the mean lymph node harvest was 16.8 (range = 0-42). The immediate postoperative pain score was 2.8 (range = 1-5) and on postoperative day 1 it was 1.4 (range = 1-3). The mean length of hospital stay was 6 days (range = 5-9). CONCLUSION: Robotic single-incision anterior resection is a safe and viable option for selected patients. Merging the principles of reduced parietal trauma and better cosmesis with the ergonomic advantages of the robotic system is a novel evolution of single-incision laparoscopic surgery.

Extended pelvic lymph node dissection including internal iliac packet should be performed during robot-assisted laparoscopic radical prostatectomy for high-risk prostate cancer.

INTRODUCTION: The indication and anatomic limits of pelvic lymph node dissection (PLND) have not been clearly defined. Therefore, we assessed whether the extent of PLND at robot-assisted laparoscopic radical prostatectomy (RALP) had any benefit on lymph node yield, staging accuracy, and biochemical recurrence (BCR) in patients with high-risk prostate cancer. PATIENTS AND METHODS: Between July 2005 and July 2010, a retrospective analysis was performed on 200 patients with high-risk prostate cancer stratified by D'Amico classification. The study population was divided into different groups: patients in Group 1 had standard PLND, and Group 2 had extended PLND (ePLND). The clinicopathologic findings of patients and surgical outcomes of PLND with each procedure were measured. Kaplan-Meier and log rank tests were used to estimate BCR-free survival rates. Univariate and multivariate survival analyses were done with the Cox proportional hazard regression model. RESULTS: Medians of 15 (interquartile range, 11-19) and 24 (interquartile range, 18-28) lymph nodes were dissected in Groups 1 and 2, respectively (P<.001). The incidences of lymph node metastasis were 5.2% (8/155) in Group 1 and 22.2% (10/45) in Group 2. Regardless of the extent of PLND, the patients with positive lymph nodes had a significantly lower BCR-free survival than those with negative lymph nodes. Twenty-five percent (7/27) of positive lymph nodes were in the internal iliac packet and common iliac packet. In particular, of the positive internal iliac nodes, 75% (3/4) of nodes were found in that location, exclusively. CONCLUSIONS: An ePLND that identifies patients with lymph node metastasis including the internal iliac packet during RALP provides an accurate pathologic staging and may have survival benefits in high-risk prostate cancer.

Laparoendoscopic single site adrenal surgery.

Laparoscopic adrenal surgery is a standard procedure for the management of benign adrenal pathology and small malignant tumors. There has been an increasing interest over the last few years in the use of laparoendoscopic single-site surgery (LESS). From recent literatures, LESS adrenalectomy was demonstrated that this technique was safe and feasible despite the relatively difficult anatomical location of the adrenal gland. We reviewed the surgical techniques and outcomes of LESS adrenalectomy including robot-assisted approach and gave an overview of the current role of LESS in adrenalectomy.

Endoscopic drainage of empyema of the gallbladder through a concurrent cholecystoduodenal fistula.

The duodenum is the most common site of cholecystoenteric fistulation resulting from cholecystitis or empyema of the gallbladder. This rare condition is usually only diagnosed intraoperatively and managed incidentally. This paper presents the endoscopic diagnosis of a case of cholecystoduodenal fistula arising from the late presentation of empyema of the gallbladder and its subsequent drainage through the fistula. As far as we can determine, this is the only reported case of opportunistic drainage of an empyema of the gallbladder through a concurrent cholecystoduodenal fistula.