Supracostal percutaneous nephrolithotomy, a safe and effective approach: A clinical audit.

OBJECTIVE: To emphasize on safety principles through anatomic approach in Supracostal Percutaneous nephrolithotomy (PCNL). METHODS: Data of patients who underwent PCNL from June 2004 to August 2014 at the Kidney Centre Karachi, Pakistan were reviewed. Patients above 14 years of age with Supracostal Access were included in study. PCNL was performed in prone position with 'Bull's Eye Technique'. Nephrostomy was placed after completion of the procedure in most cases. Data on demographic details, stone burden, stone clearance with primary PCNL and combination and complications rate was assessed using Modified Clavien Grades 1 through 5. RESULTS: Total 426 patients underwent PCNL. Seventy (70) out of 426 underwent PCNL through Supracostal Approach. Fifty (71.4 %) patients were Stone Free after PCNL and 64 (91.4%) patients were stone free after auxiliary procedures (ESWL, SECONDARY PCNL). The overall complication rate was 4.7% with 3 (4.3%) patients requiring Tube Thoracostomy and 1 (1.4%) each for angioembolisation, pulmonary oedema/ Ventilation and ICU admission due to urosepsis and renal dysfunction. CONCLUSIONS: Supracostal PCNL is a safe and effective approach for multiple stones in pelvicalyceal system. Due anatomic consideration can decrease the complication rate. In complex stones with huge burden, an elaborate and thorough counseling regarding delayed clearance and need for auxiliary procedures including secondary PCNL is mandatory.

Pericatheter urethrogram after anastomotic urethroplasty: Is it a must?

OBJECTIVE: To share our initial experience of patient undergoing anastomotic Urethroplasty and trial without catheter, without post Urethroplasty pericatheter urethrogram. METHODS: Prospectively maintained records of all patients undergoing standard transecting anastomotic Urethroplasty by single surgeon (one of the authors) at The Kidney Centre PGTI Karachi, Pakistan and Lifecare Hospital Abu Dhabi UAE from September 2006 to December 2017 were reviewed. In all except two cases, supra pubic catheter was removed at 2nd weeks and per urethral catheter by 4 to 5 weeks following which patients were assessed for TWOC without pericatheter urethrogram. Patients were further advised to follow up with Uroflowmetry (UFM) at one week, one month, three and 12 months. In our series, Qmax less than 15 ml/s on UFM were considered to have recurrence and these patients were subjected to ascending urethrogram after six weeks of procedure. RESULTS: There were 18 patients who underwent anastomotic Urethroplasty in bulbar urethra. The mean age of study patients was 37.2+11.2 years with p-value of 0.84. The recurrence rate of urethral stricture was 16.6 % (3/18 patient) with Qmax of 4.6 and 7.2ml/sec with mean follow-up period of 13.82+13.4 months (range 3-53 months) 02 patients developed infection. No patient developed incontinence or impotence. CONCLUSION: We found pericatheter urethrogram is not mandatory as a routine for all tension free anastomotic Urethroplasty before per urethral catheter removal. However, it may have a role in difficult cases with tension anastomoses or re-do procedure. This will avoid risk of infection, radiation exposure and extra cost.

Acute kidney injury in Ureteric Stones:Single centre short term analysis.

OBJECTIVE: To analyze acute kidney injury (AKI) frequency, risk factors and outcome in ureteric stone patients. METHODS: This is an observational retrospective study performed in a single tertiary care centre in Abu Dhabi from October 2014 till August 2015. Convenient sampling was done on 152 consecutive patients who underwent decompression surgery (Ureterorenoscopy LASER Lithotripsy and DJ Stenting) for ureteric stones. Serum Creatinine was used to calculate creatinine clearance by cock croft Gault formula in all patients before and after procedure. Analysis was done on SPSS version 17. RESULTS: Out of 152 patients who under went decompression surgical procedure for ureteric stones AKI was seen in 49(32.2%). Patients with AKI were found to be more higher age, increasedweight, bilateral stones, lower ureteric stones and with co morbidities in comparison to those who were without acute kidney injury. Patients developing AKI, 89.7% recovered either partially(20.4 %) or completely (69.3%). CONCLUSION: AKI is seen more in ureteric stone patients with older age, increased weight, bilateral stones, lower ureteric stones and with co morbidities. Recovery is good when obstruction is relieved.

Mamun-TKC parathyroid retractor: Parathyroid glands squashed or scooped!

Parathyroid gland by its physiologic and anatomic diversity has interestingly been dealt by multiple specialties, including Urology. Besides primary hyperparathyroidism, urologists in close working relationship with nephrologists, tend to get referrals for tertiary hyperparathyroidism. Data from 1999 to 2012 was retrieved for all parathyroidectomies. Medical record of only cases undergoing parathyroidectomy utilising the instrument Mamun-TKC Parathyroid Retractor were reviewed. It is a metal body surgical instrument resembling Gil Vernet retractor having functional flat metal head attached to solid long handle, designed in two forms; one 'Straight' and other 'Angled' at 30°. During the period, 28 cases of parathyroidectomies were performed. The instrument was used in two cases. It was found to facilitate dissection, retraction and pedicle ligation of parathyroid gland by a-traumatic handling.

Effects and outcome of Tamsulosin more than just stone clearance after extracorporeal shock wave lithotripsy for renal calculi.

OBJECTIVE: To determine the effect of Tamsulosin, as adjunctive medical therapy after Extracorporeal Shock Wave Lithotripsy for renal stones on rate of stone clearance, clearance time, pain intensity during stone clearance, steinstrasse formation and auxiliary surgical intervention required. METHOD: A prospective randomized controlled study was carried out in 120 patients who undeiwent ESWL for renal stones of 0.5-2.0 cm. They were randomized into study and control group in which Tamsulosin 0.4 mg/day was given in former as an adjunctive medical therapy. All patients underwent ESWL every 2 weeks until complete stone clearance for 8 weeks. The parameters assessed were stone clearance, clearance time, pain intensity and effect on steinstrasse. RESULTS: Of the 120 patients 60 were in each group. The stone clearance rate was greater in study than in control group, 58 (96.7%) vs. 48 (80%) respectively, (p < 0.004). The mean stone clearance time was observed earlier in study group as compared to control group with significant statistical difference in stone size between 0.6-1.Scm.The mean intensity of pain patients experienced according to Visual analogue scale (VAS) was significantly less in study group (p < 0.002). The rate of steinstrasse formation was observed to be higher in control than in study group 15 (25%) vs 6 (10%) respectively (p < 0.003), while its spontaneous clearance was higher in study group than in control group 83.3% vs 33.3% (p < 0.03). CONCLUSION: Tamsulosin significantly increases stone clearance after shock wave lithotripsy for renal stones. It also appeared to facilitate earlier stone clearance, reduces severity of pain, reduces the incidence of steinstrasse formation and tends to facilitate its spontaneous clearance.

Laparoscopy in urology practice at a tertiary care centre.

OBJECTIVE: To describe the results of laparoscopic procedures at a Urology - Nephrology tertiary care centre. STUDY DESIGN: Case series / observational study. PLACE AND DURATION OF STUDY: The Kidney Centre Postgraduate Training Institute, Karachi, from August 2007 to March 2012. METHODOLOGY: Medical records of all planned laparoscopic surgery conducted during the study period were reviewed. Those cases which to open surgery were excluded. All were performed by a single surgeon, initially as supervised and later independently. Data was maintained for demographic data, procedure details, length of hospital stay, and complications including conversion to open surgeries. Data was analyzed through SPSS 17.0. RESULTS: There were 36 planned laparoscopic surgeries in the specified period. Out of 36 cases, 8 were converted to open surgery. Those who underwent laparoscopic surgery include two diagnostic procedures and renal cyst deroofing each, four ureterolithotomy, nineteen simple nephrectomy and one radical nephrectomy. So in total 28 cases were performed on 15 females and 13 males with mean age of 33.01 ± 10.9 years. The mean operative time was 216 ± 100 minutes and mean length of hospital stay was as 2.7 ± 1.04 days. There were 10 complications in 28 cases, majority being Clavien Grade II including 7% (2/28) blood transfusion. CONCLUSION: There are technical challenges in learning laparoscopy for practicing urologists. Following some learning model in a systematic manner will help surmounting the technical challenges in learning laparoscopy.

Practicing urologist learning laparoscopy: no short cut to short cuts!

OBJECTIVE: To emphasize the importance of regular exercising in dry lab in initial phase of learning of laparoscopic surgery by a practicing urologist. METHODS: The study was performed at Dry Lab -Jayaramdas Patel Academic Centre (JPAC) attached to Muljibhai Patel Urological Hospital, Nadiad, India. The study is based on 30 sets of exercises of four standard tasks utilized to learn Hand-Eye coordination for Laparoscopic Surgery. All sets were performed by a single participant over a period of 19 days and the exercise record was retrospectively analyzed. The participant had limited exposure of one year in a low volume laparoscopy center. Correlation between Exercise number and Task Completion Time (TCT) was calculated by Pearson's Correlation Coefficient and its significance is assessed by Student paired t test. RESULTS: The current study describes 30 exercises of 4 standard tasks for hand-eye-coordination. Although the study was completed in 19 days but there were two intervals which point to the objective of this study. First interval was of 3 days and it occurred after 4th exercise. At 5th exercise the Task Completion Time started rising more than the 2nd exercise. This regression further worsened on 6th exercise which had an interval of 2 days. Here the (TCT) went up almost equal to 1st exercise (1050 vs 1054 seconds). Mean time for IT1, IT2, IT3, IT4 and TCT of over all exercises were calculated as 24.2 +/- 3.7, 121.9 +/- 54.9, 233 +/- 73.5, 199 +/- 55.1 and 582.5 +/- 174.8 seconds respectively. Significant correlation was noticed between number of exercises performed and improvement in time taken for individual tasks (IT 2 to IT4) and TCT. However there was no significant impact on Task 1. CONCLUSION: Regular Dry Lab exercises improves hand eye coordination and psychomotor skill dedicated continuous exercising has significant impact in reducing TCT.

Testicular torsion: a diagnosis not to be missed.

A 25-year-old male was seen in the outpatient with complaints of left testicular swelling and intermittent pain for 4 years, aggravated 8 months back in association with nausea and vomiting. There was no history of trauma, or fever and no lower urinary tract symptoms (LUTS) were present. After conservative management and resolution, the size of the testis reduced which was confirmed on ultrasound showing atrophy. His family physician reassured and advised him to take salicylic acid (Ascard 75 mg).

Is it necessary to remove foleys catheter late after transurethral prostatectomy in patients who presented with acute urinary retention secondary to benign prostatic hyperplasia?

OBJECTIVE: To assess the influence of early versus late removal of catheter after Transurethral Prostatectomy (TURP) in patients who presented with Acute Urinary Retention (AUR), at our centre. METHODS: The records were reviewed of patients presenting to the Emergency Room (ER) or out patient department (OPD) with AUR, after TURP done between April 2004 to June 2008, at The Kidney Centre PGTI, Karachi. Total 60 patients were enrolled. Age, size of prostate, days catheterized before TURP, the post operative day of catheter removal and results after catheter removal were recorded. RESULTS: Fifty two (86.7%) patients had successful voiding while 8 (13.3%) patients, 4 from each group, went into retention again. There was no significant difference in the results of patients who had catheters for either shorter or longer periods prior to surgery. CONCLUSION: There is no difference in early versus late removal of catheter after TURP in patients who present with AUR.

Is ascending urethrogram mandatory for all urethral strictures?

OBJECTIVE: To determine the role of ascending urethrogram in decision making for patients with suspected urethral strictures. METHODS: Medical Records were reviewed of male patients presenting with lower urinary tract symptoms who were subjected to ascending urethrogram and selected cases for cystourethroscopy from January 2001 to December 2002. Cystourethroscopy was performed on those patients who complied with treatment for urethral stricture or who had persistent low flow of urine despite ascending urethrogram reporting no urethral stricture. Data was analyzed on SPSS 10.0. Sensitivity, specificity, positive and negative predictive values were calculated for ascending urethrogram as a measure to evaluate urethral stricture. RESULTS: Ascending urethrogram was done on 92 patients. Of whom 55 were reported to have urethral stricture. The mean age of patients was 42.8 +/- 13.2 years. Of the 92 patients who had ascending urethrogram, 62 were subjected to cystourethroscopy proceed optical internal urethrotomy (OIU) in cases of stricture. It was that out of 45 reported urethral strictures on ascending urethrogram, 5 did not have stricture on cystourethroscopy (P = 0.001). Likewise in the same group of 62 patients, 17 patients were reported to have no stricture on ascending urethrogram, whereas subsequent cystourethroscopy revealed stricture in 4 patients. The calculated sensitivity of ascending urethrogram was 91% and specificity 72%. The calculated positive and negative predictive values were 89% and 76% respectively. CONCLUSION: The study concluded that Ascending Urethrogram does not completely rule out urethral stricture (Negative Predictive Value 76%). It was also observed that urethral stricture may be non-existent even though suggested in Ascending Urethrogram (Positive Predictive Value 89%). With a sensitivity of 91% and a low specificity of 72% of the ascending urethrogram for diagnosing urethral stricture, it would be advisable to subject the patient to cystourethroscopy proceed Optical Internal Urethrotomy in cases of urethral stricture. This will save cost, avoid infection reduce risk of radiation and contrast related hypersensitivity reaction.