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.

Diminution of Primary Cilia in the Stromal Cells at the Tumor-stromal Interface Correlates With an Aggressive Tumor Biology in the Urothelial Carcinoma of the Urinary Bladder.

BACKGROUND AND AIMS: Primary cilia (PC) are cellular organelles that regulate the cellular homeostasis. They are the seats of many oncogenic pathways and indirectly regulate the epithelial-mesenchymal transition (EMT) and extracellular matrix, both critical for the tumor microenvironment (TME). Though there are a few studies highlighting the alteration of PC in the tumor cells of various malignancies, none depict the PC in the stromal cells in the urothelial carcinoma of the urinary bladder (UC), the stromal cells being an essential component of TME. Therefore, we intend to evaluate the PC in the stromal cells at the tumor-stromal interface in UC. METHODS: Immunohistochemistry for acetylated-α-tubulin (for PC), Ki67, E-cadherin, and SNAI1 was performed in 141 cases of UC and 5 normal controls, and primary cilium: nucleus (C:N) ratio was counted in the stromal cells at the tumor-stromal interface. The C:N ratio was correlated with various clinical and histopathological parameters. RESULTS: The C:N ratio showed significant diminution from normal control (mean=0.75) to low-grade UC (mean=0.24) ( P =0.001) to high-grade UC (mean value=0.17) ( P =0.001). There was a significant diminution of the C:N ratio from the noninvasive to invasive UC ( P =0.025). The C:N ratio did not show any correlation with EMT although negatively correlated with the Ki67 index ( r =-0.32; P =0.001), and a higher ratio showed a trend with a higher recurrence-free survival ( P =0.07). CONCLUSIONS: The diminution of the PC in the stromal cells at the tumor-stromal interface is an early event and correlates with an aggressive tumor biology of UC.

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.

Expression of EZH2 and H3K27me3 predicts tumor biology of urothelial carcinoma.

Background: Enhancer of zeste homolog 2 (EZH2) is one of the major epigenetic modifiers involved in the transcriptional repression of target genes through trimethylation of H3K27 (lysine 27 residue of histone H3). Deregulated expression of both EZH2 and H3K27me3 has been implicated in the biological behavior and prognostic outcome of various malignancies. Aim: To assess the role of EZH2 and H3K27me3 in the carcinogenesis of urothelial carcinoma of urinary bladder. Materials and Methods: One hundred fifty consecutive urothelial carcinoma cases of urinary bladder (54.7% high-grade) were included in this study. Immunohistochemical analysis for EZH2 and H3K27me3 was performed on whole tissue sections. A multiplication score obtained by multiplying staining intensity and proportion of positively stained neoplastic cells was used for assessment. Results: EZH2 showed a significant correlation with the tumor grade and lamina propria invasion (p < 0.001). The cases with high EZH2 expression showed a significantly high proliferative index (Mean- 32.7%; p < 0.001). In contrast, negative and low expression of H3K27me3 was significantly more common in high-grade cases (p = 0.006). The expression of H3K27me3 was significantly associated with lamina propria (p = 0.01) and deep muscle invasion (p = 0.007). EZH2 showed a significantly higher expression in the high-grade invasive areas as compared to the high-grade non-invasive areas of the same tumor (p = 0.03). Conclusions: This study establishes an important role of the key epigenetic regulators EZH2 and H3K27me3 in the pathobiology of urothelial carcinomas. Strong expression of EZH2 and weak expression of H3K27me3 are associated with higher grade, proliferative index and invasive behavior.

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.

Electrochemical capacitance properties of pre-sodiated manganese oxide for aqueous Na-ion supercapacitors.

Mn-based oxides are widely investigated as electrode materials for electrochemical supercapacitors, because of their high specific capacitance in addition to the high abundance, low cost, and environmental friendliness of Mn. The pre-insertion of alkali metal ions is found to improve the capacitance properties of MnO2. While the capacitance properties of MnO2, Mn2O3, P2-Na0.5MnO2, and O3-NaMnO2etc. are reported, there is no report yet on the capacitive performance of P2-Na2/3MnO2, which has already been studied as a potential positive electrode material for Na-ion batteries. In this work, we have synthesized sodiated manganese oxide, P2-Na2/3MnO2 by a hydrothermal method followed by annealing at a high temperature of about 900 °C for 12 h. For comparison, manganese oxide Mn2O3 (without pre-sodiation) is synthesized by following the same method, but annealing at 400 °C. While P2-Na2/3MnO2 exhibits a high specific capacitance of 234 F g-1, Mn2O3 can deliver only 115 F g-1 when cycled at 0.4 A g-1 in an aqueous electrolyte of 1.0 M Na2SO4 in a three-electrode cell. An asymmetric supercapacitor Na2/3MnO2‖AC is assembled, which can exhibit a SC of 37.7 F g-1 at 0.1 A g-1 with an energy density of 20.9 W h kg-1, based on the total weight of Na2/3MnO2 and AC with an operational voltage of 2.0 V and possesses excellent cycling stability. This asymmetric Na2/3MnO2‖AC supercapacitor can be cost-effective considering the high abundance, low-cost and environmental friendliness of Mn-based oxides and aqueous Na2SO4 electrolyte.

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).

Correlation of multiparametric MRI with histopathological grade of peripheral zone prostate carcinoma.

BACKGROUND: Prostatic cancer is the second most common malignant tumor in men. Preoperative grading of prostate cancer is important for its management. Our objective is to compare individual and combined detection rates of T2-weighted imaging (T2WI), diffusion weighted imaging (DWI), dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI), and magnetic resonance spectroscopy (MRS) for prostate cancer with histopathological diagnosis as its golden standard. METHODS: Forty-four patients with positive digital rectal examination (DRE) findings and elevated prostate specific antigen (PSA), underwent multiparametric MRI (Mp-MRI). T2WI, DWI, DCE-MRI and MRS were done in all the patients. Cognitive magnetic resonance-transrectal ultrasound (MR-TRUS) fusion biopsy was done in all the patients. Sensitivity and specificity of T2WI, DWI, DCE-MRI, and Prostate Imaging - Reporting and Data System PIRADS version 2 was obtained. Apparent diffusion coefficient (ADC) value and choline/citrate ratio were obtained for each lesion and correlated with histopathological grade. RESULTS: The mean age of the patients was 68.7 ± 10.1 years, and the mean serum PSA level was 58.1 ± 22.4 ng/dL. Of the 38 lesions in peripheral zone, 33 (87%) had histopathologically proven prostate cancer. T2WI had a sensitivity and specificity of 75.8% and 80% and DWI had a sensitivity and specificity of 90.9% and 80%, respectively, for detection of malignant prostatic lesion. The mean ADC values for prostate cancer, prostatitis, and normal prostatic parenchyma were 0.702 ± 0.094 × 10-3 mm2/sec, 0.959 ± 0.171 × 10-3 mm2/sec, and 1.31 ± 0.223 × 10-3 mm2/sec, respectively. Type 3 curve has lower sensitivity (45.5%) but high specificity (80%) for diagnosing prostate cancer. CONCLUSION: DWI can be useful to differentiate benign from malignant prostatic lesions, and low-grade from high-grade prostate carcinoma. ADC value has a positive correlation with histopathological grade of prostate cancer.

Invasive micropapillary urothelial carcinoma of the renal pelvis presenting as nonfunctional kidney: A unique presentation and review of the literature.

ABSTRACT: Micropapillary urothelial carcinoma of the renal pelvis is a rare and aggressive variant and poses a diagnostic challenge, especially related to the site and histomorphology of the tumor. A 60-year-old female presented with right pelvic-ureteric junction obstruction and a nonfunctioning right kidney. She underwent a simple right nephrectomy. The microscopy examination revealed a high-grade tumor of the renal pelvis, predominant micropapillary architecture. The tumor infiltrated into the kidney, renal sinus, perinephric fat, adrenal gland, and Gerota's fascia. Extensive lymphovascular and perineural invasions were also noted. On immunohistochemistry, tumor cells were positive for GATA-binding protein 3, cytokeratin 7, and cytokeratin 20, while negative for paired box gene 8, cluster of differentiation 10, mammaglobin, and alpha-methylacyl-CoA racemase. The p63 was positive in the conventional areas and negative in the micropapillary pattern. We reported an additional case of micropapillary urothelial carcinoma of the renal pelvis, literature review, and discussed the differential diagnosis. Immunonegativity of p63 in the micropapillary component was an additional finding.