A Novel Technique of Renorrhaphy in Difficult Partial Nephrectomies by Single-Layered Parenchymal Imbrication.

Background In partial nephrectomies, achieving the trifecta outcome of negative tumor margins, no surgical complications, and minimal decline in renal function depends on various factors, with the complexity of the tumor described by the nephrometry score being chief among them. These factors often motivate surgeons toward a minimally invasive route even if the preferred route is an open approach. We describe an innovative renorrhaphy technique that overcomes the commonly encountered difficulty in reconstructing the renal parenchyma after resecting a complex tumor with a single-layered parenchymal imbrication (SLPI) technique. Methodology We conducted a retrospective review of case records of the patients who had undergone partial nephrectomies in our center from March 2017 to March 2021. The patients who underwent the SLPI technique were chosen, and data were extracted. Data collected included patients' preoperative imaging findings; intraoperative parameters such as ischemia time, blood loss, and number of renal arteries; and postoperative factors such as margin positivity rate, urine leak, secondary bleeding, follow-up imaging, and recurrence rates. Results A total of 28 patients were included in our study. The estimated blood loss was 234 mL (standard deviation [SD] = 55 mL), warm ischemia time was 31 minutes (SD 4 minutes), a hospital stay of 3 days (SD 2 days), two minor complications, two intraoperative complications, and one margin positivity. There were no major complications or recurrences. Conclusions The novel technique of SLPI renorrhaphy can help deal with complex renal masses and is an easily reproducible technique both in open and minimally invasive approaches.

Influence of tumor size in the progression of venous tumor thrombus in renal cell carcinoma: A 7-year single-center experience.

Objective: The objective of the study is to describe the perioperative outcomes, disease-specific, and overall survival status in patients diagnosed with renal cell carcinoma with inferior vena cava (IVC) tumor thrombus. Patients and Methods: We did a retrospective analysis of all patients who underwent radical nephrectomy along with IVC thrombectomy from the year 2013 to 2020. Mayo's classification was used to stratify the level of IVC thrombus. Demographic, perioperative, histopathology data, complications, and survival status were analyzed. Results: Total number of patients included in the study was 39, (Male: Female = 84.6%: 15.4%). Median age of patients was 58 (interquartile range [IQR] 50-63) years. Median size of renal tumor (in cms) was 9.5 (IQR 7.5-12), 8 (IQR 7-11.5), 8.5 (IQR 7-11.75), and 11 (IQR 9.5-11) (P = 0.998) in level 1,2,3, and 4 tumors, respectively. Clear cell variant was seen in 32 patients (82%) with R0 resection in 17 patients. Twelve patients (30.7%) had systemic metastasis on presentation. The overall mean survival time was 66.4 months with 95% confidence interval (CI) (52.4-80.5 months). Mean recurrence-free survival is 76 months with (63-90) CI of 95%. Mean survival in patients who presented with metastasis is 47 months with 95% CI (52.4-80.5). Perioperative mortality rate was 5.12% in this study. Conclusion: The tumor size does not have an influence on the progression of tumor thrombus into IVC. Significant difference in survival was observed between different levels of thrombus with high mortality in level four tumors.

Robot assisted laparoscopic adrenalectomy: Should this be the new standard?

INTRODUCTION: Minimal invasive surgeries (MIS) for large size adrenal tumors are still debatable. The objective is to evaluate the contemporary peri- and post-operative outcomes of patients undergoing (open = OA, laparoscopic = LA, and robotic = RA) adrenalectomies in three institutions. MATERIALS AND METHODS: Retrospectively gathered peri- and post-operative data of 235 patients, underwent adrenalectomy at three Institutions over a 7-year period (2013-2020) were analyzed. All patients underwent thorough radiological and endocrine workup. RESULTS: Two hundred and thirty five patients who underwent adrenalectomy (OA (n = 29), LA (n = 146), and RA (n = 60)) were assessed. OA (n = 29) versus Minimally invasive surgery (n = 206) showed significant differences (median, p value) in larger tumour size, cm (9.4 vs 5, (p = 0.0001)), longer operative time, mins (240 vs 100, (p = 0.0001)), longer hospital stay, days (8 vs 3,(p = .0001)), Higher readmission rates (14% vs 1.9%), higher blood loss, ml (400 vs 100, (p = 0.0001)) requiring blood transfusion (14% vs 4.3%) (p = 0.03), higher intraoperative complication (21% vs 6%) (p = 0.0004), and post op complications (17% vs 5.3%) (p = 0.01). Amongst the MIS (RA vs LA), RA appeared be have better outcomes in terms of shorter operative time, less blood loss and less intra operative complications with a p value <0.05. These results were consistent for the assessment of patients who had ⩾6 cm tumor size. The postoperative complication rates were lowest with RA (3.3%) compared to OA (17%) and LA (6.1%). CONCLUSIONS: Contemporary practice of adrenalectomy shows that robotic adrenalectomy is safe and effective irrespective of the tumor size.

A Hemostatic Technique in Robot-Assisted Laparoscopic Partial Nephrectomy and Its Impact on Renal Function.

Purpose Robot-assisted partial nephrectomy (RAPN) has become popular in recent years for small renal masses. We describe a technique of suturing renal defects during RAPN that is reliable and quick, does not necessitate the need for hemostatic agents, and reduces perioperative complications. Materials and methods A total of 24 patients who underwent RAPN were included in the study period between 2013 and 2018 and data were analyzed. Perioperative and postoperative outcomes were measured and compared. Results The median tumor size was 4 cm. Median warm ischemia time was 41 minutes (IQR: 38-45 minutes) and estimated blood loss was 150 mL (IQR: 120-200 mL). There were no major intraoperative complications or conversions to open surgery. No urine leaks or postoperative bleedings were observed. Conclusion Our technique is safe and effective. It negates the use of hemostatic agents, decreases perioperative complications, and negates that determination of long-term renal function is not associated with prolonged warm ischemia time alone. Hence, we propose that our technique is safe in partial nephrectomy when the pelvic calyceal system and renal vessels are opened in multiple locations.

Bladder Neck Resection Combined with Ten Point Intralesional Mitomycin C Injection in Management of Refractory Bladder Neck Contracture in Post TURP Status: A Single-Center, 2-Year Experience.

PURPOSE: Bladder neck contracture is an annoying problem for patients as well as urologists. Recurrence still remains a common problem associated with significant morbidity. This study evaluated the efficacy and side effects of mitomycin C (MMC) which has anti-fibroblast as well as anti-collagen properties in the deterrence of bladder neck contracture (BNC) recurrence after transurethral bladder neck resection (TUBNR). MATERIALS AND METHODS: Ten patients between March 2017 and April 2018 with extremely persistent BNCs who underwent multiple failed endoscopic procedures (≥3 times) were evaluated by using International Prostate Symptom Score (IPPS), uroflowmetry, quality of life (QOL) and post void residual urine (PVR) preoperatively. All patients underwent transurethral bladder neck resection (TUBNR) followed by ten-point intraoperative MMC injection, not exceeding a total dose of 2 mg (0.2 mg/mL), which was given circumferentially at the resected site, using Williams cystoscopic needle. Patients were reviewed at 3 months, 6 months, 1 year and 2 years postoperatively. RESULTS: The procedure was done on a day care basis. The recurrence period prior to our treatment was 3.2 ± 1.3 months. The follow-up was for 24 months. Overall 80% (8 of 10) of patients demonstrated resolution of BNCs as well as sufficient flow rate which was evaluated by uroflowmetry, PVR, IPPS and QoL postoperatively. One patient had detrusor underactivity. Relapse was seen in two patients. None of the patients experienced any significant adverse effects related to MMC. CONCLUSION: Intraoperative ten-site injection of MMC after TUBNR can be regarded as a safe and efficient technique with no serious adverse event.

Acquired post cesarean uretero-uterine fistula - a rare entity.

In this contemporary era,ureteric injuries are not uncommon. They are inadvertent and overwhelming complication following pelvic surgeries.We describe a case of Uretero-uterine fistula (UUF) in a 36 year old woman, who underwent repeat lower cesarean section two months earlier, admitted with complaints of paradoxical incontinence of urine and copious watery vaginal discharge. After extensive clinical and radiological evaluations, she underwent robotic bilateral ovary preserving hysterectomy with ureteroneocystostomy (Boari flap and psoas hitch with Double J stenting).

Robot Assisted Laparoscopic Adrenalectomy: Does Size Matter?

OBJECTIVE:  Open adrenalectomy (OA) is considered to be the standard care for large adrenal tumors. Minimally invasive surgery (MIS) using laparoscopic technique is considered for many patients in the modern era. Robot assisted laparoscopic adrenalectomy (RALA) can be an extremely useful tool which will negate the disadvantage of laparoscopic method. The aim of the present study is to determine whether adrenal tumor size and laterality have an impact on patients undergoing RALA with respect to perioperative and postoperative outcomes.  Methods: During the study period, 38 patients who underwent RALA in a tertiary care center were considered for retrospectively analysis. The study populations were subdivided into distinctive groups based on the tumor size (<5 cm and ≥5 cm, <8 cm and ≥8 cm), and side (right and left side). For all the subgroups, perioperative and postoperative outcomes were analyzed. Perioperative and postoperative outcomes were assessed between patient groups, group a) <5 cm and ≥5 cm tumor, group b) <8 cm and ≥8 cm, and group c) laterality (right vs left). RESULTS:  None of the patients showed any differences. In the current study, the conversion rate, readmission, and mortality were not observed. No major complications were noted. CONCLUSION:  RALA appears to be an extremely viable alternative to MIS using laparoscopic technique. The operative time, console time, blood loss, complication rates, and stay were extremely minimal irrespective of the size or laterality of the adrenal tumor.

Collecting duct carcinoma of kidney: Masquerading as genitourinary tuberculosis - Lessons learnt.

We present a case of Collecting duct of Bellini carcinoma (CDC) which was masquerading as Genitourinary Tuberculosis/chronic granulomatous disease in a 43 year old women, who presented with complaints of low grade fever, loss of appetite, left loin pain and dyspnoea with recent onset of haemoptysis. After extensive evaluation, she was referred to urology where she underwent a laparoscopic assisted open left radical nephrectomy which was reported to be Collecting duct carcinoma.This case is being presented for the diagnostic dilemma it elicited throughout the evaluation.

Cholesterol Granuloma of the Petrous Apex: A 5-Year Review of Radiology Reports with Follow-Up of Progression and Treatment.

Objectives To assess the stability and outcomes of patients with cholesterol granulomas at Brigham and Women's Hospital. Design A retrospective review of neuroradiology magnetic resonance imaging (MRI) studies was performed. The number of newly diagnosed cases of cholesterol granuloma per year was determined. Additional data included age and gender, clinical presentation if applicable, growth on imaging follow-up, and recurrence on postoperative follow-up if applicable. Participants Inclusion criteria included patients who underwent MRI studies between January 1, 2009 and July 1, 2013. Upon review of imaging of these patients, 18 patients had findings compatible with cholesterol granuloma. Results During the study period, an average of three cases of cholesterol granuloma were diagnosed on MRI per year. Three of 18 patients underwent treatment. Two underwent surgery, both of whom demonstrated recurrence on postoperative follow-up imaging. One patient who underwent computed tomography-guided percutaneous aspiration and Gelfoam (Pfizer, New York, United States) embolization had no recurrence on imaging follow-up of up to 23 months. Among the patients who were observed without intervention, growth was identified in only one patient. Conclusions Cholesterol granulomas are a rare entity; however, their appearance on imaging may be greater than previously reported. Most of the lesions demonstrate stability and can be observed.

Image-guided percutaneous aspiration and gelfoam treatment of petrous apex cholesterol granuloma: a new theory and method for diagnosis and treatment.

Although diagnosis of cholesterol granulomas of the skull base can be straightforward with computed tomography (CT) and magnetic resonance imaging (MRI) appearance, treatment is controversial with various skull base approaches described in the literature. This report describes a 35-year-old man who presented with a symptomatic, enlarging cystic lesion in the left petrous apex and clivus that had imaging features of a cholesterol granuloma (cholesterol cyst). Due to a prior history of treated mediastinal germ cell tumor, pathologic confirmation of the lesion was requested. A CT-guided percutaneous aspiration revealed dark used motor oil-like fluid. Continued aspiration yielded a change in the character of the fluid to marrow red. Injection of contrast revealed no communication with cerebrospinal fluid. Gelfoam (Pfizer, New York, New York, USA) was subsequently injected percutaneously into the residual cavity. Histopathology showed no evidence of malignancy and follow-up MRI at 1 month, 3 months, 6 months, and 1 year demonstrated continued decrease in size and signal of the lesion.

Sonographic upper gastrointestinal series in the vomiting infant: how we do it.

Sonography (ultrasound) is used routinely to assess an infant with nonbilious projectile emesis. Fluoroscopic upper gastrointestinal (UGI) series has been the standard method to evaluate infants with bilious emesis. We use sonographic UGI routinely to assess infants with nonbilious emesis as well as infants with bilious emesis. This essay illustrates our technique, the results obtained using this technique for normal anatomy, and the commonly encountered pathology.

The effects of COX-1 and COX-2 inhibitors on prostaglandin synthesis and the formation of heterotopic bone in a rat model.

INTRODUCTION: Traumatic heterotopic ossification (HO) is a common clinical condition associated with various orthopedic procedures that involve injury to soft tissues near bone. In this study, we tested the hypothesis that the prophylactic effects of NSAID's in the treatment of HO are mediated via inhibition of the COX-2 enzyme. Here we describe a rat model that simulates HO in the human that was used to test the above hypothesis. MATERIALS AND METHODS: Heterotopic ossification was surgically induced in the quadriceps by injury to the muscle and femoral periosteum and transplantation of donor bone marrow cells containing osteoprogenitors into the site of injury. HO was imaged and quantified by micro-CT scanning of femurs removed from sacrificed animals at 6 weeks post-injury, three-dimensional computer reconstructions of the scanned bones and computer-assisted morphometric analysis. Prostaglandin E(2) (PGE(2)) synthesis was quantified using an enzyme immunoassay system. The effects of a nonselective COX inhibitor or specific inhibitors of COX-1 or COX-2 following oral administration on the content of ectopic bone and PGE(2) were also measured. RESULTS: Micro-CT and histological analyses demonstrated that all of the femurs in operated limbs developed HO in the vastus lateralis muscle belly of the quadriceps close to the anterior femur. Only the COX-1,2 nonselective and COX-2 inhibitors significantly decreased HO formation (by about one-third in each case; P < 0.05). PGE(2) synthesis at the site of injury was increased 50- and 100-fold (to 25 ng/g tissue) within 1 and 7 days, respectively, post-injury with the levels declining to near baseline within 2 weeks of surgery. Both the COX-1,2 nonselective and COX-2 inhibitors significantly decreased PGE(2) levels to 25% of control HO levels within 24 h of the first administration, even at low dosages. The COX-1 inhibitor only produced the same effect after 1 week of administration. CONCLUSION: These findings suggest that although inhibitors of COX-2 or COX-1 reduced PGE(2) synthesis, only the COX-2 enzyme plays a role in the mechanism of traumatic HO.

Volumetric analysis of liver metastases in computed tomography with the fuzzy C-means algorithm.

Tumor size is often determined from computed tomography (CT) images to assess disease progression. A study was conducted to demonstrate the advantages of the fuzzy C-means (FCM) algorithm for volumetric analysis of colorectal liver metastases in comparison with manual contouring. Intra-and interobserver variability was assessed for manual contouring and the FCM algorithm in a study involving contrast-enhanced helical CT images of 43 hypoattenuating liver lesions from 15 patients with a history of colorectal cancer. Measurement accuracy and interscan variability of the FCM and manual methods were assessed in a phantom study using paraffin pseudotumors. In the clinical imaging study, intra-and interobserver variability was reduced using the FCM algorithm as compared with manual contouring (P = 0.0070 and P = 0.0019, respectively). Accuracy of the measurement of the pseudotumor volume was improved using the FCM method as compared with the manual method (P = 0.047). Interscan variability of the pseudotumor volumes was measured using the FCM method as compared with the manual method (P = 0.04). The FCM algorithm volume was highly correlated with the manual contouring volume (r = 0.9997). Finally, the shorter time spent in calculating tumor volume using the FCM method versus the manual contouring method was marginally statistically significant (P = 0.080). These results suggest that the FCM algorithm has substantial advantages over manual contouring for volumetric measurement of colorectal liver metastases from CT.