Hourglass appearance in cystocele with an impacted vesical calculus.

A 62-year-old hypertensive female presented with a mass protruding from the vagina for the past 20 years. She complained of dysuria and urinary incontinence for the past 3 months. There was no history of surgical intervention in the past. The examination revealed a tender irreducible total uterine prolapse (procidentia) and cystocele with a decubitus ulcer. Computed tomography urogram showed a total uterine prolapse along with the prolapse of a part of urinary bladder, with a vesical calculus of size 2.8 cm × 2.7 cm in the prolapsed part of the bladder, below the level of the pubic symphysis, with minimal wall thickening. After optimization, vesical lithotripsy and bilateral ureteric stenting were performed, followed by hysterectomy after 2 days.

A Prospective Comparative Study of Continuous and Interrupted Suturing in Laparoscopic Pyeloplasty in 3D Era.

INTRODUCTION: Laparoscopic pyeloplasty is becoming the gold standard procedure for pelviureteric junction obstruction. The outcome of pyeloplasty depends on precise pyeloureteral anastomosis. Though in open pyeloplasty interrupted or continuous suture are practiced, in most of the laparoscopic or laparoscopy-assisted robotic pyeloplasty continuous suturing is practiced. After acquiring a 3-dimensional (3D) camera, we prospectively analyzed the suturing time, complication rate, and success rate between interrupted and continuous suturing in laparoscopic pyeloplasty. OBJECTIVE: To prospectively review the outcome difference between interrupted suturing (group A) and continuous suturing (group B) while using a 3D camera. MATERIALS AND METHODS: Out of 93 patients who underwent laparoscopic pyeloplasty, 6 patients who underwent retro-peritoneoscopic approach, 7 patients who had nondismembered technique, 7 patients with secondary renal calculi, and 3 patients with grossly dilated pelvis were excluded from the study to reduce bias. Hence, the remaining 70 patients who underwent transperitoneal pyeloplasty from 2012 to 2017 were prospectively analyzed, comparing 35 cases of interrupted suturing with 35 cases of continuous suturing using 3D camera in an alternating manner. The primary aim was to know the difference in suturing time. The secondary outcomes were success of pyeloplasty, complications, and drain volume. The statistical analysis was done using SPSS 2.0 software. RESULTS: Of the 70 cases, with 35 in each arm studied, the mean suturing time, success rate, and complications were not significantly different. The total drain quantity during the hospital stay was observed to be more in the interrupted suturing group. CONCLUSION: The usage of a 3D camera and experience of the surgeon reduced the time difference between continuous and interrupted suturing in laparoscopic pyeloplasty. The outcome between interrupted and continuous suturing groups were the same. Though the drainage volume was more with interrupted suturing group the outcome was not altered.

Laparoscopic gastrocystoplasty for tuberculous contracted bladder.

The stomach is the preferred augmentation option for a contracted bladder in a patient with renal failure. A 49-year-old female presented with right solitary functioning kidney with tuberculous lower ureteric stricture and contracted bladder. Her creatinine was 2.8 mg%. By laparoscopic approach, right gastroepiploic artery based gastric flap was isolated using staplers and used for augmentation and ureteric replacement. At 6-month follow-up, her creatinine was 1.9 mg%, and bladder capacity was 250 ml. She had mild hematuria, which settled with proton pump inhibitors. Laparoscopic gastrocystoplasty is feasible and effective augmentation option in those with renal failure, giving the benefits of minimally invasive approach.

Differential analysis of muscle fatigue induced elbow and wrist tremor in controlled laparoscopic manoeuvring.

BACKGROUND: Fatigue induced hand tremor (FIT) is a primary limiting concern for the prolonged surgical intervention in minimally invasive surgery (MIS) and robot-assisted-minimally invasive surgery (RAMIS). A thorough analysis is necessary to understand the FIT characteristics in laparoscopic tool movement. The primary aim of this study is to perform a differential analysis of the elbow and wrist tremor due to muscle fatigue in laparoscopic manoeuvring. METHODS: We have introduced a joint angle based tremor analysis method, which enables us to perform a differential study of FIT characteristics at the individual joint. Experimental data was acquired from a group of subjects during static and dynamic laparoscopic movement in an imitative RAMIS master manipulation scenario. A repetitive task was performed with a total span of 1 h for observing the effect of muscle fatigue. Along with the joint angle variation, surface electromyography (sEMG) signal was also studied in the analysis. RESULTS: The wrist tremor is more predominant than tremor generated at the elbow, especially in highly fatigued condition. The high-frequency tremor (>4 Hz) is contributed by the wrist joint. Moreover, the variation of the wrist and elbow tremor ratio was found to be dependent upon the experience of the surgeons. CONCLUSIONS: In this work, we have investigated the attribution of elbow and wrist joints in FIT during laparoscopic tool manipulation. The outcomes may be useful for the design of robot-assisted surgical manipulator, and can be used for quality assessment of surgical training as well.

Laparoscopic Nephrectomy with Adrenalectomy for Synchronous Adrenal Myelolipoma and Renal Cell Carcinoma.

Introduction. Adrenal myelolipomas are uncommon nonfunctioning tumors of the adrenal. Synchronous renal cell carcinomas with adrenal myelolipomas are very rare. We present the case report of adrenal myelolipoma with synchronous RCC managed laparoscopically. Case Report. A 60-year-old old gentleman presented with incidental right upper polar mass with right adrenal mass. Metastatic work-up was negative. Laparoscopic radical nephrectomy with adrenalectomy was done under general anesthesia. The biopsy report was right kidney clear cell adenocarcinoma (T1b) with right adrenal myelolipoma. Conclusion. This is the first case report of laparoscopic adrenalectomy with nephrectomy for ipsilateral synchronous renal cell carcinoma with adrenal myelolipoma.

A comparison of continuous and interrupted suturing in laparoscopic pyeloplasty.

BACKGROUND: Laparoscopic pyeloplasty is one of the most common reconstructive procedures performed by urologists. Both continuous and interrupted sutures are being practiced for ureteropelvic anastomosis. The success rate and the complications associated with the suturing technique needs evaluation. We analyzed the results from of our patients who underwent laparoscopic pyeloplasty using both techniques. OBJECTIVE: To review the outcome differences among patients undergoing laparoscopic pyeloplasty regarding suturing technique. MATERIALS AND METHODS: All patients who underwent laparoscopic, transperitoneal dismembered pyeloplasty of the primary pelviureteric obstruction were analyzed. The primary outcome was successful pyeloplasty, as assessed by the resolution of symptoms and T½<10 minutes. The secondary outcomes were the complication rate and the operative parameters. The difference in the parameters was assessed by Student t test analysis. RESULTS: Of the 107 patients we studied, 65 had interrupted suturing and 42 had continuous suturing. The success rate was not significantly different among the 2 groups. The mean suturing time, postoperative drainage volume, postoperative hospital stay, and total cost of the procedure were significantly less in the continuous suturing group. CONCLUSION: The continuous suturing technique is preferred over the interrupted suturing technique for laparoscopic pyeloplasty because the success rates are equal and the postoperative stay, suturing time, drain output, and cost of the procedure are better.

Laparoscopic undiversion in a child with sacral agenesis into augmentation cystoplasty.

INTRODUCTION: In neurogenic bladder with compromised renal function or when complex reconstruction is not preferred, ileal conduit is considered. Undiversion is performed when the patient prefers the procedure, once the renal function improves, or when complications resulting from diversion are present. CASE DESCRIPTION: We present the case of a 10-y-old boy with sacral agenesis, who underwent laparoscopic-assisted ileal conduit diversion in 2006, because he had a grossly unstable, small-capacity bladder and was not compliant with intermittent self-catheterization. At present, he preferred not to have a conduit. DISCUSSION: Laparoscopic undiversion with ileal augmentation cystoplasty was performed. The postoperative course was uneventful, and he is now on intermittent self-catheterization with healthy renal function. Laparoscopic undiversion is technically challenging, yet feasible, and is an effective option in children. To our knowledge, this is the first such case reported.

Early-onset port site (drain site) hernia in pediatric laparoscopy: a case series.

INTRODUCTION: Laparoscopic procedures for children with urological problems are common under the present conditions. Laparoscopic surgery is associated with complications such as port site hernia that are not associated with open surgery. Drain site hernia is one variety of port site hernia. SUBJECTS AND METHODS: We did a retrospective analysis for the development of port site hernias among pediatric patients who underwent laparoscopic procedures. We also analyzed the various methods of prevention. RESULTS: Among the 148 children who underwent laparoscopic procedures, 5 (3.4%) had a port site hernia in the early postoperative period. All of them were drain site hernias with early presentations, and the content was omentum. Three patients had reduction under sedation. Two patients needed laparoscopy: one for the reduction into the preperitoneal space and the other for the nonreducible hernia due to omental edema. All the patients had an uneventful recovery. CONCLUSIONS: Port site hernia is an uncommon complication in children undergoing laparoscopy. The drain site is the predominant location of port site hernia. Sedation during drain removal and judicious use of drain may help to decrease such occurrences.

Laparoscopic diverticulocystoplasty for low compliance bladder in a child.

Low compliance bladder with a posterior urethral valve is a common association. Augmentation cystoplasty is one of the management options. We present the case report of a 4-y-old boy who presented with low compliance bladder, bladder diverticulum, right obstructive megaureter, and left grade IV reflux, 6 mo following PUV fulguration. He was managed by laparoscopic diverticulocystoplasty with right ureteric reimplantation and left detrusorrhaphy. The patient showed subjective and urodynamic improvement at 12 mo follow-up. The use of diverticulum for augmentation is advantageous, as it abides by the principle of bladder augmentation with urothelium. This is the first case report of successful use of diverticulum for laparoscopic bladder augmentation in a child.

Cost reductive laparoendoscopic single site surgery endotrainer and animal lab training-our methodology.

Laparoendoscopic single site surgery (LESS) is a new avenue in laparoscopic urology. The main advantage is the enhanced cosmetic benefits of single hidden scar. Lately many papers are being published on various procedures done by LESS. Like conventional laparoscopy, this approach is likely to be used more widely and hence exposure to this field is essential. However, formal training in this technique is not widely available. Expensive ports and nonavailability of endotrainer may be the factors deterring the training. We have modified the standard laparoscopic endotrainer with improvised ports, to make it suitable for single port laparoscopic training. For the animal lab training improvised ports and low cost instruments were used. Thus the overall cost of the training in LESS was reduced, and better confidence levels were achieved prior to human applications.

Modified device-free HAL: an innovative cost-reductive approach.

Hand-assisted laparoscopy (HAL) has been in vogue since 1994. The major advantages are tactile sensation, quicker dissection, and easy removal of specimen. These advantages could not be availed in developing countries due to the cost of the available HAL devices. This has initiated the use of HAL without devices in our unit. Instead of a device, a double glove with a sponge between the inner and outer glove at the wrist acted as an obturating cuff. A muscle-splitting incision in the iliac fossa helped in minimizing the air leak. In this article, we report our experience in nephrectomy and nephroureterectomy.

Modified technique of laparoscopy-assisted surgeries (transportal).

BACKGROUND AND PURPOSE: We present the role of the transportal technique of laparoscopy-assisted surgeries.This report highlights the advantages of transportal technique over pure laparoscopic surgeries and laparoscopy-assisted surgeries. PATIENTS AND METHODS: In the last 3 years, we have adopted this approach for six patients during various procedures. This report highlights modified extracorporeal (transportal) technique, namely, ileal isolation, restoration of ileal continuity in ileal conduit and ileal ureter; ileal isolation, restoration of ileal continuity detubularization of the loop in ileocystoplasty; and ureteral tailoring in the megaureter before ureteral reimplantation. This technique was performed by transportal exteriorization of the bowel through the 12- or 15- or 20-mm port followed by the conventional technique of hand-sewn anastomosis. The bowel and ureter are restored to the abdominal cavity through the same port once the extracorporeal part is completed. RESULTS: There was no significant intraoperative or postoperative morbidity or mortality. The transportal technique without a formal incision reduces operative time; is less demanding; and avoids an abdominal incision,as in the laparoscopy-assisted technique. CONCLUSION: The transportal technique of laparoscopy-assisted surgery achieves all the advantages of pure laparoscopic surgery without a formal incision, as in laparoscopy-assisted surgery. Hence, it is a less morbid, quicker, and cost-effective method.

Transmesocolic approach to laparoscopic pyeloplasty: our 8-year experience.

Open pyeloplasty is the gold standard in the treatment of congenital ureteropelvic junction obstruction. Several reports have shown that laparoscopic pyeloplasty produces comparable results. In this paper, we report a retrospective study of the transmesocolic approach to the left ureteropelvic junction obstruction in 26 patients. As colon mobilization is avoided, the field remains fairly clear. This direct approach also saves time and is least invasive. One patient was lost for follow-up, and 1 patient is awaiting a renogram. Among the remaining 24 patients, 22 patients had improved drainage (IVU or isotope renogram), and 2 of the patients had stable renal function.

Laparoscopic boari flap repair: report of 3 cases.

PURPOSE: Boari flap reimplantation is one of the options for ureteric reimplantation when the diseased ureteric segment is long. Open Boari flap reimplantation is well established. In this paper, we describe laparoscopic Boari flap reimplantation in 3 patients. MATERIALS AND METHODS: Since May 2004, 3 patients had a successful laparoscopic Boari flap ureteric reimplantation. Preoperative intravenous urogram and retrograde pyelogram confirmed the length and site of the obstruction. The first patient was a 16-year-old boy with primary obstructive megaureter, with the adynamic segment extending from just below the sacro iliac joint. The second was a middle-aged diabetic lady with a long lower ureteric stricture. The third was a ureteric injury that occurred following a laparoscopic ovarian cystectomy. RESULTS: The mean operative time was around 320 minutes. There were no intra- or postoperative complications. All the patients recovered well and are being followed up clinically and radiologically. CONCLUSION: Laparoscopic Boari flap reimplantation is a challenging procedure. With increasing technical skill and confidence, one can attempt the procedure with the obvious advantage to the patient.

Laparoscopy-assisted ileal conduit in sacral agenesis.

Sacral agenesis is a rare congenital anomaly. The neurologic deficits are usually static. However, there are reports of progressive neurologic deterioration. They have neurogenic bladder, which usually present late and managed according to the presenting urodynamic pattern. In this paper, we report the urologic management in a 4-and-half-year-old boy with sacral agenesis. He presented with constant dribbling owing to gross instability with a small-capacity bladder. He also had bilateral ureteric obstruction (i.e., stricture at the level of bilateral ureteric reimplantation, which was done at the age of 1 year for high-grade reflux). He was not compliant with intermittent self-catheterization. Various options were discussed with the parents, but they preferred an ileal conduit (which could take care of the leak and avoid complex reconstructive surgery), with an option of reconstruction later. Laparoscopic ileal conduit was performed, with the uretero ileal anastomosis and restoration of ileal continuity performed extracorporeally. Extracorporeal part of the procedure was done without any additional incision (by bringing the ureters and ileal segment outside through the 12-mm port and then pushing it back inside after the completion of the anastomosis). We present this case report for the less-morbid management of a complicated urologic problem.

Laparoscopic ureterocystoplasty before kidney transplantation.

PURPOSE: To describe the technique of total laparoscopic ureterocystoplasty. MATERIALS AND METHODS: Laparoscopic ureterocystoplasty was performed to optimize the bladder function before kidney transplantation in a 23-year-old man. This patient had undergone bilateral cutaneous ureterostomy with fulguration of a posterior urethral valve at the age of 11 months. He underwent open surgical removal of multiple renal stones at age 10. He progressed to chronic renal failure at the age of 20, at which time hemodialysis was initiated. Because of grade IV vesicoureteral reflux and a poorly compliant bladder, the patient underwent laparoscopic ureterocystoplasty. RESULTS: The patient's lower urinary tract symptoms improved, and a urodynamic study performed after 6 months revealed a compliant bladder. Subsequently, a right nephrectomy and a live-donor renal transplantation from his mother were performed. At 1-year follow-up, his renal parameters were within normal range, he does not have any significant residual urine or urinary symptoms. CONCLUSION: Laparoscopic ureterocystoplasty is an excellent option for a poorly compliant bladder, especially when a patient has had multiple open surgeries and is awaiting renal transplantation.

Laparoscopic repair of vesicouterine fistula--a case report.

We report the technique of laparoscopic repair of vesicouterine fistula. A 30 year old lady presented with incapacitating cyclical pain for one and a half years. She had undergone cesarean section 18 months ago. She was evaluated by a CT scan of abdomen and pelvis followed by a cystoscopy and diagnosed to have a vesicouterine fistula. This was managed laparoscopically (laparoscopic disconnection of fistula; closure of bladder and uterine rent; and omental interposition). There were no intraoperative or postoperative complications. Follow up CT scan of abdomen and cystoscopy revealed good healing of the repaired area. Laparoscopic repair of vesicouterine fistula is a feasible procedure.