Safe transition from open to pure laparoscopic donor nephrectomy: Approach and results.

INTRODUCTION: Laparoscopic living donor nephrectomy (LLDN) offers many advantages compared to open living donor nephrectomy. However, the perceived difficulty in learning LLDN has slowed its wider implementation. Herein, we describe the evolution of LLDN at a single center, emphasizing the approach and technical modifications and its impact on outcome. METHODS: The series included a 2½-year period and three different surgeons. We started with two-stage plan for establishing LLDN at the institute (introduction and consolidation). Data of laparoscopic donor nephrectomy performed at the institution were prospectively evaluated regarding donor and recipient outcome. RESULTS: From December 2016 to April 2019, 221 donors underwent LLDN. Three donors required conversion to open surgery. The mean operation time was 96.4 (62-158) min and the mean warm ischemia time was 186 (149-423) s. The complications were observed in 11.6% of donors from LLDN group and all complications were Class I and Class II only (Clavien-Dindo classification). No Class III and Class IV complications occurred. In the present study, there was some learning curve effect observed only in operative time (OT) with longer OT in initial cases. However, the overall operative complications were minimal, showing that this learning curve had no deleterious effects on donor safety. CONCLUSION: The present study demonstrates that with proper planning, team approach, and a few technical modifications, the transition from open to LLDN could be safe and effective.

Retroperitoneoscopic nephrectomy for benign nonfunctioning kidneys: Training and outcome.

INTRODUCTION: Between the two techniques of laparoscopic nephrectomy, retroperitoneoscopy has certain distinct advantages over transperitoneal access but may be a more difficult technique to learn. We present our experience of training novices in retroperitoneoscopic nephrectomy with a good outcome, making it a standard of care for nephrectomy at our institute. METHODS: The aim of this study was to report the initial experience, learning curve, and outcome of retroperitoneoscopic nephrectomy by novices under a mentored approach. The series included four novice urologists. The data from the initial forty retroperitoneoscopic nephrectomies performed by each of them were reviewed. RESULTS: Retroperitoneoscopic nephrectomies were successfully completed by novices in 88.1% (141/160) of the patients. Nine cases (5.6%) required the mentor's help because of nonprogression, and ten cases (6%) required conversion to open nephrectomy. The median operative time of all surgeons decreased with increased surgical experience. There was some intersurgeon variation in the learning curve ranging from 10 to 30 cases, but all surgeons showed a significant reduction in operative time across consecutive sets of ten cases. Seven cases required mentor help in the initial series (7/80) and only two in later half of cases (2/80). All minor complications were also significantly less in the later series. CONCLUSIONS: The present series represents the effectiveness of training in retroperitoneoscopic nephrectomy of novices by a responsible team and with the standard protocol and surgical steps. Through effective mentoring, the steep learning curve associated with retroperitoneoscopic nephrectomy has been overcome, making it standard of care for nephrectomy at our institute.

Adult Presentation of Ectopic Vas Deferens with Dysplastic Kidney.

A 24-year-old male presented with voiding lower urinary tract symptoms. On evaluation, the patient was found to have midbulbar urethral stricture and right dysplastic pelvic kidney with right vesicoureteral reflux. A micturating cystourethrogram (MCUG) shows opacification of the right vas deferens along the entire course till the testis. The patient underwent end-to-end urethroplasty. But soon the patient presented with urinary tract infection (UTI) and epididymorchitis in the follow-up period. The patient was explored laparoscopically to remove dysplastic kidney and ectopic vas deferens. Laparoscopically, the testicular end of the left vas deferens entering the deep inguinal ring was clipped and cut. Also the dysplastic kidney and ureter were removed till the vesicoureteral junction. At 1 year of follow-up, the patient is voiding well with no episodes of UTI.

Role of Vitamin C and E supplementation in reduction of serum level of renal injury marker following shock wave lithotripsy: Prospective single centre experience.

INTRODUCTION: Shock wave lithotripsy has become first line treatment modality for renal calculi due to its noninvasiveness. However, the destructive forces like dispersion of cavitation bubbles can cause trauma to thin-walled vessels and renal parenchyma during fragmentation of the stones. Antioxidants are our first line of defense against oxidative stress. The aim of this study was to investigate whether oral administration of Vitamin C and E help in a reduction of the serum level of inflammatory mediator by serial measurement of high sensitivity C-reactive protein (hs-CRP) and by this reduction in the risk of renal damage. PATIENTS AND METHODS: A total of 107 subjects were recruited in three groups. Group A served as a control group, and Group B and Group C received oral medication of Vitamin E 800 mg/day and Vitamin C 1000 mg/day respectively, start from 2 days prior the lithotripsy and continued for total 7 days. The level of hs-CRP was used as a mediator of the inflammatory response following lithotripsy and thus for long term renal injury. Serum level of hs-CRP was measured on 2 days prior the lithotripsy and day 2, 7 and 28 after the lithotripsy. RESULTS: Patients who were given either Vitamin C or Vitamin E showed a significant reduction of serum level of hs-CRP when compared to control the group. CONCLUSION: Oral administration of Vitamin C and E helps in reduction of serum levels of the inflammatory marker for acute renal injury and thus they can be useful in minimizing the kidney injury following lithotripsy for renal stone disease.

Live donor kidney transplantation in India: effects of donor and recipient age on graft survival.

INTRODUCTION: The increasing gap between demand and supply of human kidneys has resulted in the use of more expanded criteria donor organs are used. The influence of age on short- and long-term survival of renal allograft has not been well studied in Indian population. MATERIALS AND METHODS: Two hundred and seventy-eight patients were evaluated retrospectively who underwent kidney transplantation from Jan 2008 to June 2011. Patients were divided into 6 groups: group A (donor age 20-40 years, recipient age <50 years), group B (donor age 20-40 years, recipient age >50 years), group C (donor age 40-60 years, recipient age <50 years), group D (donor age 40-60 years, recipient age >50 years), group E (donor age >60 years, recipient age <50 years) and group F (donor age >60 years, recipient age >50 years). Uni-variate analysis was used to assess the effect of donor and recipient age as predictive factors for graft outcome, using the Kaplan-Meier method (log-rank) with p < 0.05 considered significant. RESULTS: Graft survival was found to be lowest in elderly recipients and in patients with donor age >60 years. Renal function was superior using younger donors both in short and long term. The incidence of acute rejection was found to be lower in elderly donor group than in younger, although the difference was not statistically significant. CONCLUSION: Donor's higher age did not show significant impact on allograft survival although, kidney allografts demonstrated decreased short and long term renal function.

Leiomyoma of the female urethra-a rare tumor: case report and review of the literature.

Leiomyoma is a benign smooth muscle tumor which is rarely found in urethra. Only a handful of cases have been reported in the literature. We hereby report a case of urethral leiomyoma in a twenty-seven-year-old female who presented with intermittent hematuria. Mass was completely excised with a rim of normal tissue. Patient remained asymptomatic with no evidence of recurrence in followup.

Paired exchange kidney donation in India: a five-year single-center experience.

INTRODUCTION: Paired exchange kidney donation (PKD) is an evolving strategy for overcoming the barriers that confront patients with end-stage renal disease, when the only living potential donors who are willing to donate to them are deemed to be unsuitable as donors for them owing to an incompatibility of blood type, of HLA cross-match, or of both. In the PKD, the incompatibility problems with two donor recipient pairs can be solved by exchanging donors. Although PKD is increasing worldwide, we in India have not nearly reached the estimated potential of this modality. Herein, we have reported our results with a living donor exchange program in past 5 years. MATERIALS AND METHODS: Between March 2006 and June 2011, we performed 44 living PKD transplantations. All donor and recipient procedures were performed successfully. ABO incompatibility or positive lymphocyte cross-match were found in 20 pairs and 2 pairs, respectively. RESULTS: The mean recipient age was 42.5 years (range 33-59 years). The mean donor age was 38 years (range 31-56 years). At a median follow-up of 33 months (range 1-59 months), graft survival rate was 100 %. All patients have functioning grafts with a median serum Creatinine level of 1.13, 1.5, and 1.35 mg/dl at 3 month, 1 year, and 3 years, respectively. One patient died after 4 month of transplant due to pneumonitis with sepsis. Allograft dysfunction was not seen in any of the recipients. CONCLUSION: The PKD transplantation is a viable procedure medically and economically, which can be promoted in centers with a low deceased donor transplantation rate and a high number of incompatible related donors. We achieved excellent graft outcome by using the PKD transplantation program as an option to reduce the donor organ shortage.

A comparison of the effects of diltiazem and glyceryl trinitrate ointment in the treatment of chronic anal fissure: a randomized clinical trial.

PURPOSE: Anal fissure is a common problem affecting all age groups with an equal incidence in both sexes. Traditional surgical treatments, like manual anal dilatation or a sphincterotomy, effectively heal most fissures within a few weeks but such procedures may result in anal incontinence. In recent years, various medical therapies have been used for the treatment of chronic anal fissure without fear of incontinence. METHODS: Ninety patients with a symptomatic anal fissure were randomly divided into three groups. Group I was treated with 2% diltiazem ointment, Group II was treated with 0.2% glyceryl trinitrate (GTN) ointment, and Group III was kept as the control group. The improvement in the signs and symptoms, the time taken for healing, and side effects were recorded in each group. The patients were followed up monthly and then every 3 months for any recurrence of fissure. Comparative evaluations of the three groups regarding an improvement in symptoms, progress in healing, appearance of side effects, and recurrence were made using the Tukey HSD test. RESULTS: Diltiazem ointment was found to be superior regarding pain relief, fewer side effects, and late recurrence as compared with GTN ointment. CONCLUSION: Diltiazem ointment (2%) and GTN ointment (0.2%) are both effective treatment modalities for chronic anal fissure, with diltiazem giving better patient outcome.