Laparoscopic Retrograde Nephrectomy as a Troubleshooting Technique to Prevent Open Conversion: The Technique Description With a Review of 40 Cases.

Introduction Laparoscopic nephrectomies are safe, with low complication rates in skilled hands. However, traditional approaches may be unsuitable for conditions such as post-renal abscesses, long-standing urinomas, non-functioning kidneys post-pyeloplasty, pyelolithotomies, post-partial nephrectomy recurrences, tuberculous kidneys, pyelonephritis, and redo-renal surgeries. This study describes a modified retrograde nephrectomy technique and its outcomes in 40 cases. Methods We reviewed 40 cases where the retrograde nephrectomy technique was used. Surgeons opted for this method based on intraoperative findings and initial difficulties in accessing the lower pole area. Results Traditional dissection was challenging due to adhesions in the lower pole. The retrograde technique, starting from the renal hilum, allowed early ligation of renal arteries and veins, reducing bleeding risks and facilitating safer caudal dissection. Conclusions The retrograde nephrectomy technique offers a safer and more efficient alternative for complex nephrectomies. Early vascular control minimizes hemorrhage risk, making it a valuable method in challenging renal surgeries.

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.

The Impact of En-bloc Transurethral Resection of Bladder Tumour on Clinical, Pathological and Oncological Outcomes: A Cohort Study.

Background En-bloc transurethral resection of bladder tissue (ETURBT) has recently been proposed as a good alternative technique to trans-urethral resection of bladder tissue (TURBT) in terms of outcomes for bladder carcinoma. This study aims to assess the effectiveness of the technique in terms of clinical, pathological and oncological outcomes. Methodology In this prospective study, data was collected from patients who underwent ETURBT for bladder space-occupying lesions between June 2021 and June 2022. Demographic characteristics, tumour characteristics, and postoperative outcomes were recorded. Results A total of 52 patients were studied with the majority being male and a mean age of 50.87 years. Smoking was recorded in 22 (38.5%) patients and 8 (15.4%) were on antiplatelet therapy. The majority fell in the American Society of Anesthesiology (ASA) class I (59.6%). Most of the tumours were solitary (90.4%), primary (82.8%), papillary architecture (73.1%), and between 1-3 cm in size. The lateral wall was the most common position, and detrusor muscle was seen in 98.1% of the specimens. T1 stage (57.7%) and low grade (67.3%) were the common characteristics noted. 76.9% of the ETURBT was conducted using monopolar cautery. Recurrence was noted in 3 (5.8%) and bladder perforation in 1 patient (1.9%). Cautery artifact was seen in six patients (11.5%) and obturator jerk in nine patients (17.3%). Conclusion Our study suggests that ETURBT is a technique with a good success rate for bladder tumours less than 3 cm in size. The benefits include high chances of detrusor sampling while minimising crush artefacts and cautery damage. Specimen retrieval was challenging when the bladder tumour was solid and over 2 cm.

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.

Extragonadal mixed germ cell tumor of the seminal vesicle.

Primary malignancies of the seminal vesicles are rare. Presentation of extragonadal germ cell tumor in the seminal vesicle is even rarer. We report a case of a 26-year-old male who presented with hematuria and lower urinary tract symptoms, which on imaging turned out to be a right seminal vesicle mass. The diagnosis of mixed germ cell tumor with yolk sac tumor and teratoma was made on the initial evaluation by transrectal ultrasound-guided biopsy which showed the characteristic histomorphology and immunohistochemistry profile. The patient underwent chemotherapy followed by radical pelvic exenteration. The patient is doing well with no evidence of distant metastasis in positron emission tomography/computed tomography of 1-year posttreatment.

Non-urological cause of bilateral hydroureteronephrosis.

Bilateral hydroureteronephrosis in a patient with central diabetes insipidus is a rare condition. This rare presentation poses unique diagnostic and therapeutic challenges. Herein, we report a case of diabetes insipidus associated with bilateral hydroureteronephrosis and discuss its clinical and radiographic findings with a special focus on the urological aspects. Dramatic improvement, both clinically and radiologically, was seen after the administration of desmopressin therapy.

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.

A Prospective Study on the Efficacy of Cognitive Targeted Transrectal Ultrasound Prostate Biopsy in Diagnosing Clinically Significant Prostate Cancer.

PURPOSE: We present our study, done to identify the diagnostic yield of cognitive targeted biopsy using mpMRI data, to diagnose clinically significant prostate cancers, in a cohort of biopsy and treatment naive men. MATERIALS AND METHODS: This is a prospective, single institutional study, done from September 2018 to March 2020 in 75 biopsy naive men. The patients with 3, 4 and 5 PIRADS scores underwent mpMRI cognitive target biopsy (mpMRI CTB) followed by standard biopsy (SB) in the same setting by two different urologists. Diagnostic yield of biopsy cores, complications, and stage migration of Gleason's grades was analyzed. RESULTS: Out of 75 patients, 34.6% had abnormal digital rectal examination (DRE), and the median serum PSA was 10.6 (4.5-20) ng/mL. Total MRI suspicious lesions were 163. Out of 1263 SB cores, 371 cores were positive for cancer (29.35%), and out of 326 mpMRI CTB cores, 120 were positive for cancer (36.8%) (P<0.0001). Histopathological examination (HPE) revealed 88%, 92%, and 100% clinically significant cancers in PIRADS 3, 4 and 5 lesions. SB and mpMRI CTB in combination have better cancer detection yield than either of the modality when used alone (P-<0.0001). Clavien-Dindo grade 1 and grade 4a complication were seen in 47 (62.6%) and three (4%) patients. CONCLUSION: In biopsy-naive men with suspected prostate cancer and equivocal DRE, the addition of pre-biopsy mpMRI detects greater numbers of people with clinically significant prostate cancer when compared with SB alone. Combining SB with mpMRI CTB has a superior diagnosing ability when compared with either of the biopsy modalities when used alone.

Day-case robot-assisted laparoscopic surgery: Feasibility and safety.

OBJECTIVE: The delivery of surgical services has undergone a shift in the past decade with increasing numbers of surgeries being performed in the daycare setting. Implementing a minimally invasive surgical approach with a robot with an enhanced recovery protocol permits robot-assisted laparoscopic surgeries (RALS) to be performed as a day-case (DC) procedure. This study aimed to assess the feasibility and safety of DC surgery according to our experience. MATERIAL AND METHODS: In this prospective observational study, 43 patients underwent DC RALS performed by a single surgeon over 18 months [simple nephrectomy (n=7), radical nephrectomy (n=15), radical nephrectomy with para-aortic lymphadenectomy (n=5), and adrenalectomy (n=5)]. In addition, reconstructive urological procedures that included pyeloplasty (n=9), ureteroureterostomy (n=1), and bladder diverticulectomy with ureteric re-implantation (n=1) were performed as DC surgeries during this study period. RALS was performed in the standard way with an enhanced recovery pathway of care for DC. We collected data regarding the demographic information, medical comorbidities, preoperative outcomes, intraoperative outcomes, complications, length of stay, and readmission rates. The data were analyzed and evaluated. RESULTS: All the patients (100%) were successfully discharged on the same day with no major complications (Clavien-Dindo grade>I). The readmission rates were 0%. CONCLUSION: DC RALS are safe and feasible with an enhanced recovery protocol. With adequate protocols in place, these surgeries might prove to be better than the available minimally invasive techniques and can become the standard of care in the future.

In situ Management of Large Upper Ureteric Calculus by Mini-Percutaneous Nephrolithotomy in the Era of Retrograde Intrarenal Surgery.

PURPOSE: The aim of the study is to demonstrate the ease and success of in situ management of large upper ureteric stones with mini percutaneous nephrolithotomy (PCNL). METHODS: This was a prospective observational study conducted in the Department of Urology between January 2018 and June 2019. All patients underwent standard prone mini PCNL with 15Fr amplatz with 80 cases of fluoroscopic and 12 cases of ultrasound guided access. In three cases of tortuous ureters, wire was passed via retrograde catheter and retrieved via amplatz to straighten the ureter. Calculi fragmented with laser. RESULTS: A total of 77 patients were included in this study, 62 unilateral and 15 bilateral cases (92 renal units). The mean age was 45.4±13.7 years (range 17-71), male to female ratio was 61:16, the disease laterality (left: right) was 28:34. The mean stone size was 17.6±1.4 mm. Mean operative time was 22.4±1.5 min. 88% patients were discharged as day care. Complication rate was 6.5%, three patients had transient fever and two patients had distal migration of small fragments and they were extracted at the time of DJ stent removal by rigid ureteroscopy (100%). CONCLUSION: We conclude that it is easy and effective to deal with large upper ureteric calculus when it is in a fixed position. In situ management of large upper ureteric calculus by mini-PCNL can be done safely and effectively as it is a fast procedure, prevents unnecessary manoeuvres, less complication rates and has good stone clearance rates.

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).