Is percutaneous nephrolithotomy safe in chronic kidney disease patients!!!

Introduction: Management of renal calculus in a patient of chronic kidney disease (CKD) is always challenging. Treatment options include extracorporeal shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy (PCNL). With PCNL being gold standard for renal calculus ≥1.5 cm in normal kidneys, we aimed to analyze the safety and efficacy of PCNL in CKD patients with calculus ≥1.5 cm. Materials and Methods: Sixty patients of CKD with renal calculus were included in the study: Group A with glomerular filtration rate (GFR) ≤30 ml/min/m2 and Group B with GFR >30 <60 ml/min/m2. The estimated GFR (eGFR) pre-PCNL, peak eGFR on follow-up, and eGFR at last follow-up, stone free rates, and complications were recorded. The CKD stage before and after PCNL were also compared at the last follow-up. Results: The mean age of patients was 52 years. A mean of 1.14sittings per renal unit was required for PCNL. Complete clearance was 94% after all auxiliary procedures. The mean prePCNL eGFR was 26.5 ± 4.01 and 43.6 ± 9l. 14 ml/min/1.73 m2 in Groups A and B, respectively. The mean post-PCNL eGFR was 32 ± 9.94 and 51 ± 8.85 ml/minute/1.73 m2, respectively, in Groups A and B. At a mean follow-up of 180 days, deterioration with the migration of CKD stage was seen in 13 patients (21.6%) out of which 10 patients were of Groups A and 3 in Group B. Six patients (10%) required maintenance hemodialysis. Postoperative bleeding complication requiring blood transfusions was seen in 12 (20%) and 3 (5%) required intensive care unit care postoperatively. No mortality was observed in our study. Conclusion: PCNL is an effective management strategy for renal calculus in patients with CKD with an acceptable stone clearance rates and manageable complications. Peak eGFR <30 ml/min/m2 and postprocedure complications predict deterioration and need for RRT.

Urodynamic profile of lower urinary tract symptoms in young men: A testimony of the truth?

Aim: To evaluate the impact of urodynamic study (UDS) in the management of young men presenting with lower urinary tract symptoms (LUTSs). Materials and Methods: This is a retrospective, observational study of urodynamic findings of 128 patients presented with LUTS at the Department of Urology, Institute of Nephrourology, Bangalore, over a period of 5 years (August 2014 to July 2019). Pre- and post-UDS diagnoses as well as treatment modalities were compared to evaluate the usefulness of UDS. Results: A total of 110 patients (86%) had abnormal UDS findings. Before UDS, 55 (43%) patients were clinically diagnosed for overactive bladder; after UDS, bladder outlet obstruction (BOO) was seen in 32 (25%) patients and detrusor overactivity in 18 (14.1%). Clinically, BOO was diagnosed in 36 (28.1%) patients; however, urodynamic findings of BOO were seen only in 23 (18%) patients. Pre-UDS, bladder underactivity was suspected in 23 (18%); however, underactive detrusor was noted in 20 (15.6%) patients, and 3 (2.4%) patients were normal on UDS. Post-UDS, antibiotics were not prescribed to anyone. 18 (14%) patients underwent surgery after UDS confirmation of BOO. 67 patients (52.3%) had their clinical diagnosis changed following UDS. Concomitant changes in the management were required for 59 patients (46%). Conclusion: Etiologies of LUTSs in young men are more varied. Clinical diagnosis and treatment are often empirical and inaccurate. UDS is useful to achieve accurate diagnosis and to guide appropriate treatment. Video urodyanamics should be used to evaluate LUTS in young men.

Is simple nephrectomy the right nomenclature? - Comparing simple and radical nephrectomy to find the answer.

Introduction: The word "simple" means "easily done" or "presenting no difficulty." Hence, the "Simple Nephrectomy" (SN) operation should be "easy to perform." However, in clinical practice, we have noticed that SN can be equally or more challenging surgery than radical nephrectomy (RN). This study assesses the need to modify the terminology of simple nephrectomy and identify the level of difficulty between SN and RN by comparing various intraoperative and postoperative factors. Methods: Patients undergoing open SN for benign renal disease (Group A) and RN for T1/2 renal tumors (Group B) were included in the study. Two groups were compared for operative time, estimated blood loss, postoperative complications, blood transfusion rate, and length of hospital stay. Results: A total of 114 patients were analyzed (82 in Group A and 32 in Group B). Mean age of the patients was higher in Group B (41.2 vs 53.6 years, P < 0.01). Mean operative time (136.8 vs 125.5 min, P = 0.08), incidence of postoperative complications (32.9% vs 25%, P = 0.50), length of hospital stay (7.2 vs 6.5 days, P = 0.09), estimated blood loss more than 500 ml (13.4% vs 9.3%, P = 0.75), and requirement of blood transfusion (10.9% vs 6.2%, P = 0.72) were higher in group A. Conclusion: The application of correct terminology is important to understand the subject and to convey the information. Simple nephrectomy is not an appropriate term as it is equally challenging to perform than its radical counterpart.

A comparative study of minimally invasive percutaneous nephrolithotomy and retrograde intrarenal surgery for solitary renal stone of 1-2 cm.

BACKGROUND: PCNL is the treatment of choice for renal stones. But wide array of complications due to larger tract size(>20 Fr) has lead to development of improved techniques like miniPCNL(<20 Fr) and RIRS(Retrograde intrarenal surgery). AIM AND OBJECTIVE: To perform a study comparing miniPCNL with RIRS for renal stones 1-2 cm with respect to stone free rate , complications and quality of life. MATERIALS AND METHODS: A prospective, randomised study was carried out our tertiary care centre, recruiting 40 patients in each group from Dec 2016 to Oct 2018. Patients demographic characteristics, operative findings, surgical outcomes and quality of life( SF-36 questionnaire) were recorded with 3 months of follow-up. RESULTS: RIRS has longer operative time (69.75 min > 51.58 min; p=0.003), lesser radiation exposure (p=0.012), shorter hospital stay (p =0.15), lesser blood loss and lesser post operative pain on POD1 and POD2 (p =0.005, p=0.001 respectively). RIRS group patients sufferred more post op complications (p=0.03 )of which urosepsis was most common. Stone free rate is significantly better(p =0.003) in miniPCNL group on POD1 , while SFR's at 1 month (miniPCNL-90% and RIRS -85%) and 3 month (miniPCNL- 92.5% and RIRS -87.5%) was better in miniPCNL group, but statistically insignificant.On subgroup analysis SFR in lower pole calculus was better in miniPCNL group at 1month and 3 month (p=0.008). Second intervention for stone clearance was required in 3 patients of miniPCNL and 5 patients of RIRS, out of which 4 had lower pole stone.No significant differnce was found in quality of life in both groups at 1 month. CONCLUSION: MiniPCNL is a better treatment modality for higher single step stone free rate, shorter operative time and fewer postop complication. RIRS has SFR slightly less than miniPCNL but has less radiation exposure and much less post operative pain. There is no significant difference in quality of life in both groups.

Evaluation of Testicular Workup for Ischemia and Suspected Torsion score in patients presenting with acute scrotum.

BACKGROUND: Testicular torsion is one of the causes of acute scrotum and it requires timely evaluation and surgical treatment. Color Doppler is considered investigation of choice, but it may delay treatment, as, many times, it may not be available for emergency situations. Barbosa et al. created Testicular Workup for Ischemia and Suspected Torsion (TWIST) score based on clinical parameters for clinical diagnosis of testicular torsion. We have evaluated this score in our population. MATERIALS AND METHODS: We retrospectively calculated TWIST score in patients of acute scrotum admitted to tertiary teaching institute. Patients without complete TWIST score were excluded from the study. The scoring system consisted of testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1), and high-riding testis (1). Statistical analysis was done to evaluate the validity of scores. RESULTS: A total of 118 patients were included in the study, out of which 45 (38%) patients had testicular torsion. The mean age of patients was 16.6 years in testicular torsion patients and 15.2 years in other patients. Cutoff for low-risk and high-risk patients was two and five, respectively. Fifty percent, 26.2%, and 23.8% of patients were present in low-, intermediate-, and high-risk groups. Negative predictive value of TWIST score for low-risk patients was 96.61% while positive predictive value for high-risk patients was 92.86%. CONCLUSIONS: TWIST score has high predictive value and can be used for clinical diagnosis of testicular torsion. It can decrease the need of color Doppler in about 50% of cases and can prevent delay in treatment.

Laparoendoscopic single-site surgery in urology using conventional instruments: our initial experience.

PURPOSE: To present our initial experience with laparoendoscopic single-site (LESS) urologic surgery using conventional laparoscopic instruments and to assess its feasibility and safety. PATIENTS AND METHODS: In 20 patients, we performed LESS urologic surgery, which included simple nephrectomy in 9, nephroureterectomy in 1 for a refluxing nonfunctioning kidney, radical nephroureterectomy in 1, heminephroureterectomy in 1 for a nonfunctioning upper moiety in a complete duplex kidney, marsupialization of a renal cyst in 1, ureterolithotomy in 1, varicocelectomy in 2, pyeloplasty in 2, vesicovaginal fistula (VVF) repair in 1, and orchiopexy in 1. LESS was performed using a small periumbilical incision, inserting regular trocars, and using a conventional 30-degree laparoscope and laparoscopic instruments. Data were collected prospectively with respect to feasibility, intraoperative or postoperative complications, postoperative pain, analgesic requirement, and recovery. RESULTS: Since March, 2012, a total of 20 patients have undergone LESS for various urologic conditions. All cases were completed successfully, without conversion to a standard laparoscopic or open approach. The total operative time for the nephrectomy, nephroureterectomy, pyeloplasty, VVF repair, ureterolithomy, varicocelectomy, or orchiopexy was 134 ± 20.06, 186 ± 40, 135 ± 21, 180, 150, 55, and 60, minutes, respectively. The mean blood loss was 100 mL. No intraoperative complication occurred. The mean pain score on the visual analog scale was 8.35 ± 0.9 (8-10) on day 1, 4.8 ± 1.6 (2-8) on day 2, and 2 ± 1.2 (2-4) on day 3. Similarly, the mean analgesic requirement was 220 ± 41 mg, 85 ± 74 mg, and 30 ± 47 mg of intravenous tramadol, respectively. One patient had surgical emphysema of the abdomen and another had ileus for 4 days. The mean hospital stay was 2.9 ± 1.7 (2-7) days. CONCLUSION: In selected patients, LESS for urological indications using conventional laparoscopic instruments is safe and feasible with no added cost. Additional experience and continued investigation are warranted.