Bilateral simultaneous laparoscopic adrenalectomy in Cushing's syndrome: safe, effective, and curative.

INTRODUCTION: Surgical morbidity and mortality rates are high in patients with Cushing's syndrome. Nevertheless, simultaneous bilateral laparoscopic adrenalectomy (LA) is feasible in these patients with less morbidity and good long-term results. BACKGROUND AND RESULTS: Consecutive 22 patients who underwent LA for Cushing's syndrome between 2003 and 2010 in our institute were retrospectively studied. Ninteen patients underwent bilateral simultaneous and three underwent unilateral LA. Seven patients had Cushing's syndrome after failed pituitary surgery and five each had ectopic adrenocorticotrophic hormone dependent syndrome and bilateral macronodular hyperplasia respectively. LA was bilaterally done by lateral transabdominal adrenalectomy in 15 patients and retroperitoneal endoscopic adrenalectomy in 4 on the right side. Mean operative time for simultaneous bilateral cases was 199.45±72.43 minutes with mean blood loss of 72.72±48.6 mL. Patients were fit for discharge by the fifth postoperative day from the surgical aspect. Surgical complication rate was 26% that included wound infections in two, port site hernia, pleural effusion, and atelectasis in one each. One patient died of sepsis (5% mortality). Satisfactory metabolic control was achieved in all observable patients in the long term although Addisonian crisis and Nelson syndrome were seen in 26% and 15% respectively. CONCLUSION: LA has all advantages of minimal access surgery in patients with Cushing's syndrome who are immunocompromised and at high risk of delayed wound healing and infections. Magnification decreases the risk of retained adrenal remnants. Despite advances in minimal access surgery, perioperative morbidity continues to be significant for the procedure.

Nephroscope in the management of recurrent pyogenic cholangitis.

Several minimally invasive procedures have been successfully used for removal of stones from the hepatobiliary system. We describe an innovative interventional radiologic procedure using rigid urologic instruments within the hepatobiliary system. Stones within the hepatic and bile ducts in a patient with recurrent pyogenic cholangitis were removed by a technique resembling percutaneous nephrolithotomy for renal stones.

Laparoscopic adrenal surgery in children: Lessons from a single centre experience.

PURPOSE: Although commonly performed in adults, laparoscopic adrenalectomy in children is performed only in centres with advanced laparoscopic expertise. MATERIALS AND METHODS: This is a retrospective analysis of laparoscopic adrenalectomies performed at a single centre between January 2003 and May 2010. After preoperative evaluation with biochemical assays and radiologic imaging, surgery was performed by using the lateral transabdominal approach in all patients. RESULTS: Ten laparoscopic adrenalectomies (including three bilateral) were performed in seven children, with a mean age of 9.6 years. The tumours ranged from 2 - 7 cms in size. The operative durations were 75 - 130 minutes (unilateral) and 250 - 270 minutes (bilateral). Operative blood loss was minimal. There were no open conversions, but terminal hand assistance was required in one large right pheochromocytoma. The postoperative hospital stay ranged from 3 - 10 days. The final pathological diagnoses included pheochromocytoma, hyperplasia and neuroblastoma. Follow-up at 24 - 87 months was uneventful. CONCLUSION: With adequate experience in laparoscopy, it is possible to perform adrenalectomy in selected children.

Thoracic curlicue: A case of ureteral herniation.

Isolated herniation of ureter into thoracic cavity due to a defect in the diaphragm is a very rare entity. We present clinical details and radiographic images of an incidentally detected herniation of right ureter into the thorax in an elderly lady with no previous history of trauma or urinary tract symptoms. This acquired but asymptomatic condition is confirmed by radiologic imaging that reveals the classical loop configuration which is described as the curlicue sign. Further evaluation had revealed mild renal failure but with no definite evidence of obstruction. In view of age and asymptomatic status, patient was offered non-surgical management.

Prospective analysis of psychological distress in men being investigated for prostate cancer.

OBJECTIVES: To determine the level and prevalence of anxiety and depression in men being investigated for prostate cancer (CaP) and also to identify those aspects of the diagnostic pathway that induces the most stress. MATERIALS AND METHODS: All patients undergoing transrectal ultrasound-guided biopsy (TRUS-B) of the prostate for suspected CaP at our institute between June 2008 and April 2009 were enrolled in this prospective study. All patients completed two questionnaires, prior to their biopsy (HADS1) and before receiving results (HADS2), containing the Hospital Anxiety and Depression Scale (HADS). The data were analyzed and the differences in HADS were compared. RESULTS: A total of 112 men were included in the trial. Two patients could not complete the second part of HADS (HADS2) and were excluded from the study. Prevalence of anxiety among the 110 patients was 43/110 (39.1%). Mean score for anxiety in these 43 patients before biopsy (HADS A1) was 10.74 and score just before receiving the biopsy report (HADS A2) was 11.55. Prevalence of depression before TRUSB (HADS D1) was 21/110 (19.1%) with a mean score of 10.59. Prevalence of depression while awaiting the biopsy report (HADS D2) was 22/110 (20%) with mean score of 10.62. CONCLUSION: There was a high prevalence of anxiety and depression in our study population and waiting for biopsy results was the most stressful event. Questionnaires such as HADS can identify patients with psychological distress. Minimizing the stress while waiting for a diagnosis should help optimize patient care.

Revisiting the double-barreled wet colostomy for simultaneous urinary and fecal diversion--an Indian experience.

Pelvic exenteration in advanced malignancies is usually a curative procedure aimed at improving quality of life. We analyzed the perioperative data and outcomes in 12 patients who underwent simultaneous urinary and fecal diversion with a double-barreled wet colostomy after total pelvic exenteration. Eight males and four females aged between 25 and 73 years underwent the procedure with mean operative duration of 350 min and mean postoperative stay of 15 days. Three patients developed early complications while four developed late complications. During follow up ranging from 6 to 64 months, four patients died of disease progression while four died of unrelated causes. One lady was lost to follow up, the remaining had a mean survival of 32.9 months. None had deterioration in renal function or peristomal dermatitis and all were well accustomed to managing one stoma. Our results show that double-barreled wet colostomy is technically simple and reduces surgical morbidity while providing satisfactory outcomes and patient comfort.

Adult presentation of congenital ectopic vas deferens insertion into ureter with unilateral renal agenesis.

Congenital vas deferens-ureteral connection is known to cause epididymitis and scrotal infections in infancy and childhood. Embryologically, the anomaly results from an abnormal high origin of the ureteric bud on the mesonephric duct with a resultant long common excretory duct being incompletely absorbed into the bladder. This report describes a rare adult presentation in a 20-year-old man where evaluation with ultrasonograms, isotope renogram, magnetic resonance imaging scans and cystoscopy with retrograde instillation of contrast into the right ureter confirmed aberrant insertion of vas deferens into the ureter associated with ureterocele and ipsilateral renal agenesis.

Concomitant laparoscopic urological procedures: Does it contribute to morbidity?

AIM: With advancement in minimal access surgery two laparoscopic procedures can be combined together shortening the total hospital stay, decreasing morbidity and overall reduced cost. Combining two laparoscopic procedures in a single session has been reported in general surgery. Very few articles are available in literature with regard to combined urological laparoscopic surgeries. This article retrospectively analyses the outcomes of multiple laparoscopic procedures performed in a single stage at our centre. MATERIALS AND METHODS: Patients undergoing simultaneous procedures from May 2003 to Jan 2009 were included in the study. Patients were categorised into three groups according to the primary urological organ involved, for better comparison with the control group. Diseases involving the adrenals gland were grouped in (group 1), kidney (group 2) and renal collecting system/ureter (group 3). All patients had one urological procedure for either of the above-mentioned organs combined with another surgical procedure. Similarly three control groups were chosen according to the primary urological organ involved (group 1c- unilateral laparoscopic adrenalectomy, group 2c- unilateral laparoscopic radical nephrectomy and group 3c- unilateral laparoscopic ureterolithotomy) for comparative study. The operative details, hospital stay and complications were analysed. RESULTS: Thirty-two patients underwent 64 laparoscopic procedures under single anaesthesia. The most common procedure in this series was laparoscopic adrenalectomy (n=34) followed by laparoscopic nephrectomy (n=13). Group 1 patients had a prolonged operative time ( P=0.012) and hospital stay ( P=0.025) when compared with group 1c. However, blood loss was comparable in both the groups. Patients in groups 2 and 3 had comparable operative times, blood loss and recovery period with respect to their controls. Intraoperatively, the end tidal carbon dioxide levels were within permissible limits. All procedures were completed using the laparoscopic approach, without any conversion. CONCLUSIONS: Simultaneous laparoscopic procedures can be done for urological diseases in selected patients with the advantages of single anaesthesia and hospital admission without increasing the morbidity.

Laparoscopic assisted dismembered pyeloplasty in children: intermediate results.

To study the results of an innovative minimally invasive technique of performing dismembered pyeloplasty in children. Using 5 mm camera and 3 mm working ports, the ureteropelvic junction (UPJ) is mobilized by a transperitoneal laparoscopic technique. The UPJ is brought out through a tiny flank incision and a standard dismembered pyeloplasty is performed over a double J stent. Between October 2003 and January 2005, 13 children underwent laparoscopic assisted dismembered pyeloplasty. Indications, operative duration, hospital stay, preoperative and postoperative isotope renogram parameters were analyzed. The children were in the age range of 3 months to 6 years-three were right sided and ten were left sided. Only three were symptomatic while the remaining ten were detected to have UPJ obstruction during evaluation for antenatally detected hydronephrosis. Mean operative duration was 104.2 min (range 80-150 min) with no significant difference in the two patients with crossing vessels. Incision was smaller than 2 cms in all and the average postoperative hospital stay was 3.2 days (range 2-5 days). Follow-up ranging from 28 to 44 months showed reduction in hydronephrosis and improvement in renal function of all the operated units. Isotope renogram in only one patient showed equivocal slopes and prolonged half clearance times though no further surgical intervention was required. This technique has results comparable to that of open pyeloplasty and hence, maybe considered a good option for surgeons making the transition to laparoscopic pyeloplasty.

Supracostal access for percutaneous nephrolithotomy: less morbid, more effective.

OBJECTIVES: The aim of this research was to study the success and morbidity of supracostal access for percutaneous nephrolithotomy (PCNL), as it is often avoided for fear of complications. MATERIALS AND METHODS: Between July 2000 and May 2007, 565 patients underwent PCNL, of whom 110 had a supracostal access. All procedures were performed in a single sitting under general anesthesia. Data were analyzed prospectively for indications, stone clearance rates, and preoperative and postoperative complications. RESULTS: Indications for supracostal access included large pelvic stones in 39 patients, partial or complete staghorn stones in 32, calyceal stones with major stone bulk above the level of 12th rib in 35, and upper ureteric stones in four. Patients' ages ranged between 13 and 71 years (mean 44.2 years). Fifty-six cases were left sided and 54 right sided, whereas 103 (93.6%) were radiopaque stones. All tracts were in the 11th intercostal space, though one had an additional tract in the tenth space. Single-tract access was used in 101 cases (91.8%), but nine (8.2%) required a second tract. Overall stone clearance rate with PCNL monotherapy was 86.4%, and this increased to 97.3% with secondary procedures. Overall complication rate was 11.8% and included hydrothorax/hemothorax in ten, perinephric collection in one, infection/sepsis in two, and excessive bleeding in two. Postoperative hospital stay ranged from 2 to 15 days. CONCLUSIONS: The supracostal approach gives high stone clearance rates with acceptable morbidity rates and should be attempted in selected cases. Complications when present may be managed easily with conservative measures.

Laparoscopic adrenalectomy --- is it any different in phaeochromocytoma and non-phaeochromocytoma?

BACKGROUND: Laparoscopic adrenalectomy (LA) for phaeochromocytoma is a feasible, safe and effective treatment. The effects of associated catecholamine release render LA more challenging, although with comparable morbidity to LA for other diseases of the adrenal gland. METHODS: Data from case records of 44 patients who underwent LAs between May 2002 and May 2006 were analysed retrospectively. The patients were divided into a phaeochromocytoma group (Group I) and a non-phaeochromocytoma group (Group II). The aim of this study was to assess the operative course and outcome of LA in the two groups. RESULTS: The mean operating time and blood loss were slightly higher in LA for phaeochromocytomas compared to LA for other pathologies, but these differences were not statistically significant. The mean hospital stay was 3.84 days in both groups. The phaeochromocytoma group had a slightly higher complication rate of 21% compared to 12%. None of the procedures needed open conversion. A terminal hand assist was employed in two patients in Group I and one patient in Group II. Two patients with bilateral phaeochromocytoma had single stage bilateral LA. CONCLUSION: LA is feasible and effective in phaeochromocytoma. It is associated with a slightly longer operating time, more blood loss and complications when compared with non-phaeochromocytoma masses. LA can be done in a single operation for bilateral masses. Terminal hand assist is a viable and effective option for very large masses.

Solitary fibrous tumour of prostate: evaluation and management of a rare tumour.

Solitary fibrous tumours, which are commonly described as arising from the pleura, are rarely seen in the lower urinary tract. Although malignant changes have been reported, these tumours are usually benign. This case report discusses the radiological features, management strategy and histopathology of a solitary fibrous tumour arising from the prostate.

Azathioprine-induced squamous cell carcinoma of the kidney.

Immunosuppressive therapy with azathioprine has been documented to cause squamous cell carcinoma (SCC) at various sites. We report possibly the first case of SCC of the kidney in a young male who received azathioprine for a long time. Discontinuation of azathioprine post-radical nephrectomy probably increased the patient's metastatic disease-free survival.

Laparoscopic adrenalectomy is feasible for large adrenal masses>6 cm.

OBJECTIVE: Laparoscopic adrenalectomy (LA) has become the established procedure for adrenal masses less than 6 cm. The role of LA for large adrenal masses is well defined to a lesser extent. METHODS: Thirty-six LAs were performed in 32 patients (including four patients with single stage bilateral adrenalectomies) over a period of 3 years, from May 2002 to 2005. Patients were divided into two groups based on the tumour size, i.e. masses less than 6 cm (group I) and masses 6 cm or more (group II).The results with respect to mean (95% confidence interval) operative time, blood loss, postoperative course and complications were compared. RESULTS: Group II included 11 LAs performed in 10 patients including one bilateral LA for bilateral phaeochromocytomas in multiple endocrine neoplasia 2A. The mean size (+/-standard deviation) of masses was 8 cm (+/-1.47). In comparison, 22 patients in group I underwent 25 adrenalectomies (including three bilateral single stage procedures for Cushing's syndrome). The mean size of masses was 4.1 cm (+/-1.27). There were eight and six phaeochromocytomas in groups I and II, respectively. By comparing groups I and II, only minimal increase in blood loss and operating time was noted with no significant difference in hospital stay and morbidity. Two cases required conversion to hand assistance towards the end of the procedure in view of their large size. CONCLUSION: LA is the procedure of choice for small adrenal masses but is also feasible for large functioning and nonfunctioning adrenal masses with equally good results. Even bilateral large functioning tumours can be treated safely by LA in a single stage when sufficient experience with the procedure is attained.

Bilateral nephron sparing surgeries for multiple renal angiomyolipomas in Bourneville's disease.

INTRODUCTION: Angiomyolipomas are the most common renal lesions in tuberous sclerosis complex. When symptomatic, the treatment includes nephron sparing surgery. This is especially challenging when the lesions are bilateral, large and multiple. CASE-HISTORY: A 22-year-old lady with bilateral multiple large symptomatic renal angiomyolipomas associated with other manifestations of tuberous sclerosis was managed with partial nephrectomies on either side. At 30 months of follow-up, the patient has normal renal functions and no evidence of recurrence. DISCUSSION: Intervention for renal angiomyolipomas is indicated in symptomatic tumors larger than four centimetres. Selective arterial embolisation is the therapeutic modality of choice in such cases. However, in bilateral cases when angioembolisation may not always be feasible, nephron sparing surgery maybe considered. Nephron sparing surgery of both kidneys for angiomyolipomas in association with tuberous sclerosis has only been sparingly reported in literature.

Successful surgical correction of true diphallia, scrotal duplication, and associated hypospadias.

A 1-year-old child with complete duplication of penis presented with continuous dribbling of urine. Examination revealed hypospadias of 1 penis and a duplicated scrotum with 2 normal testes. Cystourethrogram revealed a single bladder with a normal urethra in the dorsally placed phallus and ectopic insertion into the bladder of the ventral urethra. Abnormality was corrected by excision of the ventrally located penis bearing the ectopic urethra. The preputial skin of this ventral penis was used to repair the hypospadias of the dorsal penis. The case is being reported in view of its rarity and the successful surgical correction.

Schwannoma of the penis: a common tumour at a rare site.

Schwannoma is a benign tumour arising from neurilemmal cells and is commonly seen along cranial nerves. We describe the case history and histologic findings of a young adult with a schwannoma at a very rare site: the penis. Surgical excision was done and the patient remains disease-free after 2 years.