Total ablative stereotactic body radiotherapy to primary and oligometastatic renal cell carcinoma in medically inoperable cases: An institutional analysis.

Introduction: Stereotactic body radiotherapy (SBRT) has been found to be an effective and safe modality with excellent oncological outcome in medically inoperable primary renal cell carcinoma (RCC) and oligometastases. There is scarcity of data on the synchronous delivery of SBRT to primary and oligometastatic RCC in patients unfit for nephrectomy. Here, we report the findings of a retrospective study of prospectively collected data on "total ablative SBRT." Methods: Oligometastatic RCC patients with intact primary tumors were enrolled between May 2021 and June 2022. SBRT was synchronously delivered to the primary tumor and metastases. Demographics, treatment, oncologic outcomes, and toxicity were assessed. Kaplan-Meier estimates were generated for oncologic outcomes. The primary endpoint of this study was feasibility and tolerability. Results: Eleven patients were enrolled between May 2021 and June 2022. One patient died at 2 months after SBRT due to viral pneumonitis (possibly COVID pneumonia). Nine patients (82%) had metastatic disease, while 2 (18%) were stage II. The average maximal diameter of primary was 68.7 mm (range, 23-128 mm). The SBRT doses for primary and metastasis ranged from 40 to 55 Gray (Gy) in 5 to 7 fractions and 22 to 40Gy in 2 to 5 fractions, respectively. The median follow-up period was 10.5 months (Range: 4-15 months). Response assessment was available for ten patients. Local control, marginal control, regional control and initial oligometastatic control (OMC) rates were 100%. OMC declined to 87.5% as one patient had recurrence in irradiated subcarinal lymphnode at 7 months. The metastatic control rate was 80% and loco-regional progression-free survival was 8 months (range, 4-15 months). Toxicities were minimal and manageable. At the last follow-up, 7 of 11 patients were alive with an overall survival of 63.5%. Six patients received systemic therapy after SBRT. Conclusions: Synchronous delivery of SBRT to primary and oligometastatic sites in patients unfit for nephrectomy was feasible and tolerable with good locoregional control. The total ablative SBRT strategy needs to be explored in similar cohorts.

Nephroureterectomy with inferior vena-caval thrombectomy in post-chemotherapy Wilms' tumour in a child - From the eyes of the surgeon!

INTRODUCTION: Intracaval extension is present in 4-11% of all Wilms' tumour (WT). We present the open surgical nuances of inferior vena cava (IVC) thrombectomy with nephroureterectomy in post-chemotherapy WT. METHODS: A 10-year-old girl with right WT and intracaval tumour thrombus presented for surgical resection after six cycles of chemotherapy (vincristine, actinomycin D). A preoperative assessment plan of the vascular anatomy of the tumour was done. Meticulous intraoperative handling of the tumour mass, overcoming chemotherapy-induced fibrosis during inter-aortocaval groove dissection, optimal hemodynamic control during venotomy, en bloc resection of tumour with intracaval thrombus, and repair of the IVC are detailed. RESULTS: A 70 × 65 × 30 mm right renal mass with 20 × 10 × 4 mm level II IVC thrombus was excised en bloc. The intraoperative blood loss was 250 mL, operative time was 220 min, and total hospital stay was 7 days. The child completed post-surgical chemotherapy as per protocol. CONCLUSIONS: There is a paucity of literature regarding techniques for resection of WT with IVC extension in post-chemotherapy patients. With erudite preoperative planning and fine intraoperative dissection, complete resection of WT with intracaval thrombus is feasible with minimal blood loss and rapid postoperative recovery.

Gunshot Injury of Pelvi-Ureteric Junction: Management by the Rendezvous Technique.

Background: Gunshot injury of ureter is common, but isolated injury of pelvi-ureteric junction (PUJ) has not been reported. Moreover, its management is evolving from the traditional urinary diversion, stenting followed later by definitive surgical repair to a more upfront minimally invasive endourologic approach. Case Presentation: An adolescent boy presented with gunshot laceration injury of left PUJ with associated small intestinal injury. Radiological investigations confirmed a contained urinary leak. Retrograde stenting was not effective. The same guidewire was retained into the urinoma and an antegrade percutaneous access was obtained. A snare was used to retrieve the guidewire and obtain a through and through access. A ureteropelvic drainage catheter was inserted over this guidewire and secured in the upper ureter, bypassing the region of injury. Three weeks later, the drainage tube was removed and the same tract was used for antegrade stenting. A retrograde pyelogram done 3 months later during stent removal demonstrated no leak. The patient is asymptomatic for urinary symptoms on 6 months of follow-up. Conclusion: Rendezvous technique is a feasible alternative to open repair of gunshot pelvi-ureteric junction injury. Long-term follow-up is awaited.

Stepwise case selection using Guy's stone score reduces complications during percutaneous nephrolithotomy training.

INTRODUCTION: Traditional percutaneous nephrolithotomy (PCNL) training involved subjective award of cases to the trainee. We restructured this according to the Guy's stone score (GSS) such that each trainee stepwise completed 25 cases of each grade before progressing. This study compares the outcomes of training with traditional versus stepwise approach. METHODS: Four hundred consecutive cases equally distributed for two trainees in each group were compared in terms of complications (Clavien-Dindo), stone free rate (SFR), operative and fluoroscopy time. External comparison was also done against a benchmark surgeon. Multivariable regression model was created to compare SFR and complications while adjusting for comorbidity, Amplatz size, access tract location, number of punctures, body mass index, stone complexity, and training approach. RESULTS: The distribution of cases in terms of calculus complexity was similar. Overall, in comparison to traditional training, stepwise training had significantly shorter median operative time (100 vs. 120 min, P < 0.05), fluoroscopy time (136 vs. 150 min, P < 0.05) and fewer overall (29.5% vs. 43.5%, P < 0.005) as well as major complications (3% vs. 8.5%, P - 0.029), though initial SFR was higher but not statistically significant (77% vs. 71.5%). On multivariable analyses, stepwise training was independently associated with lower complications (odds ratio 0.46 [0.20-0.74], P - 0.0013) along with GSS grade, number of punctures, and Amplatz size. Stepwise training had similar fluoroscopy time, major complications and final clearance rate compared to expert surgeon. CONCLUSIONS: PCNL has a learning curve specific for each grade of calculus complexity and stepwise training protocol improves outcomes.

Giant Sarcomatoid Carcinoma with Osseous Metaplasia from Urinary Bladder Diverticulum.

Sarcomatoid carcinoma is an extremely rare aggressive tumor variant comprising about 0.3% of all primary tumors of the urinary bladder. We report a rare case of giant bladder sarcomatoid tumor arising from a bladder diverticulum. A 60-year-old male on evaluation for long-standing obstructive voiding symptoms with recurrent pyuria found to have renal failure and bladder mass with bilateral hydroureteronephrosis (HDUN) on ultrasound. Further radiologic evaluation revealed multiple bladder diverticulae and anteriorly displaced bladder with a large mass arising from one of the posteriorly located bladder diverticulum with extrinsic compression of both the distal ureters leading to severe bilateral HDUN. Rigid cystourethroscopy was not successful due to anteriorly displaced urethra. Tissue biopsy taken with flexible cystoscope revealed low-grade, noninvasive transitional cell carcinoma. After staging workup, bilateral percutaneous nephrostomy was performed initially for stabilization of renal function. This was followed by radical cystoprostatectomy with bilateral extended pelvic lymphadenectomy with ileal conduit diversion. Histopathology revealed high-grade muscle-invasive sarcomatoid variant of urothelial carcinoma with osseous metaplasia. It is imperative to recognize the rare variants of bladder tumors with different therapeutic and prognostic considerations and hence tailor the management of individual variant.

Comparative testing of reliability and audit utility of ordinal objective calculus complexity scores. Can we make an informed choice yet?

OBJECTIVES: To assess the reliability of the Guy's Stone Score, the Seoul National University Renal Stone Complexity (S-ReSC) score and the S.T.O.N.E. scores in percutaneous nephrolithotomy (PCNL), and assess their utility in discriminating outcomes [stone free rate (SFR), complications, need for multiple PCNL sessions, and auxiliary procedures] valid across parameters of experience of surgeon, independence from surgical approach, and variations in institution-specific instrumentation. PATIENTS AND METHODS: A prospectively maintained database of two tertiary institutions was analysed (606 cases). Institutes differed in instrumentation, while the overall surgical team comprised: two trainees (experience <100 cases), two junior consultants (experience 100-200 cases), and two senior surgeons (experience >1000 cases). Scores were assigned and re-assigned after 4 months by one trainee and an expert surgeon. Inter-rater and test-retest agreement were analysed by Cohen's κ and intraclass correlation coefficient. Multivariate logistic regression models were created adjusting outcomes for the institution, comorbidity, Amplatz size, access tract location, the number of punctures, the experience level of the surgeon, and individual scoring system, and receiver operating curves were analysed for comparison. RESULTS: Despite some areas of inconsistencies, individually all scores had excellent inter-rater and test-retest concordance. On multivariable analyses, while the experience of the surgeon and surgical approach characteristics (such as access tract location, Amplatz size, and number of punctures) remained independently associated with different outcomes in varying combinations, calculus complexity scores were found consistently to be independently associated with all outcomes. The S-ReSC score had a superior association with SFR, the need for multiple PCNL sessions, and auxiliary procedures. CONCLUSION: Individually all scoring systems performed well. On cross comparison, the S-ReSC score consistently emerged to be more superiorly associated with all outcomes, signifying the importance of the distributional complexity of the calculus (which also indirectly amalgamates the influence of stone number, size, and anatomical location) in discriminating outcomes. Our study proves the utility of scoring systems in prognosticating multiple outcomes and also clarifies important aspects of their practical application including future roles such as benchmarking, audit, training, and objective assessment of surgical technique modifications.

Predictive factors for lymph node positivity in patients undergoing extended pelvic lymphadenectomy during robot assisted radical prostatectomy.

INTRODUCTION: Pelvic lymphadenectomy during radical prostatectomy (RP) improves staging and may provide a therapeutic benefit. However, there is no clear consensus on the selection criteria for subjecting patients to this additional procedure. With a growing adoption of robot assisted radical prostatectomy (RARP) in India, it has become imperative to study the incidence and predictive factors for lymph node involvement in our patients. MATERIALS AND METHODS: From February 2010 to February 2014, 452 RARP procedures were performed at our institution. A total of 100 consecutive patients from July 2011 to August 2012 were additionally subjected to a robotic extended pelvic lymphadenectomy (EPLND). Lymph node positivity rates and lymph node density were analyzed on the basis of preoperative prostate specific antigen (PSA), Gleason score, clinical stage, D'Amico risk category and magnetic resonance imaging (MRI) findings. Multivariate analysis was performed to ascertain factors associated with lymph node positivity in our cohort. RESULTS: The mean age of the patients was 65.5 (47-77) years and the body mass index was 26.3 (16.3-38.7) kg/m(2). The mean console time for EPLND was 45 (32-68) min. A median of 17 (two to 40) lymph nodes were retrieved. Seventeen patients (17%) had positive lymph nodes (median of 1, range 1-6). Median lymph node density in these patients was 10%. When stratified by PSA, Gleason score, clinical stage, D'Amico risk category and features of locally advanced disease on MRI, a trend towards increasing incidence of lymph node positivity was observed, with an increase in adverse factors. However, on multivariate analysis, clinical stage > T2a was the only significant factor impacting lymph node positivity in our cohort. CONCLUSIONS: A significant proportion of men undergoing RARP in India have positive lymph nodes on EPLND. While other variables may also have a potential impact, a higher clinical stage predisposes to an increased incidence of lymph node metastases.

Age, gender, and voided volume dependency of peak urinary flow rate and uroflowmetry nomogram in the Indian population.

Objectives : The objective of this study was measurement of urine flow parameters by a non invasive urodynamic test. Variation of flow rates based on voided volume, age, and gender are described. Different nomograms are available for different populations and racial differences of urethral physiology are described. Currently, there has been no study from the Indian population on uroflow parameters. So the purpose of this study was to establish normal reference ranges of maximum and average flow rates, to see the influence of age, gender, and voided volume on flow rates, and to chart these values in the form of a nomogram. Methods : We evaluated 1,011 uroflowmetry tests in different age groups in a healthy population (healthy relatives of our patients) 16-50 year old males,> 50 year old males, 5-15 year old children, and> 15 year pre-menopausal and post-menopausal females. The uroflowmetry was done using the gravitimetric method. Flow chart parameters were analyzed and statistical calculations were used for drawing uroflow nomograms. Results : Qmax values in adult males were significantly higher than in the elderly and Qmax values in young females were significantly higher than in young males. Qmax values in males increased with age until 15 years old; followed by a slow decline until reaching 50 years old followed by a rapid decline after 50 years old even after correcting voided volume. Qmax values in females increased with age until they reached age 15 followed by decline in flow rate until a pre-menopausal age followed by no significant decline in post-menopausal females. Qmax values increased with voided volume until 700 cc followed by a plateau and decline. Conclusions : Qmax values more significantly correlated with age and voided volume than Qavg. Nomograms were drawn in centile form to provide normal reference ranges. Qmax values in our population were lower than described in literature. Patients with voided volume up to 50 ml could be evaluated with a nomogram.

Robot assisted laparoscopic pyeloplasty in patients of ureteropelvic junction obstruction with previously failed open surgical repair.

To review our experience of robotic redo pyeloplasty as a salvage procedure in previously failed repair of ureteropelvic junction (UPJ) obstruction. In one year, robot-assisted laparoscopic pyeloplasty was performed in nine patients for previously failed open pyeloplasty. Four of these patients had undergone additional retrograde endopyelotomy following failed repair, prior to being referred to us. The mean age was 16.4 years. All patients presented with persistent flank pain and an obstructive pattern on diuretic renogram. Robotic redo pyeloplasty could be performed successfully in all patients without any technical problems. Intraoperative findings for cause of UPJ obstruction were peri-ureteral fibrosis, narrow ureter, anterior crossing vessels, and redundant pelvis. The mean hospital stay was 3.4 days (2-5 days). All patients had improvement in symptoms and the nuclear scan showed non-obstructive drainage. Robot assisted redo pyeloplasty enables complex repair in patients with previous failed cases of UPJ obstruction repair. Three-dimensional magnified vision, and a dynamic articulated endowrist, allows fine dissection in the fibrosed area and precise suturing in an ergonomic fashion with a success equivalent to open surgery.

Malakoplakia of the ureter: An unusual case.

Malakoplakia of the ureter is a rare pathological entity. We discuss a 15-year-old girl with malakoplakia of the ureter. She presented with obstructive uropathy associated with left flank pain. Radiological investigations showed left lower ureteric stricture without bladder or kidney involvement. She was treated by excision of terminal ureter and ureteroneocystostomy. Histopathologic examination of the excised specimen showed malakoplakia. Postoperative course was uneventful and on follow-up, she has normal serum creatinine and no recurrence of the disease.

An unusual complication of silver nitrate therapy for chyluria.

Chyluria is a common disorder in the tropics. In our country it is most commonly managed by instillation of silver nitrate. We report a patient who developed severe perinephric hematoma due to pseudoaneurysm of renal artery following silver nitrate instillation. He was managed by angioembolisation followed by drainage of infected perinephric hematoma. We discuss various modalities of treatment of chyluria including complications of silver nitrate therapy.

Retroperitoneal pyelolithotomy for management of renal calculi.

OBJECTIVE: We evaluated the role of retroperitoneoscopic pyelolithotomy in the management of renal calculi. METHODS: Fifty-six cases (male, 27; female, 29) of solitary or multiple renal calculi were evaluated in the study. There were 46 patients with a single calculus, 4 patients with a staghorn calculus, and 6 with a caliceal calculus. Retroperitoneoscopic pyelolithotomy was carried out after creating a retroperitoneal space with the balloon dissection method. Pneumoretroperitoneum was maintained by carbon dioxide insufflation. RESULTS: Stone clearance was achieved in all cases barring 2 cases of caliceal calculi that were converted to the open procedure. The postoperative hospital stay averaged 4 days. Patients were ambulatory within 24 hours and back to work within 7 days on average. Complications encountered were peritoneal rent, subcutaneous emphysema, and superficial wound infection. The postoperative analgesic requirement averaged 100 mg of diclofenac (2 tablets). CONCLUSIONS: Retroperitoneoscopic pyelolithotomy is a safe, simple, and effective minimally invasive procedure and is a feasible option that can be recommended for management of renal calculi.