Mitrofanoff urinary diversion in a patient with cerebral palsy

Cerebral palsy is the most common motor disability in childhood which result in huge socioeconomic costs. This children have a significant incidence of lower urinary tract symptoms. Clean intermittent self-catheterization is needed to avoid deterioration of renal function. But significant spasticity and resulting contractures of the adductors can interfere with the caretakers’ ability to provide perineal hygiene. Surgery in cerebral palsy affected child is challenging due to multiple associated comorbidities. The aim of this report is to describe quality of life and renal function for a mentally retarded child with cerebral palsy before and after Mitrofanoff diversion without bladder augmentation

Cyanoacrylate injection in management of recurrent vesicovaginal fistula: Our experience

Treating recurrent vesicovaginal fistula (VVF) is a major clinical problem. We present a technique and special precautions taken during treatment of a small recurrent VVF with the help of combined cystoscopic and/or transvaginal injection of cyanoacrylate in two patients. Except for frequency of micturition in the first patient, postoperative follow-up was uneventful. Endoscopic management with cyanoacrylate is a simple and effective alternative to major reconstructive surgery

Is segmental epidural anaesthesia an optimal technique for patients undergoing percutaneous nephrolithotomy?

Background and Aims: Neuraxial anaesthesia has recently become popular for percutaneous nephrolithotomy (PCNL). We conducted a study comparing general anaesthesia (GA) with segmental (T6–T12) epidural anaesthesia (SEA) for PCNL with respect to anaesthesia and surgical characteristics. Methods: Ninety American Society of Anesthesiologists Physical Status-I and II patients undergoing PCNL randomly received either GA or SEA. Overall patient satisfaction was the primary end point. Intraoperative haemodynamics, epidural block characteristics, post-operative pain, time to rescue analgesic, total analgesic consumption, discharge times from post-anaesthesia care unit, surgeon satisfaction scores and stone clearance were secondary end points. Parametric data were analysed by Student's t-test while non-parametric data were compared with Mann–Whitney U-test. Results: Group SEA reported better patient satisfaction (P = 0.005). Patients in group GA had significantly higher heart rates (P = 0.0001) and comparable mean arterial pressures (P = 0.24). Postoperatively, time to first rescue analgesic and total tramadol consumption was higher in Group GA (P = 0.001). Group SEA had lower pain scores (P = 0.001). Time to reach Aldrete's score of 9 was shorter in group SEA (P = 0.0001). The incidence of nausea was higher in group GA (P = 0.001); vomiting rates were comparable (P = 0.15). One patient in group SEA developed bradycardia which was successfully treated. Eight patients (18%) had hypertensive episodes in group GA versus none in group SEA (P = 0.0001). One patient in GA group had pleural injury and was managed with intercostal drain. Stone clearance and post-operative haemoglobin levels were comparable in both groups. Conclusion: PCNL under SEA has a role in selected patients, for short duration surgery and in expert hands

Predictors for severe hemorrhage requiring angioembolization post percutaneous nephrolithotomy: A single-center experience over 3 years

Context and Aim: About 1% of the patients undergoing percutaneous nephrolithotomy (PCNL) have bleeding severe enough to require angioembolization. We identified factors which could predict severe bleeding post-PCNL and reviewed patients who underwent angioembolization for the same. Settings and Design: This is a single-institutional, retrospective study over a period of 3 years. Subjects and Methods: We retrospectively studied 583 patients undergoing PCNL at our institute from 2013 to 2016. We analyzed nine patients (three from our institute and six referred patients) who underwent angioembolization for severe bleeding post-PCNL. We analyzed the preoperative characteristics, intraoperative findings, and postoperative course of these patients and compared this with those patients who did not have a severe post-PCNL bleeding. Statistical Analysis Used: Fischer's exact test and Chi-square test were used in univariate analysis. Logistic regression analysis was used in multivariate analysis with a value of P < 0.05 considered statistically significant. Results: Three of the 583 patients (0.51%) who underwent PCNL at our institute required embolization to control bleeding. Preoperative characteristics that were significant risk factors for severe bleeding were a history of ipsilateral renal surgery (P = 0.0025) and increased stone complexity (P = 0.006), while significant intraoperative factors were injury to the pelvicalyceal system (P = 0.0005) and multiple access tracts (P = 0.022). Angiography revealed arteriovenous fistula in two patients and a pseudoaneurysm in seven patients. All patients underwent successful superselective angioembolization with preserved renal perfusion in six patients on control angiography postembolization. Conclusions: History of ipsilateral renal surgery, increased stone complexity, multiple access tracts, and injury to the pelvicalyceal system are risk factors predicting severe renal hemorrhage post-PCNL. Early angiography followed by angioembolization should be performed in patients with severe post-PCNL bleeding who fail to respond to conservative measures

“Spiral-Cap” ileocystoplasty for bladder augmentation and ureteric reimplant

Objective: To demonstrate the new technique of Spiral-cap ileocystoplasty for bladder augmentation and simultaneous ureteric reimplant. Materials and Methods: Seven patients with small capacity bladder and simultaneous lower ureteric involvement operated in single tertiary care institute over the last 5 years were included in this study. Spiral-cap ileocystoplasty was used in all the patients for bladder augmentation. Proximal part of the same ileal loop was used in isoperistaltic manner for ureteric reimplantation. Distal end of this ileal loop was intussuscepted into the pouch to decrease the incidence of reflux. Detubularized distal portion of the loop was reconfigured in spiral manner to augment the native bladder. Patients were analyzed for upper tract changes, serum creatinine, bladder capacity, and requirement of clean intermittent self-catheterization in follow-up over 5 years. Results: There was no evidence of any urinary or bowel leak in the postoperative period. Recovery was equivalent with those treated with other methods of bladder augmentation. Follow-up ultrasonography showed good capacity bladder. Upper tracts were well preserved in follow-up. Urinary bladder and lower ureter pathologies were addressed simultaneously. Conclusion: Spiral-cap ileocystoplasty is a useful technique in patients who require simultaneous bladder augmentation and ureteric reimplant

Transperitoneal laparoscopic repair of retrocaval ureter: Our experience and review of literature

Context and Aim: Retrocaval ureter (RCU), also known as circumcaval ureter, occurs due to anomalous development of inferior vena cava (IVC) and not ureter. The surgical approach for this entity has shifted from open to laparoscopic and robotic surgery. This is a relatively new line of management with very few case reports. Herein, we describe the etiopathology, our experience with six cases of transperitoneal laparoscopic repair of RCU operated at tertiary care center in India and have reviewed different management options. Methods: From 2013 to 2016, we operated total six cases of transperitoneal laparoscopic repair of RCU. All were male patients with average age of 29.6 years (14–50). Pain was their only complaint with normal renal function and no complications. After diagnosis with CT Urography, they underwent radionuclide scan and were operated on. Postoperative follow-up was done with ultrasonography every 3 months and repeat radionuclide scan at 6 months. The maximum follow-up was for 2.5 years. Results: All cases were completed laparoscopically. Average operating time was 163.2 min. Blood loss varied from 50 to 100 cc. Ureteroureterostomy was done in all patients. None developed urinary leak or recurrent obstruction postoperatively. Maximum time for the requirement of external drainage was for 4 days (2-4 days). Average postoperative time for hospitalization was 3.8 days. Follow-up ultrasound and renal scan showed unobstructed drainage. Conclusions: Transperitoneal or retroperitoneal approach can be considered equivalent as parameters like operative time, results are comparable for these two modalities. We preferred transperitoneal approach as it provides good working space for intracorporeal suturing

Predictive factors for fever and sepsis following percutaneous nephrolithotomy: A review of 580 patients

Aims: There has been much speculation and discussion about the infective complications of percutaneous nephrolithotomy (PCNL). While fever is common after PCNL, the incidence of it progressing to urosepsis is fortunately less. Which patient undergoing PCNL is at risk of developing urosepsis and in whom aggressive treatment of fever postoperatively may prevent the progression to severe sepsis becomes a very important question. This study aims to answer these vital questions. Settings and Design: This is a single institutional, retrospective study over a period of 3 years. Materials and Methods: Retrospective analysis of medical records of the patients undergoing PCNL from August 2012 to July 2015 was done. A total of 580 patients were included in the study, and the study variables recorded were analyzed statistically. Statistical Analysis Used: Statistical analysis was performed by Chi-square test. Results: Three factors significantly correlated with postoperative severe sepsis, namely, stone size >25 mm, prolonged operative time >120 min, and significant bleeding requiring transfusion. Factors associated with fever after PCNL which did not progress to sepsis were the presence of staghorn calculi and multiple access tracts in addition to the factors listed above for sepsis. Conclusions: Fever after PCNL is not uncommon but it has a low incidence of progressing to life-threatening severe sepsis and multiorgan dysfunction syndrome. Special precautions and monitoring should be taken in patients with bigger stone (>25 mm) and patients with severe intraoperative hemorrhage requiring blood transfusion. It is better to stage the procedure rather than prolong the operative time (120 min). Identifying these factors and minimizing them may decrease the incidence of this life-threatening complication

Feasibility of minimally invasive management in patients with forgotten double J stent: a single centre experience

Background: aim of the study was to present the experience in managing forgotten/encrusted Double J (DJ) ureteral stents and to review the literature on the subject.Methods: Author retrospectively studied patients presenting to the Outpatient Department from January 2016 to January 2019 with forgotten DJ stent(s) (six or more than six months after the insertion). Data was collected for age, gender, indication for DJ stenting, clinical features at presentation, radiological imaging and surgical procedure performed to extract the DJ stents. The post-operative stay, complications of the procedures and morbidity was also studied.Results: During the study period, a total 32 patients reported to the department with history of forgotten DJ stents. Most common age group involved was 41-60 years. Most common presenting symptoms were lower urinary tract symptoms (LUTS) or dysuria.  Duration of stent in-situ ranged from 6 month to 15 years. Most common sites of encrustations along the forgotten DJ stent were ureter and kidney followed by urinary blabber. Fluoroscopic guided DJ stent removal was done in 8 patients. A combination of Cystolithotripsy, URSL and PCNL was needed to clear the stone and extract the DJ stent in remaining patients.Conclusions: Forgotten/encrusted DJ stent may lead to complications ranging from urinary tract infections to loss of renal function. They can be safely and successfully removed, and the renal function can be preserved. Endo-urological management of forgotten encrusted stents is highly successful and often avoids the need for open surgical techniques

Evaluating LDL-C control in Indian acute coronary syndrome (ACS) patients- A retrospective real-world study LDL-C control in ACS

Background: Low-density lipoprotein-cholesterol (LDL-C) is an independent risk factor for atherosclerotic cardiovascular disease (ASCVD) progression. Although lipid lowering therapies remain the cornerstone of secondary ACSVD prevention, there exists residual dyslipidemia. The current study aimed to evaluate the real-world experience related to the treatment patterns and LDL-C control in Indian Acute Coronary Syndrome (ACS) patients. Methods: This was a real-world, descriptive, retrospective, observational, and multicentric study conducted across India. The data was collected for 1 year following the ACS event. The change in the levels of LDL-C from the baseline to the follow-up visits and the control of LDL-C, the change in lipid profile, lipoprotein levels, treatment patterns for lipid-lowering, and tolerability of existing treatments were evaluated. Results: Overall, 575 patients were included from 11 centers across India. The mean age of the patients was 52.92 years, with male predominance (76.35%). Although there was a significant reduction in the mean levels of LDL-C from the baseline [(122.64 ± 42.01 mg/dl to 74.41 ± 26.45 mg/dl (p < 0.001)], it was observed that despite high-intensity statin therapy, only 20.87% patients managed to achieve target LDL-C of <55 mg/dL and 55.65% were unable to reach LDL-C levels of <70 mg/dl one year after the event. Six patients reported adverse events without treatment discontinuation. Conclusion: The majority of the patients received high-intensity statins and did not attain target LDL-C levels, suggesting LDL-C control after an ACS event requires management with novel therapies having better efficacy as recommended by international and national guidelines