DJ Stent Research Articles

Ureteral Obstruction in Endometriosis

Aim: Endometriosis is defined as functional endometrial glands and stroma that occur outside the uterine cavity. It is an estrogen dependent, benign, inflammatory disease that affects women during premenarcheal, reproductive and postmenopausal hormonal stages.
 Methods: This is a retrospective review of six cases with diagnosis of ureteral endometriosis. All the patients were referred to Department of Surgery, Kathmandu Model Hospital and the study period was from September 2015 to August 2018.
 Results: In our study all the patients had involvement of the ureter. All the patients who had undergone open surgery had extrinsic involvement of the ureter. Two patients who had mild distal ureteric stenosis only were managed by diagnostic URS and retrograde DJ stenting. Another two patients with right distal ureteric stenosis were managed initially with retrograde DJ stenting but after removal of ureteric stent and in subsequent follow up the degree of hydroureteronephrosis increased in both the cases. These two patients were finally undergone right Lich Gregoir ureteroneocystostomy. In the remaining two patients, ureterorenoscopy (URS) guided double J stenting were attempted but failed to insert the stent due to stenosed ureter so they underwent open abdominal hysterectomy with excision endometriotic cyst with ureterolysis and double J stenting.
 Conclusions: Ureteral endometriosis is a rare disease presenting most commonly with nonspecific symptoms and signs and thus making preoperative diagnosis often difficult for the clinicians. Treatment of ureteral endometriosis is primarily surgical. The surgical procedures which are usually performed are excision of all endometriosis lesion, ureterolysis, ureterectomy with ureteroureteral anastomosis and ureteroneocystomy.

Bladder Endometriosis: Management by Cystoscopic and Laparoscopic Approaches

Study ObjectiveEndometriosis of the urinary system accounts for less than 1% of all endometriosis, wherein bladder endometriosis is the most common. Bladder endometriosis is defined as endometriosis infiltrating the detrusor muscle and represents 85% of urinary tract endometriosis [1,2]. Segmental bladder resection/partial cystectomy is the bladder-preserving surgery and offers the complete removal of bladder endometriotic nodules [3,4]. Laparoscopic/robotic excision increases the chances of complete removal of nodules but may lead to inadvertent removal of excess bladder wall and increase the risk of complications, especially in cases of large lesions in close proximity to ureteric orifices. Thus, simultaneous laparoscopy and cystoscopy offers the most effective way of complete resection of bladder endometriotic nodules, relieving symptoms and minimizing intraoperative and postoperative complications and recurrence rates in patients [5–11]. This article with accompanying video describes the systematic approach and step-by-step surgical excision of a bladder endometriotic nodule in a patient with frozen pelvis. DesignStep-by-step surgical excision of a bladder endometriotic nodule by simultaneous cystoscopy and laparoscopy. (Canadain Task Force classification: level III) SettingJyoti Hospital and Minimum Invasive Surgery Center, Ahmedabad, India. PatientA 41-year-old women, P2L2, presented with cyclical dysmenorrhea, dysuria, and chronic pelvic pain. Informed consent was obtained from the patient, and the local institutional board provided the approval. InterventionSimultaneous cystoscopy and laparoscopy. Measurements and Main ResultsA preoperative assessment was done with transvaginal ultrasonography with a partially full bladder that showed an intravesical 3-cm endometriotic nodule along with chocolate cysts of the ovary and adenomyosis of the uterus. A simultaneous cystoscopy by a urologist and laparoscopy by a gynecologist was performed. On cystoscopy the nodule was seen away from both the ureteric orifices. The nodule was marked cystoscopically with a monopolar needle and laparoscopically with bipolar scissors. Laparoscopy began with a full inspection of the abdomen, pelvis, and adhesions. Dissection started from the left round ligament, and both paravesical spaces were dissected gently, keeping the bladder partially full. Good uterine manipulation helped to delineate vaginal fornices during dissection. Dissection continued over the isthmus, and bladder was gently separated from the isthmus. The bladder was partially filled with methylene blue and intentionally cut opened to excise the demarcated bladder nodule with a monopolar hook, taking a disease-free margin of 5 mm [12]. Two stay sutures were taken at both the lateral angles of the bladder, and suture ends were brought outside the abdomen to facilitate closure of the bladder transversely. After mobilization of the bladder, both uterine vascular bundles were desiccated with bipolar and laparoscopic hysterectomy. Vaginal closure was done away from bladder stitches. The patient was discharged on day 3 with catheter and DJ stents. On day 21, 3-dimensional computed tomography cystogram showed adequate bladder volume. Catheter and DJ stents were removed, low-pressure cystoscopy showed a smooth stitch line with mucosa over it and no residual endometriosis. The patient was found to have no symptoms at the 2-year follow up. ConclusionThe video demonstrates the feasibility of simultaneous laparoscopic and cystoscopic approach for excision of a bladder endometriotic nodule. Marking the nodule by simultaneous cystoscopy and laparoscopy before excision helps in removing the disease completely and avoiding unnecessary normal bladder wall excision, thus reducing the risk of recurrence and resultant small bladder symptoms.

The significance of palliative surgery in castration-resistant prostate cancer

If prostate cancer recurs after primary treatment, deprivation therapy with LHRH analogues or antagonists is the treatment of choice in men with metastatic prostate cancer. However, this treatment only achieves palliative results. Median time to progression ranges between 11 and 78 months. After the introduction of Docetaxel as a first-line treatment in castration-resistant prostate cancer (CRPCA) and cabazitaxel as a second-line chemotherapy, several new drugs containing abiraterone, enzalutamide, radium 223 and sipuleucel-T have become available, which can lead to complete or partial remissions in metastasis, but do not have an effect on the prostate itself as has been shown recently. As a result of local progression of CRPCA, local complications of the urinary tract such as subvesical obstruction, recurrent gross haematuria with or without clotting, upper urinary tract dilatation, rectourethral or rectovesical fistulae and rectal obstruction will occur in about one third of all patients. Several surgical treatment options are available to manage the aforementioned complications. In patients with local progressive CRPCA and lower urinary tract symptoms, palliative TUR-P, radical prostatectomy or radical cystoprostatectomy with urinary diversion and even anterior and posterior exenteration can be performed in selected patients, requiring a preoperative multiparametric MRI of the prostate and the pelvic floor along with a laboratory examination to optimise surgical techniques and perioperative outcomes. In case of symptomatic involvement of the upper urinary tract system, the placement of endoluminal DJ stents or percutaneous nephrostomy in men with a poor performance status and a short life expectancy is the treatment of choice. In men with an ECOG performance status of 0 to 1, reconstructive surgery such as ureteral reimplantation, ileal ureteral replacement or placement of a subcutaneous pyelovesical bypass is an appropriate treatment option. To summarise, the aforementioned palliative surgical treatment options should be provided for selected patients and performed by well-experienced urologists.

Pulsatile Arterial Bleed from Uretero-Vesical Junction following Placement of a Double J Stent: An Endo-Urology Nightmare

The ureteric stent placement is amongst the commonest urological procedures undertaken for urological diseases. It is indicated for relief of obstructive uropathy as a temporary procedure or after endourological surgeries like ureteroscopy, stone surgery, pyeloplasty etc. Various complications which may be associated with ureteric stenting are irritative voiding symptoms (50-60%), urgency (57-60%), dysuria (40%), incomplete emptying (76%), incontinence, and haematuria (25%). Haematuria is particularly worrisome complication and needs special emphasis. We hereby report a case of massive haematuria seen after DJ stent placement which was managed with cystoscopy clot evacuation followed by cauterization of active bleeder with bugbee electrodes application. The urologists, especially trainees, need to be aware of this dreaded complication and its management.

Fate of Forgotten DJ Stent

Introduction: Double J stent is one common armamentarium used in urological procedure. It can serve both therapeutic and prophylactic function. However the use of double J stent is invariably associated with minor to some of major complications. Forgotten DJ stent is one untoward issue of stenting patient that is largely preventable and entails complex urological procedure to remove it. Methods: We performed descriptive study where data were collected prospectively from patients who have double J ureteral stent in situ after urological procedure. Stent left more than three months was defined as forgotten DJ stent. Demographic characteristics, clinic-radiological data and details of management were noted to evaluate the mode of presentation, associated complications and mode of treatment. The reason behind forgetting those stent was asked with study population and presented.Results: The total of 27 cases of forgotten DJ stent cases were recorded during period of December 2013 to January 2018. Mean age of patient was 46.6 ± 12.25 years. The longest indwelling time was 10 years. Stent syndrome was common mode of presentation followed by encrustation. Majority (92.5%) of the patients were managed with endourological approach and 26% (7) of cases required more than one modalities of treatment.Conclusions: The forgotten stent is an avoidable condition through proper patient counselling. When required the management necessitates simple cystoscopic to complex endourolgical intervention.

A comparative study of pyeloplasty in children with and without stenting

Background: PUJ obstruction is the most common among the major obstructive pathologies in pediatric patients. The study aims to compare the benefits and drawbacks of stentless pyeloplasty in pediatric population with routine DJ stent insertion.Methods: Data was collected for operated cases of PUJ obstruction and categorised into those who had DJ stent in situ and those without DJ stent. Complications associated with both these approaches was systematically assessed.Results: In patients with DJ stent in situ the perinephric drain was minimal and hence most of the patients had their drain removed on the 2nd or 3rd day. In those patients without DJ stent in situ, the average duration for removal of drain was prolonged to about 7 days.Conclusions: Routine use of Ureteric stenting with DJ stent in this series of patients was associated with decreased hospital stay and morbidity in patients without DJ stent.

636 First ever case report of priapism secondary to retroperitoneal fibrosis

To present first ever case report of retroperitoneal fibrosis leading to priapism. 46 years old man known case of retroperitoneal fibrosis (RPF) presented in ER with painful erection for last 24 hours. Aspiration from corpora was done and sent for blood gas analysis which showed venous type blood suggesting ischemic priapism. Erection resolved after aspiration/irrigation and phenylephrine injection. He had left hydronephrosis secondary to retroperitoneal fibrosis for last 10months for which he had left DJ stent in place and he was on Tamoxifen 50 mg daily. His MRI abdomen was repeated to look for progression of retroperitoneal fibrosis which showed extension of fibrosis along internal iliac branches and encasing internal pudendal vessels. CT guided biopsy of retroperitoneal soft tissue around left common iliac vessel showed fibrocollagenous tissue along with adipocytes with no evidence of malignancy.Since this presentation he is having stuttering priapism which settles with relaxation techniques but sometime require aspiration +/- phenylephrine. He reports no erectile dysfunction till last follow-up, 2years since initial presentation. He has been advised surgical management for his retroperitoneal fibrosis and stuttering priapism but he is willing to continue conservative measures.

Robot-assisted laparoscopic buccal mucosa replacement for ureteroplasty in the treatment of complex upper ureteral strictures

Objective To discuss the feasibility, safety and efficacy of robot-assisted laparoscopic buccal mucosal ureteroplasty in the treatment of long segment upper ureteral stricture. Methods Five patients with complex ureteral strictures were treated with robot-assisted laparoscopic buccal mucosa ureteroplasty (5 males; right side, 2 cases; left side, 3 cases)in our hospital from March to July of 2017. The patients aged 25-40 years with median of 35 years old. The median body mass index was 23.5 kg/m2(19-29 kg/m2). Data of surgical conditions, postoperative complications, and follow-up were collected. Results All patients were treated with robot-assisted laparoscopic buccal mucosa ureteroplasty and the operations were uneventful. The median length of stricture of upper ureter were 3 cm (2-6 cm). The median operation time was 360 min (200-400 min), median blood loss was 100 ml(50-200 ml), drainage tube retained time was 5 d(2-9 d) , post-operative hospital stay was 11 d(7-12 d), and the median creatinine value was 85 μmol/L (76-98 μmol/L). No urine leakage, infection, buccal mucosa necrosis or other serious complications occurred after surgery. Five patients’ CT examnation showed improved hydronephrosis 3 weeks post-operatively. DJ stent was removed 3 months after surgery in 2 patients, and 1 patient presented with no hydronephrosis, another one with mild hydronephrosis. DJ stent was removed 6 months after surgery in the other 3 patients with improved hydronephrosis. Conclusions Robot-assisted laparoscopic buccal mucosal ureteroplasty for the treatment of long segment upper ureteral stricture is a safe and feasible procedure, with a good short-term effectiveness and without severe complications. Key words: Buccal mucosa; Ureteral stricture; Robot; Laparoscopy

Robotic Pyelolithotomy, Extended Pyelolithotomy, Nephrolithotomy, and Anatrophic Nephrolithotomy.

We are a reporting on the indications, techniques, and limitations of robotic surgery in the management of renal stones disease. Robotic surgery is a good tool to manage large kidney and ureteral stones, particularly in patients with anatomic anomalies. We describe three techniques in managing staghorn kidney stones: robotic anatrophic nephrolithotomy, robotic pyelolithotomy, and robotic nephrolithotomy. Robotic pyelolithotomy (RP) is ideal for patients with large renal pelvis and partial staghorn stone with a wide extra-renal pelvis. Robotic nephrolithotomy (RN) is ideal for stones inside a calyceal diverticulum or a partial staghorn eroding into the renal parenchyma. Renal vascular control could be avoided in most of those surgeries. Robotic anatrophic nephrolithotomy (RAN) is the most complex procedure and is reserved for patients with complete staghorn stones when percutaneous approach was not successful or not feasible. Control of renal vasculature is required for RAN. For robotic kidney surgeries, patients are positioned in a lateral decubitus position. Four or five ports are placed based on the stone location and surgeon's preference. We prefer the trans-peritoneal approach as it gives us the optimal exposure. For RP and RN, hilar control is usually not required. The renal pelvis/ renal parenchyma is incised, and the stones are carefully removed. If needed intra-operative flexible nephoscopy can be used to remove residual stones fragments. The collecting system is closed using an absorbable suture. DJ stent if needed is placed in an antegrade fashion. For RAN, the kidney is fully mobilized, and hilar control is required to avoid excessive bleeding. The kidney is incised along Brodel's line and the stones are extracted. The kidney parenchyma is then closed using 1 or 2 layers. We achieved an almost 100% stone free rate with RP and RN. RAN remains a challenging procedure with a success rate around 70%. Robotic surgery is a viable option to manage large renal and ureteral stones particularly in situations where endoscopic approach is not successful or feasible.

V02-09 LAPAROSCOPIC PYELO-URETEROSTOMY OF GRAFT KIDNEY TO NATIVE URETER FOR A POST TRANPLANT RECURRENT URETERAL STRICTURE

You have accessJournal of UrologyBPH, Male Voiding Dysfunction, and Transplantation1 Apr 2018V02-09 LAPAROSCOPIC PYELO-URETEROSTOMY OF GRAFT KIDNEY TO NATIVE URETER FOR A POST TRANPLANT RECURRENT URETERAL STRICTURE Jitendra Jagtap, Lokesh Sinha, Vinayak Kore, Vikash Kumar, Sachin Veer, and Pradeep Rao Jitendra JagtapJitendra Jagtap More articles by this author , Lokesh SinhaLokesh Sinha More articles by this author , Vinayak KoreVinayak Kore More articles by this author , Vikash KumarVikash Kumar More articles by this author , Sachin VeerSachin Veer More articles by this author , and Pradeep RaoPradeep Rao More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.468AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Complicated recurrent ureteral strictures post renal transplantation have traditionally been managed by standard open surgical technique. We describe a successfully performed laparoscopic pyelo-ureterostomy between the graft kidney and native ureter for a long segment recurrent distal ureteral stricture in a 40 year old female. METHODS The patient had undergone a living related renal transplantation 3.5 years ago. She developed a distal ureteral stricture 3 years later and underwent an antegrade placement of a nephroureteral stent after balloon dilatation of the stricture. A month later she required an exploration, excision of distal ureteral strictured segment and ureteroneocystostomy for obstructive uropathy. Four months later she again presented with oliguria, rising creatinine and moderate hydroureteronephrosis. This time a laparoscopic pyelo-ureterostomy was performed using conventional three ports (two 10mm and one 5mm) triangulated towards the graft kidney. Intraoperative use of a 12MHz drop-in ultrasound probe aided in identification of the dilated graft pelvis and preoperative ureteral catheterisation helped in identification of right native ureter. Spatulated tension free anastomosis was performed with Polyglactin 4-0 sutures. RESULTS Operative time was 112 min with no intra operative complication. Postoperative course was uneventful. Hemoglobin drop was 0.2 gm/dL. Drain and catheter were removed on third postoperative day. Postoperative hospital stay was four days. Ultrasound on discharge showed resolution of the hydroureteronephrosis. DJ stent was removed after 15 days of surgery. CONCLUSIONS Laparoscopic pyelo-ureterostomy is a safe and efficacious technique for management of complicated recurrent ureteral strictures post renal transplantation. It additionally offers better comesis and shorter convalescence. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e169 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Jitendra Jagtap More articles by this author Lokesh Sinha More articles by this author Vinayak Kore More articles by this author Vikash Kumar More articles by this author Sachin Veer More articles by this author Pradeep Rao More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Safety and Viability of Totally Tubeless Ambulatory Percutaneous Nephrolithotomy (APCNL) in the Fast Paced World

Background: Percutaneous Nephrolithotomy (PCNL) is the gold standard for endoscopic management of large renal stones. Various modifications have been done to bring down the morbidity of this procedure. Ambulatory PCNL (APCNL) defines PCNL as day-care procedure, avoiding overnight hospital stay which is less than 24 hours. Totally tubeless makes faster recovery without the need for double J stent or nephrostomy tubes. This study aimed at exploring the feasibility and safety of APCNL in selective patients. It also aimed at improvising the procedure to facilitate early recovery and discharge of patients within 24 hrs. Materials ands Methods: In this study, 12 patients underwent APCNL under general anaesthesia with endotracheal intubation from April 2016 to March 2017. All the procedures were done by a single surgeon. The inclusion criteria were stone size of less than 2cm, without any co-morbidities, Computed Tomography (CT)/Retrograde Pyelogram(RGP) evidence of normal pyelocalyceal anatomy, patient staying within the radius of 15km, well informed patient. All patients underwent totally tubeless PCNL i.e. without nephrostomy, DJ stent and catheter. Skin infiltration was given with 0.25% Bupivacaine. Post operatively analgesia was given on demand (intramuscular Aceclofenac / oral Acetaminophen plus Tramadol). All patients were followed up after 2 weeks. Results: Twelve patients underwent prone PCNL. All patients had single puncture (10 lower calyx, 2 middle calyx), Amplatz size was less than 30F, size of the stone (1.3cm to 2cm) with a mean size- 1.7cm, saline used around 300ml. But, two patients were discharged after 36hrs and 48hrs due to pain. None of them returned to hospital with haematuria, pain or urinary tract infection. Conclusion: APCNL is a safe procedure in well informed selective patients. These are the patients with small burden of stone and staying close to the hospital. APCNL reduces the hospital stay, expenses and results in early return to work.

Tricks and tacks in the management of the forgotten double J stent

Background: Double J ureteral stent has become the part and parcel of the routine procedure for the prevention or relief of upper urinary tract obstruction. Forgotten DJ stent can lead to encrustation, infection, migration, hydronephrosis and fragmentation.Methods: Total 16 patients with forgotten double J stent at urology department of the tertiary teaching hospital from January 2014 to December 2016 were included in this retrospective study. The details reviewed included the indwelling time, presenting complaints, radiological and laboratory investigations, their management techniques and complications of the interventions.Results: Twelve were male while 4 were female with mean patient age was 41.3±10 years. Most common presenting complaints were lower urinary tract symptoms. Five had broken stent, two encrusted calcified stents while two were migrated to upper ureter. One patient was diagnosed as pyonephrosis while 6 patients were uncomplicated cases.Conclusions: Stents, which are forgotten, can lead to morbidity in stented patients. Stent register should be made, and a computer-based tracking system has also been described to ensure the safety.

Outcome of retrograde flexible ureterorenoscopy and laser lithotripsy for treatment of multiple renal stones

ObjectiveTo evaluate the efficacy and safety of retrograde intrarenal surgery (RIRS) using flexible ureterorenoscopy (F-URS) and laser lithotripsy as a treatment option for multiple renal stones greater than 1cm. Patients and methodsBetween June 2015 and February 2017, 42 patients who were treated with RIRS via F-URS and laser lithotripsy were evaluated. Stones were divided into two categories according to stone burden, 11–20mm and 21–30mm. Patient's demographics, stones characteristics, operative outcomes and complications were evaluated prospectively. Stone free rate (SFR) was determined 4 weeks postoperatively using findings on non-contrast computed tomography (NCCT). ResultsMean stones burden was 25.7mm (range from 1.3 to 30mm), 8 patients had 11–20mm stones burden with SFR 100% and 34 had 21–30mm stone burden with SFR 91.2%. The overall SFR was 92.8%. Multiple stones were two in 31 patients (73.8%), three in 9 (21.4%) and four in 2 (4.8%). Regarding stone number per kidney and SFR, SFR was 100%, 77.7% and 50% for kidneys with two, three and four stones respectively. In terms of stone location in the pelvi-calyceal system and corresponding SFR, there were renal pelvic stones in 6 (14.3%) patients with 100% SFR, upper calyx and or mid calyx and or renal pelvis in 12 (28.6%) with SFR 91.6% and lower calyx with or without other locations in 24 with SFR 91.6% also. Complications were minor and included, UTI in 3 patients (7.1%), hematuria of 4 days duration in 2 (4.8%), severe DJ stent irritative symptoms in one (2.4%) and minor ureteral perforations in one (2.4%). ConclusionRIRS via F-URS and laser lithotripsy is a safe and effective treatment option with high success rate for patients with multiple renal stones of 11–30mm stone burden. It is indicated when other stone treatment modalities contraindicated or have failed. However, for complex or challenging stones, staged procedures may be required.

The safety and efficacy of nephron sparing surgery in T1N0M0 renal cell carcinoma

Background: Renal cell carcinoma (RCC) accounts for approximately 3% of adult malignancies and 90-95% of neoplasm arising from the kidney. Objective was to explore the safety and efficacy of nephron sparing surgery (NSS) for T1N0M0 renal cell carcinomas (RCC) and to assess the oncological outcome of NSS in T1N0M0 RCC.Methods: A total of 31 cases were enrolled for the study of which 11 (35.5%) underwent NSS and 20 (64.5%) underwent radical nephrectomy (RN). The clinical results were followed up and comparatively analyzed.Results: NSS was performed using a margin of 1cm, no positive surgical margin was detected. The mean blood loss and mean duration of surgery in NSS and RN was comparable. Among all one patient from NSS group experienced urinary leak which was managed by placement of DJ stent. The overall complication rate was 9.1% in NSS. Lab. tests before surgery and after surgery at 6month was done in the both groups and results obtained was within normal limits. Only one patient developed metastasis from NSS group and died at 14th month of fallow-up, whereas neither metastasis nor mortality were recorded in RN group.Conclusions: Nephron sparing SURGERY has proven to be a safe and effective approach for Renal cell carcinoma with comparable clinical results to radical nephrectomy especially in tumour ≤4cm.

UPPER URETERIC STONES

Objectives: Compare the efficacy of Extracorporeal Shock Wave Lithotripsy withPneumatic Lithotripsy in the management of upper ureteric stones. Settings: Department ofUrology, Lahore General Hospital, Lahore. Duration of Study: From November 2008 to August2009. Results: In our study, the patients were divided into two groups ie; Extracorporeal ShockWave Lithotripsy group (ESWL) and Pneumatic Lithotripsy group (PnL). The mean age inPneumatic Lithotripsy (PnL) was 39+15.23 years, whereas mean age was 40.6+14.62 years inExtracorporeal Shock Wave Lithotripsy group (ESWL). In Extracorporeal Shock Wave Lithotripsygroup (ESWL), 38(76%) patients were male and 12(24%) patients were female while numberwas 34(68%) and 16(32% in Pneumatic Lithotripsy group (PnL) respectively. In both groups,there was male preponderance. In ESWL group, majority of patients were treated as outdoorpatients. 95% of them received intramuscular analgesia where as 5% required intravenoussedation. All patients were followed at two weekly interval up till 6 weeks. Fifty patients requiredmore than 125 sessions of ESWL with mean shock waves 2960+222.23 at at mean energy6.46+0.503kv, 2952+327.77 at 6.45+0.504 kv and 2842+410.03 at 6.76 0.436 kv at 2, 4 and 6weeks respectively. The partial clearance was achieved in 34 patients at 2 weeks, 26 patientsat 4 weeks and 5 patients at 2 weeks. Stone free status at 2 weeks, 4 weeks and 6 weeks were18%, 40% and 84% respectively. In Pneumatic Lithotripsy group (PnL) all of the 50 patientswere given general anesthesia. DJ stent was placed in all patients after the procedure for sixweeks follow up. 42(84%) of patients received shots of Pneumatic Lithotripsy on pulse modewhile in 8(16%) patients, shots were on continuous mode. The partial clearance was achieved in5(10%), 3(6%) and 2(4%) patients at 2, 4 and 6 weeks respectively. Stone free status was 48%,52% and 54% at 2, 4 and 6 weeks respectively. In 20(40%) patients, stone migrated into calyces.Only in 1(2%) patients, there was no effect on stone. All patients in both groups were neededtwo weekly follow up till six weeks. Stone clearance was 84% in Extracorporeal Shock WaveLithotripsy (ESWL) group while it was 54% in Pneumatic Lithotripsy group (PnL), p<0.001.Conclusion: Extracorporeal Shock Wave Lithotripsy offers higher stone free rates with minimalinvasiveness and high safety compared to Pneumatic Lithotripsy, which provides immediatehigh stone free rates, but with high risk of treatment failure.

COMPARISON OF EXTRA CORPOREAL SHOCK WAVE LITHOTRIPSY WITH PNEUMATIC LITHOTRIPSY IN THE MANAGEMENT

Objectives: Compare the efficacy of Extracorporeal Shock Wave Lithotripsy withPneumatic Lithotripsy in the management of upper ureteric stones. Settings: Department ofUrology, Lahore General Hospital, Lahore. Duration of Study: From November 2008 to August2009. Results: In our study, the patients were divided into two groups ie; Extracorporeal ShockWave Lithotripsy group (ESWL) and Pneumatic Lithotripsy group (PnL). The mean age inPneumatic Lithotripsy (PnL) was 39+15.23 years, whereas mean age was 40.6+14.62 years inExtracorporeal Shock Wave Lithotripsy group (ESWL). In Extracorporeal Shock Wave Lithotripsygroup (ESWL), 38(76%) patients were male and 12(24%) patients were female while numberwas 34(68%) and 16(32% in Pneumatic Lithotripsy group (PnL) respectively. In both groups,there was male preponderance. In ESWL group, majority of patients were treated as outdoorpatients. 95% of them received intramuscular analgesia where as 5% required intravenoussedation. All patients were followed at two weekly interval up till 6 weeks. Fifty patients requiredmore than 125 sessions of ESWL with mean shock waves 2960+222.23 at at mean energy6.46+0.503kv, 2952+327.77 at 6.45+0.504 kv and 2842+410.03 at 6.76 0.436 kv at 2, 4 and 6weeks respectively. The partial clearance was achieved in 34 patients at 2 weeks, 26 patientsat 4 weeks and 5 patients at 2 weeks. Stone free status at 2 weeks, 4 weeks and 6 weeks were18%, 40% and 84% respectively. In Pneumatic Lithotripsy group (PnL) all of the 50 patientswere given general anesthesia. DJ stent was placed in all patients after the procedure for sixweeks follow up. 42(84%) of patients received shots of Pneumatic Lithotripsy on pulse modewhile in 8(16%) patients, shots were on continuous mode. The partial clearance was achieved in5(10%), 3(6%) and 2(4%) patients at 2, 4 and 6 weeks respectively. Stone free status was 48%,52% and 54% at 2, 4 and 6 weeks respectively. In 20(40%) patients, stone migrated into calyces.Only in 1(2%) patients, there was no effect on stone. All patients in both groups were neededtwo weekly follow up till six weeks. Stone clearance was 84% in Extracorporeal Shock WaveLithotripsy (ESWL) group while it was 54% in Pneumatic Lithotripsy group (PnL), p<0.001.Conclusion: Extracorporeal Shock Wave Lithotripsy offers higher stone free rates with minimalinvasiveness and high safety compared to Pneumatic Lithotripsy, which provides immediatehigh stone free rates, but with high risk of treatment failure.

Single Session Endourological Management for Bilateral Forgotten/Neglected Double J (DJ) Ureteric Stents Using Galdakao-Modified Supine Valdivia Position

Background: Management of forgotten/neglected DJ stent is time consuming, impairing quality of life, complicated, costly and can be lethal. We use galdakao-modified supine Valdivia position to managed bilateral forgotten/neglected DJ stent to reduce the length of operation time and complication. Case presentation: we treated a 33-year-old female with bilateral forgotten/neglected DJ stent. We decided to performed retrograde intrarenal surgery using semi-rigid ureteroscope for the right forgotten/neglected DJ stent and supine percutaneous nephrolithothomy under galdakao-modified supine valdivia position for the left forgotten/neglected DJ stent in a single session. Post operative course was uneventfull and the patient was discharged on the second day. Conclusion: Galdakao-modified valdivia position is a good patient position to perform multiple endourological safe procedure in a single session that could reduce the length of operation time and hospital stay in managing patient with bilateral forgotten/neglected DJ stent.

Ureterorenoscopy And Lithotripsy with and Without DJ Insertion; Experience at Allied Hospital, Faisalabad

Objective: To evaluate the success and safety of URS and lithotripsy with and without DJ stenting. Settings: Department of Urology and Kidney Transplantation, Faisalabad Medical University / Allied Hospital, Faisalabad-Pakistan. Duration: From January 2015 to August 2018. Methodology: It was prospective study. Total 210 were included in the study. 190 patients completed their follow up. URS and lithotripsy was done with pneumatic lithoclast. DJ stenting was done in 92 patients and 98 patients were left without DJ insertion. Results: All patients were divided into two groups. Group A comprised of 105 cases and Group B comprised of 105 patients. URS and lithotripsy were done successfully in 98 cases in group A and 92 cases in group B. Group A was without DJ insertion and Group B was with DJ insertion. Data was analyzed by chi-square test and p-value was calculated. Lower urinary tract symptoms, pain, Hematuria, stone passage, AUR and fever were noted in both groups. Lower urinary tract symptoms including dysuria was seen in 20(20.40%) in non-stented patients and 31(33.36%) in stented patients. Hematuria was seen in 3(3.06%) in non-stented patients and 4(4.34%) in stented patients. Fever was noted in 3(3.06%) in non-stented patients and 7(7.60%) in stented patients’ Acute urinary retention which needs catherization was found in 1(1.02%) in non-stented group and 2(2.17%) in stented group. Flank pain was seen in 22(22.44%) in non-stented patients and 18(19.56%) in group B. Five (5.10%) were unable to pass stone in group A and 2(2.17%) were unable to pass stone in group B. All these patients required repeat ureterorenoscopy and lithotripsy. There was no case of forgotten DJ or broken DJ in any group. Conclusion: URS and lithotripsy are procedure of choice for ureteric calculi. It can be performed safely and successfully without DJ insertion in most of the cases.

Is retrograde intrarenal surgery the game changer in the management of upper tract calculi? A single-center single-surgeon experience of 131 cases.

Introduction:Success of any modality for stone disease needs to be evaluated in terms of Stone Free Rates (SFR), auxiliary procedures needed; complications and follow up. SFR in RIRS is subject to parameters like stone burden, location, number, hardness, composition; calyceal and ureter anatomy; use of ureteric access sheath (UAS); surgeon experience etc.Methods:The aim of this study is to evaluate the efficacy and safety of RIRS for managing upper tract stones. The objectives include evaluating SFR in RIRS in relation to stone burden, location and number. Other objectives include evaluating SFR after re RIRS in relation to stone burden, necessity of pre DJ stenting, use of UAS and post operative complication rate. 131 patients operated by single surgeon for single/multiple renal and/or upper ureteric stones were evaluated. Stone size > 3 mm on follow up CT KUB was considered as residual. Re RIRS was required for residual stones.Results:The overall SFR was 76%. SFR were statistically lower with stone burden > 1.5 cm, lower calyceal stones and single stones with stone burden > 1.5 cm. SFR was 90% after 2nd RIRS and 98.5% after 3rd RIRS procedure. No significant difference in SFR was noted between single v/s multiple stones, single calyx v/s multiple calyx stones and renal v/s upper ureteric stones. No major complication was noted.Conclusion:Larger stone burden and lower calyceal location are important factors deciding SFR in RIRS. With auxiliary procedure, RIRS is safe and effective compared to PCNL.

Pediatric renal transplantation using flow cytometry crossmatch and HLA immunophenotyping based on DNA for screening: a case report

Renal transplantation is the most successful treatment option for children with kidney failure. Patient survival rate at 1, 5 and 10 years is, respectively, 99%, 97%, and 96%. Successful renal transplantation can almost restore a child´s normal life. Flow cytometry crossmatches and HLA typing based on DNA is more sensitive for predicting chronic rejection than CDC crossmatch. We report the experience of kidney transplant surgery in a child, using screening-flow cytometry crossmatches and HLA immunophenotyping based on DNA- to predict graft rejection between the recipient and the donor, at Dr. Saiful Anwar Hospital in Malang, the first time this was conducted in Indonesia. We evaluated a 15-year-old female adolescent with end-stage chronic kidney disease. We predicted graft rejection using flow cytometry crossmatch and HLA typing based on DNA between the recipient and the donor. A 15-year-old female adolescent with end-stage chronic kidney disease underwent hemodialysis for 3 months, and renal transplantation was planned. Flow cytometry-based crossmatch analysis from T and B cell lymphocytes showed a negative crossmatch. HLA-ABDR immunophenotyping using a PCR-SSP (polymerase chain reaction-based sequence-specific primers) method showed a 3/6 mismatch. A kidney from her mother was transplanted using the end-to-end anastomose method. Tension occurred during the operation, and the donor's kidney was installed in mesh to increase vascularization of the kidney. After the transplantation procedure, the recipient received immunosuppressive treatment. A 4-month follow-up showed no graft rejection and normal daily activity, but there was an increase in the renal function test. Re-evaluation of the recipient indicated ureteral stenosis, so we performed ureterorenoscopy with a Holmium laser, and inserted a DJ stent. Kidney transplantation is considered as the treatment of choice for end-stage renal disease, particularly in childhood. Flow cytometry crossmatch and HLA immunophenotyping based on DNA can be used to predict graft rejection between the recipient and the donor. Kidney transplantation offers better management than dialysis for children suffering from kidney failure, in terms of cost-effectiveness, survival, and quality of life.