Saurabh Mishra

Recurrence of fistula is one of the very common complications of fistula repair. The disease has immense psychosomatic effect on the patients due to continuous leakage of urine. Management of recurrent vesico-vaginal fistula (VVF) repair poses a challenge to surgeons. Group I-12 patients with recurrent VVF, having robotic repair from August 2006 to June 2008, were included in the present study. Group II-20 patients matched in all possible parameters with recurrent VVF having open surgical repair in the past were taken as controls. Patients in both the groups were evaluated by assessing relevant clinical details; performing urine routine examination and culture, renal function test, three swab test, ultrasonogram-kidney, ureter, and bladder radiograph, intravenous urogram (to look for upper tract and rule out uretero-vaginal fistula), and urethro-cystoscopy. The details were retrospectively recorded from the case sheets. In group I, 100% were successfully managed as compared with 90% in group II, but it was not statistically significant (p > 0.05). Mean blood loss was significantly less (p < 0.05) in group I compared with group II (mean 88 vs. 170 mL). The mean hospital stay also was significantly less (p < 0.05) in group I in comparison with group II (mean 3.1 vs. 5.6 days). None of the patients had complications in group I compared with group II, but it was not significant. The present study suggests that robotic VVF repair is a better option for recurrent fistulas in view of its reduced morbidity, without compromising the results.

To analyze the feasibility and outcome of retroperitoneoscopic nephrectomy for benign nonfunctioning kidneys and compare it with open simple nephrectomy. From January 1998 to December 2006, 505 retroperitoneoscopic nephrectomies were performed. In the same time period, 112 open nephrectomies were also performed. In the retroperitoneoscopic group, the mean age was 39 years (range 15-74 years); 204 (40.4%) were men and 301 (59.6%) were women. Forty in this group had a history of surgery. Thirty-six patients had a pyonephrotic kidney; 33 of these patients had undergone percutaneous nephrostomy preoperatively. The cause of the nonfunctioning kidney was ureteropelvic junction obstruction in 198 patients, calculus disease in 193 patients, genitourinary tuberculosis in 48 patients, renal dysplasia in 19 patients, anomalous kidney in 20 patients, and renovascular hypertension in 16 patients. In 11 patients, there were other causes for the nonfunctioning kidney. Retroperitoneoscopic nephrectomy was performed in 476 (94.2%) patients. Conversion to open nephrectomy was necessary in 25 patients. The mean operative time was 85 minutes (range 45-240 min) in the retroperitoneoscopic group and 70 minutes (range 35-120 min) in the open group. The mean blood loss was 110 mL (range 30-600 mL) in the retroperitoneoscopic group and 170 mL (range 70-500 mL) in the open group. Four (0.8%) patients in the retroperitoneoscopic group needed a blood transfusion, whereas 5 (4.5%) patients in the open group had a blood transfusion. The hospital stay in the retroperitoneoscopic group was 3 days (range 1-7 d) and was 5 days (range 3-12 d) in the open group. Retroperitoneoscopic nephrectomy, although technically challenging, is becoming a gold standard for patients with nonfunctioning kidneys caused by benign conditions.

To evaluate the outcome of percutaneous nephrolithotomy (PCNL) in anomalous kidneys performed at our center. A total of 46 patients (52 renal units) with renal abnormalities were offered PCNL from January 2000 to December 2007 at our department. Of these 46 patients, 35 had a fusion anomaly (31 with a horseshoe kidney and 4 with crossed fused ectopia), 7 had malrotation, and 4 had ectopic pelvic kidneys. All 4 patients with a pelvic ectopic kidney underwent laparoscopic-assisted PCNL. The mean age was 31.5 years (range 16-52). The male/female ratio was 1.55, the left-to-right ratio was 1.3, and 6 patients had bilateral renal stones (all in horseshoe kidneys). The mean stone size was 2.4 cm (range 1-5). In addition, 8 patients (5 with a horseshoe kidney, 2 with an ectopic pelvic kidney, and 1 with a malrotated kidney) had a history of failed extracorporeal shock wave lithotripsy. Complete clearance was achieved in all renal units (45 at the first attempt and 7 with a "relook"). The stone was cleared by a single tract in 46 renal units (88.5%), and 6 required 2 tracts (3 horseshoe kidneys, 2 malrotated kidneys, and 1 crossed fused ectopic kidney). Five patients with a horseshoe kidney underwent tubeless PCNL. The mean operating time for PCNL was 82.5 minutes (range 30-150), and the mean hospital stay was 3.2 days (range 1-8). The average decrease in hemoglobin was 1.4 g/dL (range 0.5-4). One patient developed injury to the pleura that was managed by intercostal tube drainage. Two patients developed post-PCNL sepsis. Although PCNL in anomalous kidneys is technically demanding, it gives excellent results for large or extracorporeal shock wave lithotripsy-refractory stones, if performed carefully.

Congenital absence of uterus and vagina, Mayer–Rokitansky–Kuster–Hauser (MRKH) syndrome, is mullerian agenesis and is the second most frequent cause of primary amenorrhea. Only atypical form of MRKH (type B) is associated with renal skeletal and ovarian abnormalities. We report the management of an unusual case of atypical MRKH, unilateral gonadal agenesis, and solitary ectopic pelvic kidney with pelviureteric junction obstruction (PUJO). After doing thorough Medline search, to the best of our knowledge, this is the first case reported with this combination.

Abstract:  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.

To assess the efficacy, safety, and morbidity of tubeless percutaneous nephrolithotomy (PCNL) and compare it with standard PCNL. A total of 135 patients (140 renal units) undergoing tubeless PCNL (group 1) from June 2000 to September 2007 were compared with a similar group of 185 (194 renal units) patients undergoing standard PCNL (group 2) in the same period. Patients who needed more than two percutaneous tracts; who had significant intraoperative bleeding, intraoperative perforation of the pelvicaliceal system, excessive manipulation at the ureteropelvic junction, or a residual stone after the procedure; and who had a solitary kidney or azotemia were excluded from the study. The chi-square test was performed for statistical analysis of qualitative variables and the student's t test for quantitative variables. A P value < 0.05 was considered significant. The mean age in group 1 was 34.4 years (range 9-66 yrs) and in group 2 was 32.6 years (range 6-74 yrs). Male/female ratio was 1.7 and 1.6 respectively. The average stone size in group 1 was 3.2 cm (range 2-5.5 cm) v 3.6 cm (range 2.2-6.0 cm). Sixteen patients in group 1 and 24 patients in group 2 were in the pediatric age group. Simultaneous bilateral PCNL was performed in 6 patients in group 1 and 10 patients in group 2. Both the groups were comparable in age, sex ratio, side ratio, stone size, location, preoperative incidence of urinary tract infection, method of tract dilatation, and mean operative time. The incidence of single tract (95 v 98 in group 1 and group 2) for complete stone clearance was significantly more in the tubeless group. Mean hospital stay (1.8 v 2.9 days) and the analgesic requirement (68 mg v 210.5 mg of pethidine) was also significantly less in the tubeless group. Blood loss and mean operative time were also less in the tubeless group but were not statistically significant. Tubeless PCNL is safe and effective. It has significantly less morbidity, a shorter hospital stay, and less postoperative analgesic requirement in comparison with standard PCNL.

To assess the safety and effectiveness of transurethral vapor resection of prostate (TUVRP) for the management of prostate glands with a volume of >100 g. Thirty-nine patients who were found to have benign prostatic hyperplasia and prostate volume of >100 g, as determined by abdominal ultrasonography, were offered TUVRP between July 2002 and August 2008. International prostate symptom score (IPSS), prostate volume, postvoid residue (PVR), and maximum flow rate (Qmax) formed part of preoperative evaluation. We also assessed intraoperative and postoperative parameters, including operative time, irrigant fluid requirement, blood loss, duration of postoperative catheterization, hospital stay, and postoperative complications. The mean prostate volume was 121.39 g (range 101-232 g). The mean age was 65.70 years (range 54-94 years). About 12 patients had a catheter preoperatively. Mean IPSS was 24.87 (21-28). Mean Qmax and PVR were 7 mL/seconds (4-12) and 133 mL (77-160), respectively. Mean operative time was 77 minutes (50-115), and mean irrigant fluid used was 26.48 L (18-36). Mean resected weight of prostate was 49.4 g (43-54). Average postoperative catheter duration was 2.38 days (2-2.5) with average postoperative hospital stay being 3.75 days (2-5). Effectiveness assessed at 6 months was IPSS 5.7, Qmax 20.5 mL/seconds, and insignificant PVR. TUVRP is an alternative treatment modality for prostates >100 g owing to its excellent intraoperative vision, shorter operative time, and reduced hospital stay.

Objectives:  To evaluate the success rate of redo anastomotic urethroplasty and to compare it with primary anastomotic urethroplasty.Methods:  We compared 52 patients with post-traumatic posterior urethral strictures (group 1, mean age 24.6 years, range 10–62) who had undergone redo urethroplasty with 66 patients (group 2, mean age 22.6, range 6–71) who had undergone primary anastomotic urethroplasty. Mean stricture length was 2.0 cm (1–4.5) and 2.5 cm (1.5–6), respectively. All of the patients in group 1 had a stricture located at the bulboprostatic anastomotic site. In group 2, 43 (65.2%) had a bulbomembranous stricture and 23 (34.8%) had a prostatomembranous stricture.Results:  Mean operative time was 140 (100–240) and 90 min (75–200) in group 1 and 2, respectively. Mean blood loss was 180 (80–900) and 125 mL (50–700), respectively. Mean hospital stay was comparable (6.6 days vs 5.5 days) between the two groups. Mean follow up was 54 months (10–144) for group 1 and 62 months (12–122) for group 2. Corporal separation, inferior pubectomy, a transpubic approach and urethral rerouting were required in 22 (42.3%) and 12 (18.2%), 7 (13.5%) and 3 (4.5%), 12 (23%) and 5 (7.6%), 2 (3.8%) and nil patients in group 1 and 2, respectively. An excellent or acceptable outcome was achieved in 42 (80.8%) and 57 (86.4%), 8 (15.4%) and 7 (10.6%) patients, respectively. Two patients in each group failed.Conclusions:  Previously failed end-to-end urethroplasty does not alter the success rate of redo end-to-end urethroplasty.

Currently, surgical repair for vesicovaginal fistula (VVF) provides excellent results, but the recurrent VVF is difficult to treat as compared to primary. Sixty-eight patients (44 primipara and 24 multipara) with recurrent VVF repair from January 2002 to December 2007 were included in present study. The mean size of fistula was 2.8 cm (1.0-6.5). The previous surgical repair was through the abdominal route in 50 patients (73.53%) and through the vaginal route in the remaining 18 patients (26.47%). The procedure was successful in 62 of 68 patients (91.17%). The mean duration of surgery was 146.6 min (100-210). Mean blood loss was 160 ml (110-400) and mean hospital stay was 5.6 days (4-10). Eight patients developed complications. Recurrent VVF is difficult to treat, but excellent results can still be achieved by strictly sticking to the principals of surgical repair for VVF.