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Context Although percutaneous nephrolithotomy (PCNL) has been performed for decades and has gone through many refinements, there are still concerns regarding its more widespread utilization because of the long learning curve and the potential risk of severe complications. Many technical details are not included in the guidelines because of their nature and research protocol. Objective To achieve an expert consensus viewpoint on PCNL indications, preoperative patient preparation, surgical strategy, management and prevention of severe complications, postoperative management, and follow-up. Evidence acquisition An international panel of experts from the Urolithiasis Section of the European Association of Urology, International Alliance of Urolithiasis, and other urology associations was enrolled, and a prospectively conducted study, incorporating literature review, discussion on research gaps (RGs), and questionnaires and following data analysis, was performed to reach a consensus on PCNL. Evidence synthesis The expert panel consisted of 36 specialists in PCNL from 20 countries all around the world. A consensus on PCNL was developed. The expert panel was not as large as expected, and the discussion on RGs did not bring in more supportive evidence in the present consensus. Conclusions Adequate preoperative preparation, especially elimination of urinary tract infection prior to PCNL, accurate puncture with guidance of fluoroscopy and/or ultrasonography or a combination, keeping a low intrarenal pressure, and shortening of operation time during PCNL are important technical requirements to ensure safety and efficiency in PCNL. Patient summary Percutaneous nephrolithotomy (PCNL) has been a well-established procedure for the management of upper urinary tract stones. However, according to an expert panel consensus, core technical aspects, as well as the urologist’s experience, are critical to the safety and effectiveness of PCNL.

There has been recent introduction of novel lithotripters and high-power lasers for stone disintegration. With miniaturization of PCNL, there is need of effective disintegration and faster stone-clearance. This study aimed to evaluate efficiency of Trilogy™ and Thulium fibre laser (TFL) in mini-percutaneous nephrolithotomy (mini-PCNL). This is prospective study comparing efficiency and outcomes of Trilogy™ and TFL in mini-PCNL between January 2019 and February 2020. Primary objective was to compare stone fragmentation rates, with secondary objectives beings stone-free rates and complications. There were 60 mini-PCNL with suction using either Trilogy™ or TFL energy source. Mean stone size and density were 27.60 ± 10.17 mm, 22.04 ± 9.69 mm (p = 0.05) and 1172.9 ± 313.5HU, 1308.9 ± 333.9HU (p = 0.10) for Trilogy™ and TFL, respectively. Using 3D doctor imaging software from CT images, mean stone volumes were 3718.9 ± 3038.7mm3 for Trilogy™ and 3425.9 ± 3096.1mm3 for TFL(p = 0.77). Using probe-activation time or lasing time, stone-fragmentation rate was 5.98 ± 4.25mm3/sec for Trilogy™ and 3.95 ± 1.00mm3/sec for TFL(p = 0.015). Treatment time (puncture to complete clearance) was 32.48 ± 15.39 min for Trilogy™ and 28.63 ± 18.56 min for TFL(p = 0.38). Haemoglobin drop was 1.19 ± 0.76gm/dl for Trilogy™ and 0.99 ± 0.74gm/dl for TFL (p = 0.30). Trilogy™ arm had 96.6% complete clearance and TFL had 76.6% in TFL at 48 h. One patient in Trilogy™ arm required auxiliary RIRS for residual stone. Both arms had complete stone clearance at 1 month follow-up. Trilogy™ arm had 3 Clavien–Dindo grade-II complications while TFL had 2 Clavien–Dindo grade-II complications (UTI requiring antibiotics). There was no blood transfusion in either of arm. Trilogy™ had significantly better stone fragmentation rate than TFL in managing renal stones. However, stone-free rates and complications were comparable for Trilogy™ and TFL.

To compare and analyze the results of laparoscopic ureteric reimplantation and robotic-assisted ureteric reimplantation at our tertiary institute.We retrospectively reviewed data of adult patients who underwent laparoscopic ureteric reimplantation and robotic-assisted ureteric reimplantation between January 2000 and December 2020. Data were analyzed for 19 patients in the laparoscopic group and 47 patients in the robotic group. The data were compared in both the groups.The most common presentation was flank pain (67.89%) followed by recurrent UTI (21.05%) in both the groups. The baseline characteristics and demographic data including age, gender, laterality, Charlson comorbidity index, and BMI were comparable in both the groups. The time range from previous surgeries to presentation varied from 7 days to 5 years. There is statistically significant difference between the operative time in the laparoscopic (224.23 ± 76.61 min) and robotic groups (187.06 ± 52.81 min) (p = 0.027). There is statistically significant difference between the hospital stay also between the two groups (9.07 ± 2.75 vs. 6 ± 1.65 days p-0.001). There were no differences in the complication rate and postoperative outcomes in both the groups. Mean length of follow-up was 28 ± 25.5 (2-108) months and 20.57 ± 19.91 (2-96) months in both the groups, respectively. The success rates in terms of symptomatic improvement, decrease in hydronephrosis, and improved drainage in the laparoscopic and robotic groups were 94.73% and 95.45%, respectively, which were statistically not significant.Robotic ureteric reimplantation and laparoscopic ureteric reimplantation are comparable in clinical outcomes. Robotic-assisted laparoscopic ureteric reimplantation is feasible, safe, and faster with excellent outcomes, decreased hospital stay, and minimal complications.

Introduction and Objective: Single-use flexible ureteroscopes have the benefit of decreasing infection transmission, avoiding sterilization need, and no maintenance cost. Primary objective was to c...

Gleason grading, a risk stratification method for prostate cancer, is subjective and dependent on experience and expertise of the reporting pathologist. Deep Learning (DL) systems have shown promise in enhancing the objectivity and efficiency of Gleason grading. However, DL networks exhibit domain shift and reduced performance on Whole Slide Images (WSI) from a source other than training data. We propose a DL approach for segmenting and grading epithelial tissue using a novel training methodology that learns domain agnostic features. In this retrospective study, we analyzed WSI from three cohorts of prostate cancer patients. 3741 core needle biopsies (CNBs) received from two centers were used for training. The κquad (quadratic-weighted kappa) and AUC were measured for grade group comparison and core-level detection accuracy, respectively. Accuracy of 89.4% and κquad of 0.92 on the internal test set of 425 CNB WSI and accuracy of 85.3% and κquad of 0.96 on an external set of 1201 images, was observed. The system showed an accuracy of 83.1% and κquad of 0.93 on 1303 WSI from the third institution (blind evaluation). Our DL system, used as an assistive tool for CNB review, can potentially improve the consistency and accuracy of grading, resulting in better patient outcomes.

To report safety and efficacy of mini-PCNL with suction attached to sheath combined with high-power Thulium Fibre laser (TFL). The secondary aim was to evaluate optimal laser settings for maximum stone dusting. Prospective, single arm study was conducted from June 2019–December 2019 using miniPCNL with suction and TFL in 54 patients with renal stones 3 mm) and weighed. Xray/CT scan imaging was performed in all patients within 48 h and 30 days to assess stone clearance. Optimal laser settings were evaluated for maximum dusting. Mean stone size was 18.32 ± 6.37 mm, volume was 2337.75 ± 1996.84mm3 and stone density was 1300.55 ± 435.32 HU. Total operative time was 39.85 ± 20.52 min, laser time was 10.08 ± 7.41 min and stone fragmentation rate was 5.02 ± 3.93 mm3/s. The procedure was completely tubeless in 37.04%, nephrostomy tube in 37.04% and DJ stent placed in 25.92%. Postoperatively, three patients had urinary infection (Clavien 2). Complete stone clearance at 48 h was achieved in 35 (64.8%) cases. 19 patients (35.2%) who had residual fragments at 48 h, had 100% clearance at one month on CT/Xray KUB. MiniPCNL using a nephrostomy sheath with suction along with high power Thulium Fibre Laser is safe and effective modality for lithotripsy. An initial laser setting of 0.2 J and 125–200 Hz was optimal for maximum dusting and simultaneous aspiration. Randomized comparative studies with other energy sources are being considered.

The prevalence of food allergies has reached epidemic levels but the cause remains largely unknown. We discuss the clinical relevance of the gut mucosal barrier as a site for allergic sensitization to food. In this context, we focus on an important but overlooked part of the mucosal barrier in pathogenesis, the glycoprotein-rich mucus layer, and call attention to both beneficial and detrimental aspects of mucus–gut microbiome interactions. Studying the intricate links between the mucus barrier, the associated bacteria, and the mucosal immune system may advance our understanding of the mechanisms and inform prevention and treatment strategies in food allergy.

Summary Reproducible in vivo models are necessary to address functional aspects of the gut microbiome in various diseases. Here, we present a gnotobiotic mouse model that allows for the investigation of specific microbial functions within the microbiome. We describe how to culture 14 different well-characterized human gut species and how to verify their proper colonization in germ-free mice. This protocol can be modified to add or remove certain species of interest to investigate microbial mechanistic details in various disease models. For complete details on the use and execution of this protocol, please refer to Desai et al. (2016)., Graphical abstract, Highlights • Colonization of germ-free mice with a synthetic human gut microbiome • One-medium-fits-all culturing approach for phylogenetically distinct bacteria • Rapid and easy-to-perform verification of colonization success • Useful to study functional aspects of the microbiome in various diseases, Reproducible in vivo models are necessary to address functional aspects of the gut microbiome in various diseases. Here, we present a gnotobiotic mouse model that allows for the investigation of specific microbial functions within the microbiome. We describe how to culture 14 different well-characterized human gut species and how to verify their proper colonization in germ-free mice. This protocol can be modified to add or remove certain species of interest to investigate microbial mechanistic details in various disease models.

Obsessive-compulsive disorder (OCD) is phenotypically heterogeneous. Gender is an important factor mediating this heterogeneity. We examined gender differences in a large sample (n = 945) of OCD patients under a multi-centric study in India. Cross-sectional assessments were done on consecutive adult (>18 years) treatment-seeking patients with a DSM-5 diagnosis of OCD. Subjects were assessed on Structured Clinical Interview for DSM-5-Research Version for comorbid psychiatric illnesses, Yale Brown Obsessive Compulsive Scale for OCD phenomenology and symptom severity, Brown Assessment of Beliefs Scale for insight, Beck’s Depression Inventory for severity of depressive symptoms, and the Obsessive Beliefs Questionnaire. On multivariate backward Wald logistic regression analysis, males (59.7%) had more years of education, had a higher rate of checking compulsions and comorbid substance use disorders. Women were more likely to be married, more commonly reported precipitating factors, had a higher rate of hoarding compulsions and comorbid agoraphobia. Findings from this large study validate gender as an important mediator of phenotypic heterogeneity in OCD. The mechanistic basis for these differences might involve complex interactions between biological, cultural and environmental factors.

Present study examined effectiveness of Integrative Body Mind Spirit (I-BMS) intervention among individuals with alcohol dependence. A 2-group single blind RCT design was used, comparing I-BMS to treatment as usual (TAU) on drinking and psychological outcomes. One hundred participants diagnosed with alcohol dependent syndrome were randomly assigned to receive 7 sessions of I-BMS or TAU. Measurements done by a registered nurse who was blinded to the experimental design used standardized questionnaire on wellbeing, readiness to change, craving, quantity and frequency of drinking before and up to 6 months after the intervention. With respect to the within group effects, the I-BMS group demonstrated significant improvement in all outcome measures with large effect size. Compared to TAU, I-BMS participants showed lesser relapse rates and quantity of drinking at 3-month follow-up, reduction in craving and drinking days at 2-month follow-up. At 6 months follow-up, participants in I-BMS group reported significant improvement in wellbeing and motivation compared to TAU. Results of binary logistic regression showed that number of previous attempts and living in urban area positively predicted participant's relapse possibility at 6-month follow-up. Results suggest that I-BMS is worthy of further efficacy testing. In conclusion, it is feasible to implement I-BMS intervention for individuals with alcohol dependence.

Purpose Urinary tract infection (UTI) is the most common bacterial infection among infectious complications in kidney transplant recipients (KTR). After transplantation, infections can result from surgical complications, donor-derived infections, pre-existing recipient infections, and nosocomial infections. Post-transplant infection is still a major cause of morbidity, mortality, graft dysfunction and rejection. In this paper, we aimed to review a few compelling questions in kidney transplantation (KTX). Methods To identify relevant clinical questions regarding KTX and UTI a meeting was conducted among physicians involved in the KT program in our hospital. After discussion, several clinically relevant questions related to UTI after KTX. The 5 first rated in importance were judged generalizable to other clinical settings and selected for the purposes of this review. Results Nearly half of the patients present in the first three months of transplant with UTI. The most common uropathogens in post-transplant UTIs are Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecalis. Risk factors for UTI include female sex, advanced age, recurrent UTI before transplant, prolonged urethral catheterization, delayed graft function, and cadaveric kidney transplant. Conclusion The incidence of post-transplant UTI is similar in both developed and developing countries. E.coli is the most common pathogen in most of studies. Cadaveric donor and post-dialysis transplantation are defined as independent risk factors for post-transplant UTI. Further studies are still required to identify risk factors after kidney transplantation and UTI's importance for graft function and patient outcome.

Purpose To evaluate the balance between existing evidence and expert opinions on the safety and efficacy of new technological improvements in lithotripsy techniques for percutaneous nephrolithotomy (PCNL). Methods A scoping review approach was applied to search literature in Pubmed, Embase, and Web of Science. Consensus by key opinion leaders was reached at a 2-day meeting entitled “Consultation on Kidney Stones: Aspects of Intracorporeal Lithotripsy” held in Copenhagen, Denmark, in September 2019. Results New-generation dual-mode single-probe lithotripsy devices have shown favourable results compared with use of ballistic or ultrasonic lithotripters only. However, ballistic and ultrasonic lithotripters are also highly effective and safe and have been the backbone of PCNL for many years. Compared with standard PCNL, it seems that mini PCNL is associated with fewer bleeding complications and shorter hospital admissions, but also with longer operating room (OR) time and higher intrarenal pressure. Use of laser lithotripsy combined with suction in mini PCNL is a promising alternative that may improve such PCNL by shortening OR times. Furthermore, supine PCNL is a good alternative, especially in cases with complex renal stones and large proximal ureteric stones; in addition, it facilitates endoscopic combined intrarenal surgery (ECIRS). Conclusion Recent technological improvements in PCNL techniques are promising, but there is a lack of high-level evidence on safety and efficacy. Different techniques suit different types of stones and patients. The evolution of diverse methods has given urologists the possibility of a personalized stone approach, in other words, the right approach for the right patient.

The consumption of prebiotic fibers to modulate the human gut microbiome is a promising strategy to positively impact health. Nevertheless, given the compositional complexity of the microbiome and its inter-individual variances, generalized recommendations on the source or amount of fiber supplements remain vague. This problem is further compounded by availability of tractable in vitro and in vivo models to validate certain fibers. We employed a gnotobiotic mouse model containing a 14-member synthetic human gut microbiome (SM) in vivo, characterized a priori for their ability to metabolize a collection of fibers in vitro. This SM contains 14 different strains belonging to five distinct phyla. Since soluble purified fibers have been a common subject of studies, we specifically investigated the effects of dietary concentrated raw fibers (CRFs)—containing fibers from pea, oat, psyllium, wheat and apple—on the compositional and functional alterations in the SM. We demonstrate that, compared to a fiber-free diet, CRF supplementation increased the abundance of fiber-degraders, namely Eubacterium rectale, Roseburia intestinalis and Bacteroides ovatus and decreased the abundance of the mucin-degrader Akkermansia muciniphila. These results were corroborated by a general increase of bacterial fiber-degrading α-glucosidase enzyme activity. Overall, our results highlight the ability of CRFs to enhance the microbial fiber-degrading capacity.

Context In an effort to reduce morbidity related to percutaneous nephrolithotomy (PCNL), some investigators have progressively introduced miniaturised approaches. The development of miniaturised nephroscopes facilitated widespread dissemination of these techniques and a significant expansion of the role of PCNL in endourology. Objective To discuss the different techniques comprising modern PCNL and identify the pros and cons of each of them. Evidence acquisition Data for this review were identified through a search of PubMed, including studies published in the last 20 yr in core clinical journals in English. The search terms included “urolithiasis”, “nephrolithiasis”, or “urinary stones” in combination with “miniaturised PCNL”, “mini-PCNL”, “micro-PCNL”, “minimally invasive PCNL”, and “ultra-mini PCNL”. Publications relevant to the subject were retrieved and critically appraised. Evidence synthesis The indications for miniaturised PCNL have not been standardised yet. Even though data in the literature reveal limitations and conflicting results, these techniques seem promising in terms of effectiveness and safety for the treatment of renal stones. The development of miniaturised scopes facilitated knowledge of the physics behind the vacuum cleaner effect generated during procedures, and greater efficacy of holmium laser generators and surgeon skill have led to progressive expansion of the indications for miniaturised techniques. Well-designed, randomised, multi-institutional studies are needed to better understand the indications for these miniaturised techniques before considering them a standard procedure for potential replacement of conventional PCNL. Conclusions Miniaturised PCNL represents a valuable new tool in the armamentarium of modern endourologists, capable of offering good outcomes with lower complications rates compared to the standard technique and higher cost effectiveness compared to flexible ureteroscopy. Patient summary Miniaturised percutaneous nephrolithotomy represents a safe and effective alternative to standard techniques for the treatment of renal stones. Each patient needs to be considered individually and tailored surgical treatment has to be offered.

The main aim of the paper is to report a single-centre experience with RAKT, focusing on surgical, perioperative and functional outcomes at a median follow-up of 2.8 years. Data of 26 RAKT patients was prospectively collected from December 2014 to February 2019 with follow-up of up to 55 months. All donors were done laparoscopically. We followed Vattikuti–Medanta technique with modification of using pfannenstiel incision instead of Gelpoint and patient positioned in steep Trendelenburg position (30°) with leg split position. Hypothermia was maintained using a “modified graft hypothermia jacket”. The engrafted kidney is oriented with the vessels being tagged with Prolene sutures. The mean BMI was 26.1 ± 4.7. The mean warm, cold and total ischemia times were 4.8 ± 1.1, 113.8 ± 20.9 and 118.7 ± 21.2 min, respectively. Mean rewarming time was 62.5 ± 10 min. The mean post-operative day (POD) 1, 3, 7, 30, 6 months, 1 year and most recent creatinine was 3.4, 2.4, 1.8, 1.4,1.2, 1.2 and 1.69 mg/dl. There was no case of delayed graft dysfunction (DGF) with graft survival of 1.8-55 months. The mean GFR at POD 1, 1 month and 1 year was 24, 53.16 and 64.6. We had two intraoperative complications—one topsy turvy graft placement with anastomosis of donor ureter to native ureter and other had to be converted to open technique after anastomosis to control graft surface bleeding. Three postoperative complications—one patient has graft pyelonephritis which was managed conservatively with antibiotics. Two patients had lymphocele. One patient was managed with just aspiration while the other required laparoscopic de-roofing of the lymphocele. The mean hospital stay was 13.5 ± 3 days. RAKT is feasible and safe only if performed by surgeons with appropriate background in robotic surgery and kidney transplantation after proper surgical training at experienced centres in the mid-term follow-up. Further studies need to confirm the long-term safety of RAKT.

Summary The gut microbiome expresses a multitude of enzymes degrading polysaccharides in dietary plant fibers and in host-secreted mucus. The quantitative detection of these glycan-degrading enzymes in fecal samples is important to elucidate the functional activity of the microbiome in health and disease. We describe a protocol for detection of glycan-degrading enzyme activity in mouse and human fecal samples, namely sulfatase and four carbohydrate-active enzymes. Assessing their activity can inform treatment strategies for diseases linked to the gut microbiome. For complete details on the use and execution of this protocol, please refer to Desai et al. (2016)., Graphical Abstract, Highlights • Quantitative detection of bacterial glycan-degrading enzymes • Determination of functional activities of the gut microbiome • Suitable for both mouse and human fecal samples, The gut microbiome expresses a multitude of enzymes degrading polysaccharides in dietary plant fibers and in host-secreted mucus. The quantitative detection of these glycan-degrading enzymes in fecal samples is important to elucidate the functional activity of the microbiome in health and disease. We describe a protocol for detection of glycan-degrading enzyme activity in mouse and human fecal samples, namely sulfatase and four carbohydrate-active enzymes. Assessing their activity can inform treatment strategies for diseases linked to the gut microbiome.

Flexible uretero-renoscopy (FURS) is an accepted modality for management of renal calculi in orthotopically placed kidney. Though it has been used in management of calculi in anomalous kidneys, the literature is scarce.To define the role of FURS in the management of stones in anomalous kidneys.We performed a retrospective analysis of all the patients with anomalous kidneys who primarily underwent FURS from January 2010 to December 2015 at our institute. In our study, we included patients with anomalies of lie, fusion and rotation. A total of twenty-five patients with twenty-five renal units having renal calculi in anomalous kidneys were evaluated. Indications for FURS included stone size less than or equal to 2 cm, contraindication to PCNL like bleeding tendencies, patients on anticoagulants or patients who refused ESWL and PCNL. Complete clearance of stone was defined as no residual fragment greater than 2 mm at the end of 4 weeks. The parameters evaluated were patient demographics, type of renal anomaly, stone size, location, laterality, patient's presentation, need for preoperative stenting, operative time, need for postoperative DJ stent, hospital stay, analgesic requirement, number of stages or auxiliary procedures required for stone clearance, success rate and complications.Twenty-five patients with calculi in anomalous kidneys were managed with FURS. These 25 patients had a total of 37 stones. Out of 25 patients, 14 had ectopic kidneys with 19 stones, 5 had malrotated kidneys with 6 stones, 5 had horseshoe kidneys with 11 stones and one had a left-to-right crossed fused ectopia with a single stone. Average age of presentation was 38.28 ± 12.59 years. Majority of the patients had the stones located in pelvis (n = 11) or lower calyx (n = 11). Eight stones were in middle calyx (n = 8), five in upper calyx (n = 5) and two in upper ureter (n = 2). Fifteen patients had a single stone, and 10 of them had 2 or more stones. Average size of stone was 14.71 ± 4.11 mm and average density being 1210.8 ± 237.7 Hounsfield units. Five patients had a preplaced DJ stent. Average Operative time was 74 ± 21.2 min, and patients had an average hospital stay of 59.48 ± 17.8 h. DJ stent was placed postoperatively in 21 patients, and four were managed with a ureteric catheter. Complete clearance was achieved in 22 (88 %) patients, three patients required two stages and one required the third stage. Three patients (12 %) could not be managed with FURS and required percutaneous stone clearance.Primary FURS is an effective and less invasive modality for management of renal calculi less than 2 cm in kidneys with anomalies of lie, fusion and rotation. It can offset the low clearance rate and high complication rate of ESWL and PCNL, respectively. Ureteral access sheath is an important tool to overcome anatomical challenges of anomalous kidney. Basket and Laser are indispensable accessories for FURS in anomalous kidneys.

Changes in the human gastrointestinal microbiome are associated with several diseases. To infer causality, experiments in representative models are essential, but widely used animal models exhibit limitations. Here we present a modular, microfluidics-based model (HuMiX, human–microbial crosstalk), which allows co-culture of human and microbial cells under conditions representative of the gastrointestinal human–microbe interface. We demonstrate the ability of HuMiX to recapitulate in vivo transcriptional, metabolic and immunological responses in human intestinal epithelial cells following their co-culture with the commensal Lactobacillus rhamnosus GG (LGG) grown under anaerobic conditions. In addition, we show that the co-culture of human epithelial cells with the obligate anaerobe Bacteroides caccae and LGG results in a transcriptional response, which is distinct from that of a co-culture solely comprising LGG. HuMiX facilitates investigations of host–microbe molecular interactions and provides insights into a range of fundamental research questions linking the gastrointestinal microbiome to human health and disease., Research on the interactions between the gut microbiota and human cells would greatly benefit from improved in vitro models. Here, Shah et al. present a modular microfluidics-based model that allows co-culture of human and microbial cells followed by 'omic' molecular analyses of the two cell contingents.

Objective To compare outcomes of ureteric and renal stone treatment with ureteroscopy (URS) in patients with or without the placement of a preoperative JJ stent. Patients and Methods The Clinical Research Office of the Endourological Society (CROES) URS Global Study collected prospective data for 1 year on consecutive patients with ureteric or renal stones treated with URS at 114 centres around the world. Patients that had had preoperative JJ stent placement were compared with those that did not. Inverse-probability-weighted regression adjustment (IPWRA) was used to examine the effect of preoperative JJ stent placement on the stone-free rate (SFR), length of hospital stay (LOHS), operative duration, and complications (rate and severity). Results Of 8 189 patients with ureteric stones, there were 978 (11.9%) and 7 133 patients with and without a preoperative JJ stent, respectively. Of the 1 622 patients with renal stones, 590 (36.4%) had preoperative stenting and 1 002 did not. For renal stone treatment, preoperative stent placement increased the SFR and operative time, and there was a borderline significant decrease in intraoperative complications. For ureteric stone treatment, preoperative stent placement was associated with longer operative duration and decreased LOHS, but there was no difference in the SFR and complications. One major limitation of the study was that the reason for JJ stent placement was not identified preoperatively. Conclusions The placement of a preoperative JJ stent increases SFRs and decreases complications in patients with renal stones but not in those with ureteric stones.

The goal of this randomized controlled trial was to compare the outcomes of robot-assisted laparoscopic donor nephrectomy (RDN) with standard laparoscopic donor nephrectomy (LDN).Forty-five voluntary kidney donors (27 for right subgroup and 18 for left subgroup) who met inclusion and exclusion criteria were randomized into 2 groups, RDN and LDN in 1:2 ratio. Primary endpoints were visual analogue scale (VAS) pain scores, analgesic requirement, and hospital stay of donors. Secondary endpoints were donor's intraoperative and postoperative parameters, graft outcomes, and donor surgeon's difficulty scores.All procedures were completed without any intraoperative complications. VAS pain scores at 6, 24, and 48 hours (p = 0.00), analgesic requirement (p = 0.00), and hospital stay (p = 0.00) were less in RDN than in LDN. Longer graft arterial length could be preserved with robotic approach on right side (p = 0.03) but not on left side (p = 0.77). The RDN group required more number of ports (p = 0.00), longer retrieval time (p = 0.00), and warm ischemia time (WIT) (p = 0.01). Total operative time (p = 0.14), hemoglobin drop (p = 0.97), postoperative donor complications (p = 0.97), and the recipient estimated glomerular filtration rate at 9 months (p = 0.64) were similar in both groups. Difficulty scores of console surgeon were less in most steps on right side but not on left side. Patient-side surgeon in RDN had higher difficulty scores for retrieval.RDN is safe and is associated with better morbidity profile than LDN. Robotic approach provides technical ease and facilitates preservation of longer length of renal artery on right side. Left RDN is associated with longer WIT; however, this does not translate into poor graft outcome.

The intestinal mucosal barrier is composed of epithelial cells that are protected by an overlying host-secreted mucous layer and functions as the first line of defence against pathogenic and non-pathogenic microorganisms. Some microorganisms have evolved strategies to either survive in the mucosal barrier or circumvent it to establish infection. In this Review, we discuss the current state of knowledge of the complex interactions of commensal microorganisms with the intestinal mucosal barrier, and we discuss strategies used by pathogenic microorganisms to establish infection by either exploiting different epithelial cell lineages or disrupting the mucous layer, as well as the role of defects in mucus production in chronic disease.

OBJECTIVE To report procedure process improvements and confirm the preserved safety and short-term effectiveness of a second-generation Aquablation device for the treatment of lower urinary tract symptoms (LUTS) attributable to benign prostatic hyperplasia (BPH) in 47 consecutive patients at a single institution. PATIENTS AND METHODS Aquablation was performed in 47 patients with symptomatic BPH at a single institution. Baseline, peri-operative and 3-month urinary function data were collected. RESULTS The mean (range) patient age was 66 (50-79) years, and transrectal ultrasonography-measured prostate volume was 48 (20-118) mL. A median lobe was present in 25 patients (53%) and eight patients had catheter-dependent urinary retention. The mean (range) total procedure time was 35 (13-128) min and the tissue resection time was 4 (1-10) min. Five Clavien-Dindo grade I/II and five Clavien-Dindo grade III complications were recorded in eight patients. The mean (range) hospital stay was 3.1 (1-8) days and the mean (range) duration of urethral catheterization was 1.9 (1-11) days. The mean International Prostate Symptom Score (IPSS) decreased from 24.4 at baseline to 5 at 3 months; IPSS quality-of-life score decreased from 4.5 to 0.3 points; peak urinary flow rate increased from 7.1 to 16.5 mL/s and post-void residual urine volume decreased from 119 to 43 mL (all P

Objectives To present our single-centre experience of the micropercutaneous nephrolithotomy (microperc) technique and define its role in the management of renal calculi as well as to analyse the factors predicting outcome. Patients and Methods We retrospectively analysed data from 139 patients who underwent microperc for renal calculi between June 2010 and November 2014 at our institution. The factors analysed were demographic variables, which included age, sex, stone volume, stone density (Hounsfield units [HU]) and stone location, and intra- and peri-operative variables, such as operating time, drop in haemoglobin level, stone clearance and complications. Results The mean ± sd (range) patient age was 38.99 ± 17 years (9 months to 73 years), stone volume was 1 095 ± 1 035 (105–6 650) mm3 and stone density was 1 298 ± 263 HU. The mean ± sd (range) operation duration was 50.15 ± 9.8 (35–85) min, hospital stay was 2.36 ± 0.85 (2–5) days and drop in haemoglobin level was 0.63 ± 0.84 (0–3.7) mg/dl. Eight patients had renal colic that was managed by antispasmodic medication, four patients had renal colic severe enough to warrant JJ stenting and three patients had urinary tract infections which were managed with appropriate antibiotics. We were able to complete microperc in 130 patients, with 119 (91.53%) patients being rendered completely stone-free, while in 11 patients (8.46%) there were some residual fragments seen on imaging. On multivariate analysis, stone number, volume and density were found to be significant predictors of clearance. Conversion to mini- or standard percutaneous nephrolithotomy was required in nine patients (6.47%), with intra-operative complications and stone number being the significant factors warranting conversion on a multivariate basis. Conclusion The outcomes in the present study suggest that microperc is a promising treatment method for solitary renal stones with volumes

Objective To devise a management protocol for chylous ascites after laparoscopic nephrectomy. Patients and Methods We retrospectively reviewed the data of the patients that underwent laparoscopic nephrectomy between January 2010 and January 2014 in our institution for different indications and were diagnosed with chylous ascites. We also analyzed a different management protocol that was used. Results The overall incident rate of chylous ascites was 0.77%. It was more commonly seen on left side and with simple nephrectomy rather than radical. Three out of 9 patients were managed by surgical intervention, rest were successfully managed on conservative treatment in the form of dietary modification, total parenteral nutrition, or octreotide. Conclusion Chylous ascites is a rare but morbid condition following laparoscopic nephrectomy. To manage this complication, we propose preventive and treatment strategies based on symptoms and amount of chylous ascites using our experience and review of the literature.

To review the most recent literature and contemporary role of the use of porcine and chicken models in laparoscopic and robotic simulation exercises, for training and skill assessment.There are multiple types of the simulators which include mechanical, virtual reality, hybrid simulators and animal models. The recent literature has seen insurgence of several of such simulators, specifically the animate ones comprising porcine and chicken models. The different training models reported have evolved from generalized and simpler, to a more task dedicated and complex versions. Unlike in the past, the recent publications include analysis of these models incorporating different measures of validity assessment.On account of the natural tissue properties inherent to these porcine and chicken models, they are proving to be instrumental in acquisition of higher surgical skills such as dissection, suturing and use of energy sources, all of which are required in real-time clinical scenarios be it laparoscopy or robotic-assisted procedures. In-vivo training in the animal model continues to be, perhaps, the most sophisticated training method before resorting to real-time surgery.

Urolithiasis is a significant worldwide source of morbidity, constituting a common urological disease that affects between 10 and 15% of the world population. Recent technological and surgical advances have replaced the need for open surgery with less invasive procedures. The factors which determine the indications for percutaneous nephrolithotomy include stone factors (stone size, stone composition, and stone location), patient factors (habitus and renal anomalies), and failure of other treatment modalities (ESWL and flexible ureteroscopy). The accepted indications for PCNL are stones larger than 20 mm2, staghorn and partial staghorn calculi, and stones in patients with chronic kidney disease. The contraindications for PCNL include pregnancy, bleeding disorders, and uncontrolled urinary tract infections. Flexible ureteroscopy can be one of the options for lower pole stones between 1.5 and 2 cm in size. This option should be exercised in cases of difficult lower polar anatomy and ESWL-resistant stones. Flexible ureteroscopy can also be an option for stones located in the diverticular neck or a diverticulum. ESWL is the treatment to be discussed as a option in all patient with renal stones (excluding lower polar stones) between size 10 and 20 mm. In addition, in lower polar stones of size between 10 and 20 mm if the anatomy is favourable, ESWL is the option. In proximal ureteral stones, ESWL should be considered as a option with flexible ureteroscopy Active monitoring has a limited role and can be employed in post-intervention (PCNL or ESWL) residual stones, in addition, asymptomatic patients with no evidence of infection and fragments less than 4 mm can be monitored actively.

Despite the accepted health benefits of consuming dietary fiber, little is known about the mechanisms by which fiber deprivation impacts the gut microbiota and alters disease risk. Using a gnotobiotic mouse model, in which animals were colonized with a synthetic human gut microbiota composed of fully sequenced commensal bacteria, we elucidated the functional interactions between dietary fiber, the gut microbiota, and the colonic mucus barrier, which serves as a primary defense against enteric pathogens. We show that during chronic or intermittent dietary fiber deficiency, the gut microbiota resorts to host-secreted mucus glycoproteins as a nutrient source, leading to erosion of the colonic mucus barrier. Dietary fiber deprivation, together with a fiber-deprived, mucus-eroding microbiota, promotes greater epithelial access and lethal colitis by the mucosal pathogen, Citrobacter rodentium. Our work reveals intricate pathways linking diet, the gut microbiome, and intestinal barrier dysfunction, which could be exploited to improve health using dietary therapeutics.

The energy source used for stone fragmentation is important in miniperc. In this study, we compared the stone fragmentation characteristics and outcomes of laser lithotripsy and pneumatic lithotripsy in miniperc for renal calculi.After Institutional Review Board approval, 60 patients undergoing miniperc for renal calculi of 15 to 30 mm were equally randomized to laser and pneumatic lithotripsy groups. Miniperc was performed using 16.5F Karl Storz miniperc sheath and a 12F nephroscope. Laser lithotripsy was performed using a 550-μm laser fiber and 30 W laser with variable settings according to the need. Pneumatic lithotripsy was performed using the EMS Swiss lithoclast. Patient demographics, stone characteristics, intraoperative parameters, and postoperative outcomes were analyzed.The baseline patient demographics and stone characteristics were similar in both groups. The total operative time (P = 0.433) and fragmentation time (P=0.101) were similar between the groups. The surgeon assessed that the Likert score (1 to 5) for fragmentation was similar in both groups (2.1 ± 0.8 vs 1.9 ± 0.9, P=0.313). Stone migration was lower with the laser (1.3 ± 0.5 vs 1.7 ± 0.8, P=0.043), and fragment removal was easier with the laser (1.1 ± 0.3 vs 1.7 ± 1.1, P=0.011). The need for fragment retrieval using a basket was significantly more in the pneumatic lithotripsy group (10% vs 37%, P=0.002). The hemoglobin drop, complication rates, auxiliary procedures, postoperative pain, and stone clearance rates were similar between the groups (P0.2).Both laser lithotripsy and pneumatic lithotripsy are equally safe and efficient stone fragmentation modalities in miniperc. Laser lithotripsy is associated with lower stone migration and easier retrieval of the smaller fragments it produces.

To analyze our experience in management of urolithiasis in renal donors.The stones were treated either pretransplant or posttransplant. The Amsterdam forum criteria for acceptance of living donors were used for donor selection. The donors underwent the following procedures: pretransplant extracorporeal shock wave lithotripsy (ESWL) (n=5), pretransplant retrograde intrarenal surgery (RIRS) (n=1), ex-vivo ureteroscopy (ex-vivo URS) (n=1), and ex-vivo pyelolithotomy (ex-vivo Pyl) (n=2); intraoperative Double-J stent; and observation (n=3). Data were analyzed for technical feasibility, intraoperative and postoperative complications, and stone clearance.The male and female ratio was 4:8 and average age was 52.3 years (38-71). In the pretransplant ESWL group, average of 740 shocks (600-1500) was given; the power was not ramped up beyond 12 kV. Ex-vivo URS was performed on bench with 6F pediatric cystoscope, while in the ex-vivo Pyl, a 12F nephroscope was introduced via a pyelotomy and stones were retrieved intact with a dormia basket. A postoperative ultrasound at one month revealed complete clearance of stones in all except one donor. At a mean follow-up of 36 months (10-58), there was no stone recurrence in donor or recipient.This report shows the feasibility and safety of ex-vivo URS and ex-vivo Pyl in living donors, in select cases with subcentimeter calculi, an option of conservative management with Double-J stent is safe. ESWL/RIRS can be performed safely in the pretransplant setting. Proper donor selection and follow-up are crucial to success. We propose a treatment selection algorithm for management of these donors.

To evaluate effect of intraperitoneal bupivacaine on postoperative pain in patients undergoing laparoscopic live donor nephrectomy. Hundred patients undergoing laparoscopic live donor nephrectomy were included in the study and were divided randomly into two groups based on computer-generated randomization chart of fifty each. Patients were made familiar with VAS chart preoperatively. Group A received 20 mL of 0.5 % bupivacaine, while group B patients received 20 mL of 0.9 % normal saline intraperitoneally Postoperatively, patients were assessed based on VAS and requirement of rescue analgesic, hemodynamic parameters and presence of any adverse effects. Student’s t test was used for statistical analysis. At all-time interval, mean pain scores were higher in group B than group A. The difference between the mean pain scores was statistically significant (p

Purpose of review Miniaturization of instruments in percutaneous nephrolithotomy (PCNL) has spawned an interest in so-called 'microperc' in which the procedure is carried out through 16-gauge needle. Recent findings The greatest limitation of extracorporeal shock wave lithotripsy is its unpredictable results. The main limitation of retrograde intrarenal surgery is high sustainable cost and poor durability. The main limitation of PCNL is its invasiveness and associated morbidity. The interest in reducing the tract size was to potentially reduce the invasiveness of the procedure, and, therefore, attending complications. In a historical study, postrenal biopsy bleeding was found to be significant only after the tract of the needle was less than 16 gauge. Microperc extended the concept of 'All-seeing needle' to perform PCNL through a 4.85-Fr (16 gauge) tract. The working hypothesis of the 'All-seeing needle' is that if the initial tract is perfect, then the tract-related morbidity could be reduced. The optical needle helps to avoid any traversing viscera and confirms the visual cues of a correct papilla. The other advantage of microperc is that it is a novel single-step renal access procedure, resulting in a shorter insertion to lithotripsy time. This may provide a new standard of obtaining renal access. Summary Only a few published studies have documented efficacy and safety. Till further prospective and multicentric articles are published, it is still an experimental procedure requiring further research.

Staghorn stone volume and its distribution within the collecting system, "staghorn morphometry," predicts the requirement of tract and stage for percutaneous nephrolithotomy (PCNL) monotherapy. The purpose of the study was to develop a CT urography staghorn morphometry-based prediction algorithm to predict tract(s) and stage(s) for PCNL monotherapy and classify staghorn accordingly.A retrospective case-control design of 94 units was used. CT software calculated the total stone volume (TSV) with absolute volume and percentile volume in the pelvis, planned entry calix, favorable and unfavorable calix. Entry calix was the optimum calix chosen, keeping the relations of the ribs and adjoining viscera that could clear maximum stone volume. Unfavorable calix was defined as having an acute angle from the entry calix and infundibular width of ≤ 8 mm. A prediction model with odds ratio (OR) (95% confidence interval) was constructed on univariate and multivariate regression factors.On univariate analysis, TSV (P=0.013), unfavorable calix stone volume (0.007), and percentile distribution of stone in pelvis (0.026), pelvis and entry calix (0.001), and unfavorable calix (0.001) predicted tracts while total stone (0.001), pelvic stone (0.0046), and unfavorable calix stone (0.001) volume and percentile volume in pelvis (0.04), pelvis and entry calix (0.005) and unfavorable calix (P0.001) predicted stage. Multivariate analysis showed that unfavorable calix stone percentile volume predicted tract (area under the curve [AUC] - 0.91) while TSV and unfavorable calix stone percentile volume (AUC - 0.846) predicted stage. The OR-based prediction model suggested a need for single tract and stage PCNL vs multiple tract and stage PCNL for TSV and unfavorable calix percentile stone volume of (5,000 mm(3) and 5%) and (20,000 mm(3) and 10%), respectively.The model predicts the tract and stage for PCNL monotherapy. Staghorn morphometry differentiates staghorn into type 1 (single tract and stage); type 2 (single tract-single/multiple stage, or multiple tract-single stage), and type 3 (multiple tract and stage).

Context Incidence, prevention, and management of complications of percutaneous nephrolitholapaxy (PNL) still lack consensus. Objective To review the epidemiology of complications and their prevention and management. Evidence acquisition A literature review was performed using the PubMed database between 2001 and May 1, 2011, restricted to human species, adults, and the English language. The Medline search used a strategy including medical subject headings (MeSH) and free-text protocols with the keywords percutaneous, nephrolithotomy, PCNL, PNL, urolithiasis, complications, and Clavien, and the MeSH terms nephrostomy, percutaneous/adverse effects, and intraoperative complications or postoperative complications . Evidence synthesis Assessing the epidemiology of complications is difficult because definitions of complications and their management still lack consensus. For a reproducible quality assessment, data should be obtained in a standardized manner, allowing for comparison. An approach is the validated Dindo-modified Clavien system, which was originally reported by seven studies. No deviation from the normal postoperative course (Clavien 0) was observed in 76.7% of PNL procedures. Including deviations from the normal postoperative course without the need for pharmacologic treatment or interventions (Clavien 1) would add up to 88.1%. Clavien 2 complications including blood transfusion and parenteral nutrition occurred in 7%; Clavien 3 complications requiring intervention in 4.1.%; Clavien 4, life-threatening complications, in 0.6%; and Clavien 5, mortality, in 0.04%. High-quality data on complication management of rare but potentially debilitating complications are scarce and consist mainly of case reports. Conclusions Complications after PNL can be kept to a minimum in experienced hands with the development of new techniques and improved technology. A modified procedure-specific Clavien classification should be established that would need to be validated in prospective trials.

Background In percutaneous nephrolithotomy (PNL), the best possible way to access the collecting system is still a matter of debate. There is little possibility of correcting a suboptimal access. Objective To describe our initial experience using a micro-optical system through a specific puncture needle to confirm the quality of the chosen access prior to dilatation of the operating tract. Design, setting and participants Micro-optics of 0.9- and 0.6-mm diameter were used. The micro-optic with integrated light lead was inserted through the working sheath of the puncture needle. The modified needle had a 1.6-mm (4.85-Fr) outer diameter. The optical fiber was connected via a zoom ocular and light adapter to a standard endoscopic camera system. For sufficient intraoperative sight, an irrigation system was connected. Intervention The optical puncture needle was used in 15 patients for renal access prior to standard PNL procedures. Measurements The optical assessment included determination of the distortion, resolution, angle, and field of view. The irrigation flow was assessed in an ex vivo setting, with the puncture stylet or the needle shaft either empty or with a 0.018-in guidewire inserted. Results and limitations In all cases, visualization of the punctured kidney calyces was successful and the presence of the target calculi could be confirmed prior to guidewire placement and tract dilation. The 0.9-mm optic was found to be significantly superior in all optical parameters in contrast to the 0.6-mm optic. No significant complications were observed. Conclusions The optical puncture needle for PNL appears to be most helpful for confirming the optimal percutaneous access to the kidney prior to dilation of the nephrostomy tract, improving the safety of the technique.

The purpose of this study was to compare in a randomized fashion the clinical outcomes following standard laparoscopic and laparoendoscopic single-site (LESS) donor nephrectomies.Fifty voluntary renal donors who met the inclusion and exclusion criteria were randomized to standard laparoscopic (group A) and LESS (group B) donor nephrectomies. The primary end point of the study was patients' postoperative pain. The clinical outcomes, patient's quality of life, body image, and cosmetic scores on follow-up were also compared.The operating times were similar in both groups (175.83 ± 47.57 vs. 172.20 ± 38.33 minutes, p = 0.38). The surgeon's difficulty as measured using a visual analog scale was significantly more in group B in 4 of 10 defined steps. The postoperative patient pain scores were similar till 48 hours following surgery (3.84 ± 1.68 vs. 3.68 ± 0.75, p = 0.33), but following which the patients in group B had improved pain scores (2.08 ± 0.91 vs. 1.24 ± 0.72, p = 0.0004). Analgesic requirements were similar in both groups (p = 0.47). The warm ischemia times in group B (5.11 ± 1.01 vs. 7.15 ± 1.84 minutes, p0.0001) were longer but the total ischemia times in both groups were similar (62.55 ± 9.46 vs. 62.71 ± 12.14 minutes, p = 0.48). All grafts had on-table urine output in the recipient. Intraoperative (8% vs. 16%, p = 0.2) and postoperative complications (20% vs. 16%, p = 0.99) in both groups were comparable. The patients in group B had shorter hospital stay (4.56 ± 0.82 vs. 3.92 ± 0.76 days, p = 0.003). There was no graft loss in either group except for one recipient in group A who sustained sudden cardiac death. The estimated glomerular filtration rates of recipients at 1 year were comparable for both groups (80.87 ± 22.12 vs. 81.51 ± 29.01 mL/minute, p = 0.46). The donor's quality of life, body image, and cosmetic scores were comparable for both groups.In this select group of donors, LESS donor nephrectomy, although challenging to the surgeon with longer warm ischemic times, gave early pain relief with shorter hospital stay and comparable graft function.

Uro Trainer (UT; Karl Storz GmbH, Tuttlingen, Germany), a virtual reality simulator for transurethral resection of prostate (TURP), has been infrequently validated. To ascertain the utility of such a trainer, we performed a basic face and content validity study.Ten experts and nine novices (done more than 50 and less than 3 TURPs, respectively) performed a TURP on UT and rated simulator usefulness (seven items), realism (five items), and overall score (one item) on a Likert's 10-point scale. Scores of6.0, 6.0 to 8.0, and8.0 on the Likert scale 1 to 10 were considered not, slightly, and highly acceptable, respectively.Novices rated UT as more helpful than experts in the following aspects of face and content validity: usefulness general (p = 0.0001, statistically significant), hand-eye coordination (p = 0.04, statistically significant), material knowledge and skills (p = 0.02, statistically significant), spatial skills (p = 0.003, statistically significant), cystoscopy (p = 0.002, statistically significant), TURP (0.002, statistically significant), visual aspects (p = 0.003, statistically significant), and overall score (p = 0.007, statistically significant). One item of usefulness (coagulation) and three items of realism (tissue feel, depth feel, and capsule identification) failed to impress both novice and experts. UT usefulness domain was highly acceptable for 77.7% and slightly acceptable for 100% of the novices and experts, respectively. The general realism domain was highly and slightly acceptable for 33.3% and 66.6% of the novices while slightly acceptable for 100% of the experts.Novice group found UT more useful than the experts group. Further modification is advisable to increase the realism of the UT.

The objective of this study was to assess the face, content, construct, convergent, and predictive validities of virtual reality-based simulator in acquisition of skills for percutaneous renal access.A cohort of 24 participants comprising novices (n = 15) and experts (n = 9) performed a specific task of percutaneous renal puncture using the same case scenario on PERC Mentor. All objective parameters were stored and analyzed to establish construct validity. Face and content validities were assessed by having all experts fill a standardized questionnaire. All novices underwent further repetition of the same task six times. The first three were unsupervised (pretest) and the later three after the PERC Mentor training (posttest) to establish convergent validity. A subset of five novice cohorts performed percutaneous renal access in an anesthetized pig before and after the training on PERC Mentor to assess the predictive validity. Statistical analysis was done using Student's t-test (por= 0.05 statistically significant).The overall useful appraisal was 4 in a scale of 1 to 5 (1 is poor and 5 is excellent). Experts were significantly faster in total performance time 187 +/- 26 versus 222 +/- 29.6 seconds (p0.005) and required fewer attempts to access 2.00 +/- 0.20 versus 2.8 +/- 0.4 (p0.001), respectively. The posttest values for the trained novice group showed marked improvement with respect to pretest values in total performance time 42.7 +/- 6.8 versus 222 +/- 29.6 seconds (p0.001), fluoroscopy time 66.9 +/- 10.20 versus 123.3 +/- 19.40 seconds (p0.0001), decreasing number of perforation 0.8 +/- 0.3 versus 1.3 +/- 0.2 (p0.001), and number of attempts to access 1.3 +/- 0.10 versus 2.00 +/- 0.20 (p0.001), respectively. Access without complication was attained by all five when compared with one with three complications (baseline vs. posttraining group, respectively) in the porcine model.All aspects of validity were demonstrated on virtual reality-based simulator for percutaneous renal access.

Introduction: Laparoscopic adrenalectomy remains a controversial procedure for large tumors. The incidence of adrenocortical carcinoma increases and technical difficulty of adrenalectomy increases as the size increases. We examined the outcome and complications of laparoscopic adrenalectomy for such lesions. Materials and Methods: Twenty-nine patients underwent laparoscopic adrenalectomy, of whom 19 had tumors larger than 5 cm in diameter, having a median tumor size of 7.0 cm. They were compared with patients whose adrenal tumors were smaller than 5 cm. Results: Patients with small tumors (< 5 cm) had a significantly shorter median operative time of 90 minutes as compared to 145 minutes in those with large tumors (> 5 cm). There was no significant difference in the median hemoglobin drop (1.05 g/dL versus 1.30 g/dL), time for starting oral intake (24 hours in both groups) or hospital stay (3.5 days versus 4.0 days) between patients with small and large tumors, respectively. There were no intra-operative complications except for 1 incidence of supraventricular tachycardia in a patient with a large pheochromocytoma. There were no major complications seen in any of the patients and no open conversions. Histopathology of large tumors revealed 16 benign tumors (8 pheochromocytomas, 4 adenomas, 2 ganglioneuromas, 1 pseudocyst, and 1 myelolipoma) and 3 malignancies, of which 1 was primary adrenocortical carcinoma and 2 were metastatic renal cell carcinoma. Conclusion: In experienced hands, laparoscopic adrenalectomy is safe and feasible for large functioning adrenal tumors. Large adrenal tumors suspicious of harboring malignancy with no peri-adrenal involvement can be tackled laparoscopically.

The impact of percutaneous nephrolithotomy (PCNL) in chronic kidney disease (CKD) patients was retrospectively analyzed in this study. We analyzed the factors that can impair renal function and predict the need for renal replacement therapy (RRT) after PCNL.Ninety-one chronic kidney patients with a mean age of 52.5 +/- 13 involving 117 renal units underwent PCNL in our institution for 5 years. A mean of 1.6 +/- 1.1 tracks and 1.3 +/- 0.6 sittings per renal unit was required for PCNL. The estimated glomerular filtration rate (eGFR) pre-PCNL (postdrainage), peak eGFR on follow-up, and eGFR at last follow-up were recorded. The CKD stage pre-PCNL was compared with the CKD stage at last follow-up.Complete clearance, auxiliary procedure, and complication rates were 83.7%, 2.5%, and 17.1%, respectively. The mean eGFR pre-PCNL and peak eGFR at follow-up were 32.1 +/- 12.8 and 43.3 +/- 18.8 mL/minute/1.73 m(2), respectively (p0.0001). At a mean follow-up of 329 +/- 540 days, deterioration with up-migration of CKD stage was seen in 12 patients (13.2%). Eight patients (8.8%) required RRT in the form of either maintenance hemodialysis or renal transplantation. Postoperative bleeding complication requiring blood transfusions was seen in seven (5.9%) and two (1.7%) of the renal units subsequently required super selective angioembolization. There were two mortalities in the postoperative period. Postoperative complications and peak eGFR (less than 30 mL/minute/1.73 m(2)) at follow-up are two factors that predict renal deterioration and RRT. Renal parenchymal thickness (8 mm) also predicts the need for RRT.PCNL has a favorable impact in CKD patients with good clearance rates and good renal functional outcome. PCNL in this high-risk CKD population is to be done with care and full understanding of its complications.

OBJECTIVE To review the development of the technique of percutaneous nephrolithotomy (PCNL), for ease of learning and development of instrumentation for staghorn calculi at our centre since 1991, and to assess the results and outcomes. PATIENTS AND METHODS We retrospectively analysed the hospital records of 773 patients (632 males and 141 females, 834 renal units) who underwent PCNL for staghorn calculi at our centre from January 1991 to August 2008. We divided the patients into three groups depending on the changes in treatment policy, global trends and advances in equipment as follows: the first 200 cases (group I) from January 1991 to December 1996 (216 renal units); the next 200 (group II) from January 1997 to December 2001 (212 renal units); and the last 373 (group III) from January 2002 to August 2008 (406 renal units). RESULTS The mean (sd, range) operative duration in groups I, II and III, respectively, were 138.2 (52.7, 60–310), 121.4 (42.8, 70–250) and 112.5 (51.5, 55–310) min; the decrease in haemoglobin level was 3.2, 2.6 and 1.6 g/dL, respectively, and continued to decrease with improvements in technique. With increasing experience, the number of stages required for stone clearance and the number of tracts required decreased exponentially. Most of the severe complications occurred early in our experience. The stone clearance rate in groups I, II and III was 81%, 86% and 93%, respectively, after completing the procedure; the overall clearance rate with observation/auxiliary procedures was 86%, 89% and 96%, respectively. The mean hospital stay for groups I, II and III was 11.1 (3.9, 7–25), 9.5 (3.4, 5–22) and 7.1 (3.6, 4–28) days, respectively. CONCLUSION The percutaneous management of staghorn calculi requires considerable expertise. Our data suggest that ‘multiperc’ PCNL is difficult to learn and requires experience. Although over the years our results improved, complete clearance remains a challenge. A constant review and application of newer techniques and results will improve the overall clearance rates further.

Laparoscopic Boari flap, psoas hitch, and direct ureteral reimplantation have all been described in the management of benign distal ureteral strictures.A retrospective review of a single center experience of laparoscopic reconstructive surgery for benign distal ureteral strictures was undertaken. The results of this initial series were compared with the published literature. To date, six patients with benign distal ureteral strictures have undergone laparoscopic reconstructive surgery at our center. Stricture etiology was stone disease in two patients, postvaginal hysterectomy in one patient, and unknown in the remaining two. In all cases, the operative procedure was undertaken with five-port transperitoneal access. Depending on healthy ureteral length, a decision for direct reimplantation was made in two patients, and Boari flap reconstruction was undertaken in the remaining three patients.Mean operative time was 322 minutes (range 240-360 min), which is longer than in the published literature, reflecting our initial learning curve in reconstructive laparoscopy. The mean drop in hemoglobin, however, was only 0.5 g/dL, which is comparable to that in other series. Further, there were no complications, and patients were discharged at a mean of 6.6 days postoperatively (range 5-9 days). All patients had satisfactory follow-up intravenous urograms with a mean follow-up period of 4 months.Laparoscopic reconstructive surgery for managing benign distal ureteral strictures is both safe and effective. Although open surgery currently remains the gold standard for these patients, all operative steps can be replicated laparoscopically, and this may become the future standard treatment.

To create a model for laparoscopic pyeloplasty training using the crop and esophagus of a chicken. The model can be used to simulate the steps taken during laparoscopic pyeloplasty and to help trainees practice laparoscopic suturing skills.The chicken crop and esophagus were used to simulate the renal pelvis and ureter, respectively. These were exposed by reflecting the skin overlying the neck and thorax. The crop was thoroughly cleaned and filled with water via the esophageal end to simulate the dilated renal pelvis. The chicken was positioned within an indigenously made laparoscopic training box. Laparoscopic pyeloplasty was performed using the dismembered Anderson Hynes technique. The model was used over a period of 1 month by three urology trainees in their final year of training. They were assessed with respect to time needed to complete anastomosis and quality of anastomosis.The mean operative time showed a marked reduction from the second to the fourth attempt. There was also a significant improvement in the quality of anastomosis from the first to the fourth attempt. At the end of four attempts, all trainees were able to satisfactorily complete a good quality ureteropelvic anastomosis in a mean time of 67.7 minutes (range 62-76 min).Laparoscopic suturing skills require effective training and constant practice to perfect the technique. Adequate practice on this chicken model shortens the learning curve, makes the trainee more confident of his or her skills, and improves his operative performance.

We prospectively compared the results of the Swiss LithoClast System with the holmium: yttrium-aluminum-garnet (Ho:YAG) laser for ureteral lithotripsy for management of upper ureteral stones.Fifty patients were randomized to two groups: LithoClast classic 2 (n = 25) and Ho:YAG laser (n = 25) between January 2005 and January 2007. Procedure selection was decided by random chit allotment. All patients who successfully had ureteral dilatation (up to 10F) were included in the study. An 8/9.8F semirigid ureteroscope was used in all procedures with LithoClast 2, and either an 8F or 7F was used in patients who underwent laser lithotripsy. Patients were analyzed for fragmentation time, stone-free rate, stone up-migration, intraoperative complications, and auxiliary procedures.Average stone size was 9.63 +/- 2.46 mm2 and 10.17 +/- 2.28 mm2 with overall stone-free rates of 84% and 88% (P = 0.41), respectively, for laser and LithoClast 2 groups. Stone up-migration was 24% and 16% (P = 0.82), mean stone fragmentation time was 9.82 +/- 7.58 and 7.86 +/- 3.25 minutes (P = 0.12), and stone fragments requiring ancillary procedures were 16% and 12% (P = 0.99), respectively, in laser and LithoClast 2 groups. Postoperative hematuria (up to 72 hours) was significantly (P = 0.04) prolonged in the laser group (36%) compared with the LithoClast 2 group (8%). Three patients in the LithoClast 2 group had instrument breakage.Both Ho:YAG laser and LithoClast 2 were equally efficient in managing ureteral stones with effective stone clearance, minimum morbidity, and reduced stone up-migration.

To evaluate the outcomes of laparoscopic nephrectomy for benign renal conditions associated with dense perinephric inflammation, such as xanthogranulomatous pyelonephritis (XGPN), pyonephrosis, tuberculous pyelonephritis, and calculus pyelonephritis, and compare outcomes with a matched group of patients undergoing open nephrectomy for similar indications. An additional objective was to evaluate factors predictive of complications and open conversions.We retrospectively analyzed data from 84 patients with benign inflammatory diseases who underwent laparoscopic nephrectomy and compared the data with data from 94 matched patients undergoing open nephrectomy. Both groups were compared with regard to operative time, blood loss, intraoperative and postoperative complications, analgesia requirement, blood transfusion, and hospital stay. Univariate analysis assessed the predictive value of factors such as kidney size, presence of hilar lymphadenopathy, perinephric and perihilar adhesion, laterality and body mass index on complications and risk of open conversion.Mean operative time was 170 +/- 59.8 and 148 +/- 42.5 minutes, blood loss was 156.2 +/- 6.8 and 154.6 +/- 68.8 mL, analgesia requirement was 165 +/- 71.2 and 284 +/- 81 g diclofenac sodium, and average hospital stay was 4.34 +/- 0.8 and 8.07 +/- 1.8 days in the laparoscopic and open groups, respectively. Abnormal renal hilum (71%) and perihilar adhesions (86%) were common findings in patients with XGPN, whereas abnormal hilum and hilar lymphadenopathy (55%) were commonly seen in those with tuberculosis. The renal hilum was relatively unaffected in patients with pyonephrosis and calculus pyelonephritis. Pleural entry was more common (P0.0001) in the open group, and visceral injury was more common in the laparoscopic group (P = 0.04). Blood transfusion was necessary in 7% and 11% of patients in the laparoscopic and open groups, respectively. Open conversion was required in 8 cases (autosomal dominant polycystic kidney disease-3, pyonephrosis, 2, XGPN and calculus pyelonephritis, 3). Intestinal obstruction that required laparotomy and adhesinolysis developed in one patient in the laparoscopic group.Laparoscopic nephrectomy can be performed safely in most patients with benign inflammatory conditions that require surgical extirpation. Proper patient selection and technical modifications may help reduce morbidity. One should keep a low threshold for laparoscopic-assisted open conversion whenever necessary.

To evaluate the safety and efficacy of simultaneous bilateral percutaneous nephrolithotomy (SBPCNL) for bilateral renal calculus disease.A retrospective study was conducted from June 1996 to February 2006 involving 38 male and 7 female patients with a mean age of 44 years (range 5-73 years) with 90 affected renal units who underwent SBPCNL under general anesthesia. Those patients with established nephrostomy tracts were excluded from the study group.The average duration of the procedure was 107 +/- 43 minutes (range 60-220 minutes). The average drop in hemoglobin was 2 +/- 1.2 g/dL (range 0.3-5.6 g/dL), with 3 patients (7%) requiring blood transfusion. In 87% of patients, a single stage was performed on both sides, while 13% required two stages on one side. A single tract was on both sides utilized in 78%, while 22% of the patients required two tracts on one side. None required two tracts on both sides or more than one stage on both sides. The stone-clearance rate was 96%. The average hospital stay was 6 days. Complications consisted of renal-pelvic perforation in two patients and transient pyrexia in five. Three patients had persistent urine leak on one side, of which two stopped spontaneously and one necessitated ureteral stenting.Simultaneous bilateral PCNL is a safe procedure and can be used effectively in adults as well as in children. In addition to being cost effective, it involves only a single anesthesia with a shorter hospital stay and faster convalescence. However, patients with a large stone burden or complex pelvicaliceal anatomy should not be selected for SBPCNL.

There are various concerns regarding percutaneous nephrolithotomy (PCNL) in the prone position, especially in the morbidly obese and patients with compromised cardiopulmonary status and stature deformity. We present our experience with supine PCNL with special reference to its technique, indications, advantages, and disadvantages.A series of 62 patients underwent PCNL in the supine position, 57 under general anesthesia and 5 with epidural anesthesia. Their average age was 48 +/- 14.16 years, and the average bulk of the stone was 316 +/- 275 mm2, with 11% of the patients having staghorn stones and 19 both renal and upperureteral stones. The average body mass index was 24.28 +/- 4.69, and 11% of the patients were morbidly obese. Nearly all patients (93%) had an anesthesia risk of ASA grade 3 or above. Two patients had hip ankylosis. All patients were placed in a modified dorsal lithotomy position with a 45 degrees tilt to the contralateral side. Under ultrasound guidance, the desired calix was punctured in or near the posterior axillary line.The average hemoglobin drop was 1.62 +/- 1.03 gm/dL, but only 3% of the patients required blood transfusion. None of the patients suffered visceral injury. Nearly all (95%) of the patients were rendered free of stones by the initial PCNL with or without ureteroscopy.Supine PCNL is an effective and safe procedure in high-risk and obese patients and allows simultaneous management of renal and ureteral stones.