Biomedical subjects

A K Hemal

Publications and source records attributed to A K Hemal.

At least 19 recordsLinked to original sources

PubMed2002

Retroperitoneal laparoscopic radical nephrectomy and nephroureterectomy and comparison with open surgery.

To compare the efficacy, safety and oncological completeness of retroperitoneoscopic radical nephrectomy (RPRN) and nephroureterectomy (RPRNU) with that of the open retroperitoneal approach for radical surgery for localised renal cell carcinoma and upper tract transitional cell carcinoma. Eighteen patients of RPRN, nine of RPRNU, 11 of open radical nephrectomy (ORN) and five patients who underwent open radical nephroureterectomy (ORNU) were evaluated. The groups were similar to each other. The mean operative times in the laparoscopic group were longer (147 and 188.7 min for RPRN and RPRNU vs 127.7 and 184 min for ORN and ORNU, respectively); however, the mean analgesic requirement (203.3 and 275 mg for RPRN and RPRNU vs 400 and 650 mg pethidine for ORN and ORNU, respectively), hospital stay (3.2 and 5.1 days for RPRN and RPRNU vs 7.6 and 9.2 days for ORN and ORNU, respectively) and return to normal activities (2 and 2 weeks in RPRN and RPRNU vs 4.3 and 4.6 weeks for ORN and ORNU, respectively) were lower in the retroperitoneoscopic group. Tumour-free margins could be achieved in all the cases. The mean duration of follow-up for RPRN and RPRNU was 17.7 and 15.0 months and for ORN and ORNU were 32.5 and 19.0 months, respectively. There was no port site or local recurrences. Distant metastasis developed in one case of RPRN and in two cases of RPRNU. The retroperitoneoscopic approach for a localised malignancy of the upper urinary tract appears to be effective and safe. An oncologically complete removal of the tumour is possible as in open surgery. The retroperitoneoscopic approach is associated with less morbidity and faster recovery.

Adult↗

PubMed2002

Potential of MRI and 31P MRS in the evaluation of experimental testicular trauma.

OBJECTIVES: To prognosticate and assess the metabolic status of germ cells of the testis after unilateral blunt testicular trauma using both magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS). MRI is a noninvasive technique suitable for evaluating testicular trauma, and MRS is useful in assessing the metabolic status of the testis. METHODS: The right testis of 35 male prepubertal Wistar rats, aged 30 days, was explored through an inguinal incision. The rats were randomized into control (group 1, sham surgery, n = 10) and study (n = 25) groups. The study group received unilateral blunt testicular trauma to the right testis. T(1)- and T(2)-weighted proton MRI of the ipsilateral testis were taken 6 hours after sham surgery or injury, and the rats were stratified on the basis of the absence or presence of intratesticular hemorrhage on MRI into groups 2 (n = 14) and 3 (n = 11), respectively. At 60 days of age, the contralateral testis of each rat was evaluated by 31P MRS and histologic examination. Quantification of phosphomonoesters, phosphodiesters, phosphocreatine, and adenosine triphosphate (gamma, alpha, and beta) was done. RESULTS: A statistically significant difference (P <0.05) in the phosphomonoester/adenosine triphosphate ratio, seminiferous tubular diameter, and Johnsen score of the contralateral testis was observed, indicating decreased testicular maturation of the contralateral testis in group 3 rats compared with groups 1 and 2. CONCLUSIONS: MRI after testicular trauma helped to stratify the extent of injury as determined by the presence or absence of intratesticular hemorrhage with prognostic value; 31P MRS and histologic examination revealed that testicular trauma significantly affects the maturation of the contralateral testis.

Age Factors↗

PubMed2002

Retroperitoneoscopic extirpation for adult multicystic calcified dysplastic kidneys with contralateral ureteral abnormalities mimicking genitourinary tuberculosis.

PURPOSE: To identify adult multicystic calcified dysplastic kidneys (AMCDK) with contralateral ureteral abnormalities mimicking urinary tuberculosis and to evaluate the feasibility and efficacy of retroperitoneoscopic extirpation in their management. PATIENTS AND METHODS: We retrospectively identified a group of adult patients who were referred to us as having unilateral nonfunctioning kidney containing calcified cystic masses with a contralateral normally functioning kidney along with segmental dilation of ureter. Two patients had histories of treatment elsewhere with antitubercular drugs on the basis of imaging studies, before being referred to our center for retroperitoneoscopic nephrectomy with a diagnosis of nonfunctioning left kidneys and urinary tuberculosis. The other two cases with similar findings on imaging studies were detected incidentally while the patients were undergoing investigations for vague abdominal symptoms. RESULTS: All these patients had AMCDK on the left side and a contralateral normally functioning kidney with ureteral abnormality. Retroperitoneoscopic extirpation of the nonfunctioning left renal unit was carried out uneventfully with a mean operating time, blood loss, and hospital stay of 124 minutes, 80 mL, and 3 days, respectively. There were no complications. The dissection in these cases was difficult, as the dysplastic calcified kidney was plastered in the retroperitoneum. CONCLUSION: Unilateral AMCDK with contralateral segmental dilation of the ureter may be separate entity or a coincidental finding, and it should not be confused with urinary tuberculosis unless there is microbiological and radiologic or histopathologic evidence of infection. Minimally invasive surgery in the form of retroperitoneoscopic extirpation is feasible, safe, and effective in such cases, although difficult, and it requires skills as well as experience.

Adolescent↗

PubMed2002

Bilateral cryptorchidism with bilateral inguinal hernia and retrovesical mass in an infertile man: single-stage laparoscopic management.

A 30-year-old married man presented with the complaint of inability to procreate. Examination revealed bilateral nonpalpable testes and bilateral inguinal hernia. Ultrasonography of the abdomen could not locate the testis; instead, a hypoechoic 5 x 5-cm mass was found behind the bladder. A CT scan of the abdomen revealed the right testis near the right inguinal canal. The left testis could not be identified beside the soft tissue mass. The patient was taken for diagnostic as well as therapeutic laparoscopy. The testis on the right was found just proximal to the internal inguinal ring, and right orchidopexy was done. The left testis was small and rudimentary; hence, orchidectomy was done. Bilateral laparoscopic herniorrhaphy was carried out with polypropylene mesh by fixing it intracorporeally to the pubic bone, Cooper's ligament, inguinal ligament, and conjoint tendon. Subsequently, the retrovesical mass was excised and retrieved by dilating the umbilical port site. The operative time was 3.5 hours with minimal blood loss. The postoperative period was uneventful, and the patient was discharged after 24 hours. The histopathology examination of the retrovesical mass showed an extragonadal germ cell tumor compatible with seminoma.

Adult↗

PubMed2002

A rare case of urachovesical calculus: a diagnostic dilemma and endo-laparoscopic management.

Urachal anomaly in an adult is extremely rare, as the majority of urachal remnants obliterate shortly after birth. A 55-year-old man presented with irritative voiding symptoms. A plain film demonstrated a radiopaque shadow in the region of the urinary bladder. Ultrasonography showed a fixed echogenic focus in relation to the anterior bladder wall. With these investigations, the patient was referred to us with a diagnosis of a vesical stone. We suspected it to be a case of a urachal calculus. Therefore, a CT scan of the pelvis was obtained, which showed a midline tubular tract containing a cylindrical stone, further extending into the bladder as a pedunculated stone. The patient was managed by a combination of endoscopic and laparoscopic techniques. A urachovesical stone like a cherry (pedunculated) has not been reported previously in the English-language literature. This case also illustrates for the first time the combined use of endoscopy and laparoscopy to retrieve a urachovesical stone and the excision of the urachus.

Calculi↗

PubMed2002

Is incidental appendectomy necessary during radical cystectomy?

OBJECTIVE: To find out the incidence of acute appendicitis leading to acute abdominal pain and necessitating appendectomy in the follow-up of patients after radical cystectomy and urinary diversions. METHODS: A prospective 160 consecutive radical cystectomy patients with urinary diversion in whom appendectomy was not done between January 1991 and June 2001 were reviewed for the incidence of acute appendicitis. Ages ranged between 26 and 73 years. There were 143 males and 17 females. 120 patients had ileal conduit, 20 sigmoid neobladder, 5 continent urinary diversion, and 15 ureterosigmoidostomy as urinary diversion. Each patients was followed up regularly till death or last follow-up. The follow-up ranged between 4 months and 10 years (mean 6 years). RESULTS: Intestinal obstruction (11%) and acute pyelonephritis (16%) were the most common causes of acute abdominal pain. The remaining causes include sigmoid neobladder perforation (0.6%), parastomal hernia (0.6%), urinary retention due to mucus (1.8%) and renal colic (1.8%). In all patients, diagnosis was easily made and they were managed accordingly. None of the patients had acute appendicitis requiring appendectomy on follow-up. CONCLUSION: Incidental appendectomy is not required during radical cystectomy as the risk of subsequent appendicitis is extremely low.

Adult↗

PubMed2002

Retroperitoneoscopic lymphatic management of intractable chyluria.

PURPOSE: We present our experience with retroperitoneoscopic lymphatic disconnection for the treatment of patients with intractable chyluria and review the current literature. MATERIALS AND METHODS: Our study included 6 males and 3 females 22 to 55 years old who presented with intractable chyluria of filarial origin and variable duration (2 to 11 years), and were selected for retroperitoneoscopic management of 11 renoureteral units. Diagnosis was based on urine examination for the presence of chyle and fat globules, cystoscopy, excretory urogram and retrograde ureteropyelography. The technique of retroperitoneoscopic management of chyluria consisted of nephrolympholysis, ureterolympholysis, hilar vessel stripping, fasciectomy and nephropexy. The first 3 procedures were done in all cases, whereas fasciectomy was only done in 4 cases and nephropexy in 3 as required. RESULTS: Chyluria disappeared in all ipsilateral renal units of the patients who underwent retroperitoneoscopic management but it recurred in 2 patients at 1 and 9 months of followup from the contralateral side. Both cases have since been successfully treated with contralateral retroperitoneoscopic management. Complications included lymphatic leak through the drain which persisted for 5 days in 1 case and an inadvertent clipping of a branch of the posterior segmental artery of the kidney in 1. The latter patient did not have pain or hypertension and the renal scan did not reveal any focal deficit at followup. All patients were followed periodically from 6 months to 41/2 years (mean of 31 months). CONCLUSIONS: The objectives of open surgical treatment of intractable chyluria can be achieved by the minimally invasive retroperitoneoscopic technique. Nephrolympholysis, ureterolympholysis and stripping of hilar vessels were essential in all cases. Fasciectomy and nephrectomy were done in a few patients and as mentioned are not recommended routinely. This approach has all of the benefits of laparoscopic surgery without compromising the principles of open surgery. Retroperitoneoscopic management was safe, effective and efficient.

Adult↗

PubMed2001

Retroperitoneoscopic nephrectomy and nephroureterectomy for benign nonfunctioning kidneys: a single-center experience.

OBJECTIVES: To report our experience of 185 cases of retroperitoneoscopic nephrectomy and nephroureterectomy for benign nonfunctioning kidneys with various modified techniques for differing etiologies. The feasibility, complications, and long-term outcomes are discussed. METHODS: The present study comprised 185 patients who underwent retroperitoneoscopic nephrectomy or nephroureterectomy during a 57-month period beginning July 1995. All procedures were done using the retroperitoneoscopic approach. Thirty-two patients had a history of previous surgery, 20 patients had a percutaneous nephrostomy, and 12 patients had mild renal impairment. RESULTS: Retroperitoneoscopic nephrectomy and nephroureterectomy were completed successfully in 167 patients. Eighteen patients required conversion to open surgery, 4 on an emergent basis and 14 electively. The mean operating time was 100 minutes (range 45 to 240), mean blood loss was 133 mL (range 30 to 1200), and mean hospital stay was 3 days (range 2 to 8). A total of 37 complications (16.2% were minor and 3.78% were major) occurred. Re-intervention was needed in 1 patient. No mortality resulted. Previous surgery, percutaneous nephrostomy, and chronic renal impairment did not affect the outcome. Apart from one incisional hernia, no long-term complications occurred. CONCLUSIONS: Retroperitoneoscopic nephrectomy and nephroureterectomy can be performed safely and successfully with obvious advantages for benign nonfunctioning kidneys regardless of the etiology or pathogenesis, with modifications in the approach in very difficult cases. Patients with conditions often considered to be contraindications (ie, genitourinary tuberculosis, pyonephrosis, history of previous surgery, percutaneous nephrostomy, stone disease, chronic renal failure, and horseshoe kidney) can also be successfully treated by skillful dissection and modifications in the surgical technique.

Adolescent↗

PubMed2001

Impact of power index, hydroureteronephrosis, stone size, and composition on the efficacy of in situ boosted ESWL for primary proximal ureteral calculi.

OBJECTIVES: The efficacy, safety, feasibility, and outcome of in situ treatment applied to select proximal ureteral calculi was assessed and analyzed with a view to avoiding auxiliary interventions and providing high clearance rates in the shortest possible time. We studied the impact of several clinically important variables, including power index, degree of hydroureteronephrosis (HDUN), stone size, and composition on the efficacy of sequential in situ boosted extracorporeal shock wave lithotripsy (ESWL) in a select group. The power index requirement for the in situ boosted protocol and the impact of the stone size/composition, degree of HDUN, and clearance rates were also analyzed. METHODS: An in situ (no instrumentation) boosted protocol was applied to 130 primary unimpacted proximal ureteral calculi with no prior intervention. A typical session with the Siemens Lithostar Plus comprised 3000 shock waves, in installments of 500, deployed at a power setting of 1 to 4 kV with a gradual stepwise escalation. Sequential boosted additional sessions of ESWL were administered on days 2, 7, and 14, tailored to the degree of fragmentation, clearance status, and amount of residual stone bulk. Several parameters (shock waves, kilovolts used, fluoroscopy time, number of sessions, stone size, composition, fragmentation, clearance, and HDUN) were recorded and the results analyzed statistically. RESULTS: The results were excellent in 83.8%, with a mean duration to complete clearance of 11.3 days. In situ ESWL failed in 7.69%, and the auxiliary intervention rate was 10.7%. Pre-ESWL HDUN was present in 78.3%, the mean power index was 184.6/session/case, and the average stone burden was 8.9 mm(2). Calcium oxalate monohydrate was the most common stone (56%). Renal colic was the most common side effect observed. The power index, fragmentation at the first session, and stone size were found to be the most favorable significant variables affecting stone clearance. The degree of HDUN, number of sessions, and stone composition did not significantly impact the clearance rates. CONCLUSIONS: In situ boosted ESWL should be the first-line therapeutic modality in select unimpacted primary proximal ureteral stones.

Adolescent↗

PubMed2001

Severely encrusted polyurethane ureteral stents: management and analysis of potential risk factors.

OBJECTIVES: To review the management of heavily encrusted and stuck JJ ureteral stents. We report our experience and review current published reports in managing heavily encrusted and stuck JJ stents, the guidelines for management, and the prevention of such problems. METHODS: We reviewed our stent records from January 1994 to December 2000 and analyzed our stent complications and their final outcome. Fifteen patients had heavily encrusted and stuck stents. Of these, 14 were encountered in patients with a sizable stone burden (400 to 650 mm(2)) and 1 occurred in a patient with malignant ureteral obstruction. Sandwich combinations of multiple extracorporeal shock wave lithotripsy/traction and endourologic procedures were used to render them stone and stent free. The stent was examined and the encrustation was analyzed by x-ray crystallography. RESULTS: Of 15 patients, 13 were available for evaluations; 1 patient was lost to follow-up and 1 patient died. The average stone burden was 625 mm(2). The encrustation was localized to the upper end in eight and to the lower and upper end in three. In 4 cases, the entire stent was encrusted, and the lumen was occluded in 12. All 13 patients with stuck, fragmented, and encrusted stents were rendered stone and stent free; 2 of the 13 had clinically insignificant residual stones (less than 2 mm). Calcium phosphate and monohydrate stones were the most commonly encountered stone encrustations. CONCLUSIONS: Stent encrustation is one of the most serious complications of polyurethane JJ stents. Multimodal endourology should form the cornerstone of therapy for heavily encrusted stuck stents. It is important to maintain an efficient computerized stent log under the direct supervision of a physician. Patients with probable risk factors should be monitored even more frequently to avoid mishaps and morbidity.

Adult↗

PubMed2001

Laparoscopic management of renal cystic disease.

Laparoscopic management of renal cystic disease is a highly effective, safe, and minimally invasive alternative to open surgery and antegrade or retrograde endoscopic procedures. Simple renal cysts can be accessed either transperitoneally or retroperitoneally. Almost all studies of the laparoscopic approach have demonstrated great satisfaction in terms of efficacy, minimal complications, operative time, minimal blood loss, hospital stay, recuperation, and cosmesis over other methods of treating renal cysts. Laparoscopic unroofing of peripelvic cysts is more challenging owing to their proximity to hilar vessels and the collecting system. Such surgery should be considered an advanced laparoscopic procedure. Access may be achieved either transperitoneally or retroperitoneoscopically. The basic principle of adequate exposure is essential for effective treatment. If the cyst is not completely excised, the surgeon must fulgurate the edge and tack perirenal fat in the residual cyst cavity to prevent recurrence and facilitate drainage. Laparoscopic evaluation of complex cysts seems to be sound. The results are promising, and follow-up does not show any increase in peritoneal seeding, tract recurrence, or distant metastases in the small number of neoplasms diagnosed at laparoscopy. Nevertheless, more studies are required with long-term follow-up. Bosniak type IV renal cysts or malignancy in renal cysts can be managed by laparoscopic radical nephrectomy with either access. Laparoscopic cyst marsupialization in patients with ADPKD is the latest emerging indication for laparoscopy in renal cystic disease. This procedure not only effectively reduces pain in some patients but also improves hypertension and stabilizes renal function, delaying renal replacement therapy. Long-term follow-up and further evaluation are needed.

Diagnostic Imaging↗

PubMed2001

Stone necklace of urinary tract presenting as renal failure: one stage management.

We describe three cases with bilateral extensive involvement of both upper and lower urinary tract with calculi presenting in renal failure. The management of these patients in a single operative session and rendering them stone free is discussed. Modern endourologic techniques have made it possible to treat patients with such an extensive involvement of the urinary tract with stone disease with minimum morbidity.

Aged↗

PubMed2001

Efficacy and outcome of surgical intervention in patients with nephrolithiasis and chronic renal failure.

AIM: To prospectively evaluate the efficacy and outcome of surgical intervention in patients with renal stones and chronic renal insufficiency. METHODS: The study was carried out from January 1999 till January 2001. Only patients with chronic renal failure without medical renal disease were taken up for study. All patients were subjected to an ultrasound assessment of the kidney, ureter and bladder. In case of obstructed and infected systems a preliminary percutaneous nephrostomy was carried out. After correction of dyselectrolytemia, acid base imbalance and dialysis (if indicated) patients were subjected to surgical intervention (open surgery or percutaneous nephrolithotomy). ESWL was offered for stones persisting after surgery. The stone burden, composition, therapeutic procedures required to render patients stone free were assessed. The outcome of stone removal on renal function was also evaluated by serial renal dynamic scans and creatinine clearance estimations. RESULTS: Out of 90 patients operated for staghorn or calyceal calculi, complete follow up data was available in 70. Pyelo-nephrolithotomy and percutaneous nephrolithotomy was carried out in 63 and 7 patients respectively. Out of 15 patients with residual stones ESWL was successfully performed in 9 cases. Mixed, calcium oxalate monohydrate, calcium oxalate dihydrate, and struvite stones were encountered in 48%, 14%, 17% and 21% respectively. The average pre operative serum creatinine was 4.76 (1.9-16) mg%. The maximum duration of follow up was 9 months. By the 9th post operative month the average fall in serum creatinine values was 1.53 mg/dl (32%) and the average functional improvement by renal dynamic scans stood at 20.665%. 41 patients were saved from further dialysis. CONCLUSION: Patients with mild to moderate renal failure showed maximal improvement in renal function forestalling or reducing the need for dialysis/renal replacement therapy.

Adult↗

PubMed2001

Endoscopic management of an unusual foreign body in the urinary bladder leading to intractable symptoms.

A 70-year old female patient presented with intractable lower abdominal pain and recurrent urinary tract infection following an endoscopic bladder neck suspension. Investigations revealed it to be a case of suture and pledget migration leading to foreign body granuloma in urinary bladder. It is being reported as an uncommon complication of endoscopic bladder neck suspension. An early endoscopic evaluation should be carried out in cases of unexplained lower urinary tract symptoms following any surgical procedure for incontinence. It is also appropriate to retrieve these foreign bodies endourologically without resorting to open surgery and thus extending safe, comfortable, and short postoperative course with good long term results.

Aged↗

PubMed2001

Colovesical fistula an unusual complication of cytotoxic therapy in a case of non-Hodgkin's lymphoma.

A 65-year old man, a known case of non-Hodgkin's lymphoma of base of the tongue and epiglottis presented with complaints of pneumaturia and faecaluria. He had received the first cycle of cytotoxic therapy (CHOP-regimen). At the end of the cycle he developed febrile neutropenia (circulating granulocyte count <1500/mm3). Cystogram showed air in the bladder area and a fistulous communication to a cavity behind the bladder. CT-scan showed air in the bladder, a fistulous communication between the sigmoid colon and bladder along with an intervening small abscess cavity. On exploration a fistulous communication between the sigmoid and bladder along with an intervening small abscess cavity was found. Resection of involved portion of sigmoid and end to end anastomosis along with a diverting colostomy was done. The bladder was closed in two layers with an omental interposition between it and the sigmoid along with a suprapubic cystostomy. The histopathology demonstrated only inflammatory response without any evidence of malignancy or diverticular disease.

Aged↗

PubMed2001

Cost-reductive retroperitoneal excision of large adrenal pseudocyst: a case report and review of the literature.

We report a case of a non-functioning cystic adrenal mass. It was detected on an abdominal ultrasound carried out for right flank pain in a 45-year-old lady. Biochemical parameters like 24-hour urinary free cortisol, catecholamines and serum potassium level were normal. Retroperitoneoscopic excision of the large cystic mass was done by using our cost-reductive technique as previously described. Histopathology turned out to be a pseudocyst with wall fibrosis and calcification.

Adrenal Gland Diseases↗

PubMed2001

Ureteral stent--help or hindrance? In healing of post traumatic nephrocutaneous fistula.

Nephrocutaneous fistulas are rare complications of blunt or penetrating renal trauma. The majority are managed conservatively, some may require percutaneous drainage or ureteral stenting and some require operative intervention. Diversion of the urine by a ureteral stent usually aids in the healing of the fistula. We present an unusual case of nephrocutaneous fistula following blunt renal trauma which persisted as long as a stent was in place but healed immediately after the stent was removed.

Adolescent↗

PubMed2001

Upper and mid-ureteric stones: a prospective unrandomized comparison of retroperitoneoscopic and open ureterolithotomy.

OBJECTIVES: To review our experience of retroperitoneoscopic ureterolithotomy (RPUL) and to compare the results with those from open surgery. PATIENTS AND METHODS: Between March 1994 and mid-December 2000, 55 patients with large (mean 2.1 cm) upper and mid-ureteric calculi, and with normal renal values, underwent RPUL. In 22 patients, earlier attempts with extracorporeal shock wave lithotripsy and ureteroscopy had failed. These patients were compared with 26 (mean stone size 2.4 cm) who underwent open ureterolithotomy during the same period. The two groups had similar distributions for age, sex, stone size and stone location; most stones were calcium-based. RESULTS: The mean operative duration and blood loss for RPUL and open surgery were 108.8 and 98.8 min, and 58.5 and 50.5 mL, respectively (not significant). The mean analgesic (pethidine) requirement and hospital stay for RPUL and open surgery were 41.1 and 96.9 mg, and 3.3 and 4.8 days, respectively (P<0.001). The duration of convalescence was significantly less after RPUL than open surgery (1.8 weeks vs 3.1). There were 10 conversions, which occurred early in the series, and one significant complication amongst patients who underwent RPUL. CONCLUSIONS: RPUL is comparable with open surgery for operative duration and blood loss, but the laparoscopic procedure has significant advantages over open surgery for analgesia, hospital stay, recuperation and cosmesis. RPUL is a viable alternative for large upper and mid-ureteric calculi and in those patients where a previous attempt at endourological management has failed. However, the technique requires significant training and experience before good results can be obtained.

Adult↗