Biomedical subjects
Publications and source records attributed to Rajiv Goel.
We report an extensive form of emphysematous pyelonephritis (EPN) in the right kidney extending from the anterior abdominal wall to the scrotum in a patient with renal calculi with obstructive uropathy and describe the progression route of infection from retroperitoneum to scrotum. Such an extensive occurrence of EPN is very rare. The patient succumbed after 48 h despite aggressive treatment.
Two patients presented with calculi in ectopic kidneys. Complete clearance of calculi was achieved by laparoscopic assisted percutaneous nephrolithotomy (PCNL), by different but related techniques. In one patient with prior history of open pyelolithotomy, the anterior surface of the kidney was exposed by mobilizing the overlying sigmoid colon laparoscopically and the percutaneous tract was established into the desired calyx under combined laparoscopic and fluoroscopic control. In the second patient, the tract was established between the major mesenteric vessels without any mobilization of the bowel. Herein, we outline the nuances of these two related techniques, and the indications and contraindications for their use for laparoscopic assisted PCNL in ectopic kidneys.
BACKGROUND: Children with poorly controlled asthma are at high risk of airway remodeling, sleep disruption, school absenteeism, and limited participation in activities. OBJECTIVE: To determine asthma prevalence and characterize disease severity and burden in school-aged children. METHOD: A case-finding study was conducted via a multiple-choice questionnaire and asthma algorithm. Items used for analysis include physician diagnosis of asthma, symptom severity, and health care utilization. The chi2 test was used to determine the significance of differences among cases. Logistic regression was used to evaluate the association of patient factors and asthma indicators. RESULTS: Of the 5,417 children surveyed, 1,341 (25%) were classified as being at risk of asthma. Of these asthma cases, 55% were positive by diagnosis and algorithm (active), 10% were positive per algorithm alone (suspected), and 35% were positive per diagnosis alone (nonactive). Only 14% of all asthma cases reported experiencing no respiratory symptoms (< 1% active, 2% suspected, and 40% nonactive) compared with 75% of noncases. Also, 75% of noncases reported never missing school compared with 19%, 33%, and 54% of active, suspected, and nonactive asthma cases. African American race, Medicaid enrollment, and male sex were independent predictors of asthma risk. Similarly, African American race, Medicaid enrollment, age, and persistent asthma were independent predictors of emergency department use among asthma cases. DISCUSSION: Prevalence of active symptoms suggestive of poor asthma control was extremely high among urban, minority children enrolled in Arkansas' largest public school district. Poor asthma control greatly affects quality of life, including school attendance and performance. Interventions should raise expectations and emphasize the importance of achieving asthma control.
An 8-year-old boy with right flank pain was found on ultrasonography and intravenous urography to have hydronephrosis secondary to ureteropelvic junction obstruction with calculi in the lower pole of the right kidney and a fusion anomaly. Transperitoneal laparoscopic dismembered pyeloplasty and removal of calculi was carried out. The patient had uneventful recovery and is doing well at 6 months' follow-up. To our knowledge, this is the first reported case of laparoscopic pyeloplasty with pyelolithotomy in crossed fused ectopic kidneys in the pediatric population.
Laparoscopic removal of the pyonephrotic moiety of a horseshoe kidney is challenging because of inflammation, aberrant vasculature, abnormal kidney location, and the renal isthmus. We herein report retroperitoneoscopic nephrectomy of the nonfunctioning pyonephrotic right moiety of a horseshoe kidney.
A Boari flap may be required to bridge long defects of the middle and lower ureter to the bladder. Laparoscopic construction of a Boari flap was performed in a patient with a ureteral stricture secondary to iatrogenic injury. The salient steps performed were spatulation of the transected ureteral end, fashioning of a Boari flap from the bladder, end-to-side anastomosis of the ureter to the flap, placement of a stent with the aid of a suction cannula, and closure of the flap over the stent. A Boari flap can be accomplished laparoscopically with minimal morbidity.
AIMS: Laparoscopic nephrectomy has become a standardized procedure for removal of benign non-functioning kidneys. We present our experience of retroperitoneoscopic pre-transplant native kidneys nephrectomy. METHODS: Comparison of 40 patients who underwent retroperitoneoscopy with 40 open simple pre-transplant nephrectomy patients was done. RESULTS: Forty retroperitoneoscopic nephrectomies were done between June 2003 and April 2005. The mean operative time was similar in the two groups; however, the mean blood loss, postoperative analgesic requirement, complication rate, hospital stay and convalescence period were significantly less in the retroperitoneoscopic group. CONCLUSION: Retroperitoneoscopic nephrectomy should be offered as the primary treatment modality to patients requiring pre-transplant native kidney nephrectomy, except in patients where it is contraindicated.
Vesicovaginal fistula (VVF) may be a complication of prolonged repair or urogynecologic surgery. Failing conservative management, it may be repaired using an abdominal or vaginal approach. We herein report laparoscopic repair of VVF following vaginal hysterectomy and detail the operative steps.
Antegrade endopyelotomy was performed in a patient with pelvic kidney. Nephrostomy tube had been placed in the patient during a previous open pyelolithotomy. The nephrostomy tract was used for establishing percutaneous access. The ureteropelvic junction (UPJ) was balloon dilated and incised laterally under vision. At 3-month-follow-up renal dynamic scan showed no evidence of UPJ obstruction.
OBJECTIVES: To present our initial experience with laparoscopic ureteroneocystostomy in patients with traumatic disruption of the distal ureter owing to gynecologic procedures. Reconstructive laparoscopic procedures are still evolving. METHODS: Six patients with ureterovaginal fistula in whom endoscopic management had failed underwent laparoscopic ureteroneocystostomy with a psoas hitch between July 2003 and December 2004. RESULTS: All procedures were completed successfully. No intraoperative or postoperative complications were noted. Postoperative intravenous urography did not reveal any evidence of obstruction. No reflux was seen in 5 of the 6 patients during micturating cystography. CONCLUSIONS: Laparoscopic ureteroneocystostomy is a safe and feasible minimally invasive option for patients with gynecologic distal ureteral injury.
BACKGROUND AND PURPOSE: Some patients undergoing percutaneous nephrolithotomy (PCNL) have purulent fluid in the pelvicaliceal system at the time of puncture, although preoperative features are not suggestive of infection. We report the management and outcome of 19 such patients. PATIENTS AND METHODS: Among the 639 patients who underwent PCNL at our center from July 2000 to October 2003, 19 had purulent fluid in the kidney at initial puncture. The preoperative findings, operative details, hospital course, and final outcome in these patients were analyzed. Twelve patients had stone removal at the first sitting (option 1), while seven had a nephrostomy tube placed initially with stone removal deferred for 3 to 7 days (option 2). RESULTS: With option 1, stones were cleared with one to three tracts in 45 to 120 minutes. Seven patients recovered smoothly, three had transient fever, while one had grade I and another had grade II sepsis. The purulent fluid grew E. coli in two cases and Proteus or Serratia in one case each and was sterile in eight. With option 2, stones were cleared using one to three tracts in 60 to 100 minutes. The fluid grew E. coli or Klebsiella in one case each and was sterile in five. Three patients had a smooth recovery, two had transient fever, one had grade I sepsis, and another had grade II sepsis. Risk factors for sepsis, irrespective of the option, were a recent history of febrile urinary-tract infection, borderline elevation of total leukocyte count, thick or foul pus as opposed to mere turbidity, the use of a single tube or tract or delayed creation of second tracts, and operating time >90 minutes. CONCLUSIONS: Despite normal preoperative urine and blood values, one may find purulence on puncture during PCNL, which is not always infected. If any one or more of the above risk factors is present, it is safer to drain the kidney initially, making sure that all blocked calices are drained, inserting multiple tubes if necessary.
PURPOSE: To determine the safety and efficacy of retroperitoneoscopic decortication of symptomatic renal cysts. PATIENTS AND METHODS: A total of 24 patients with symptomatic 6- to 14-cm (mean 10.9-cm) simple renal cysts, right sided in 13 and left sided in 11, underwent retroperitoneoscopic decortication for pain relief at our center between January 1997 and December 2002. The diagnosis was based on an ultrasonogram and contrast-enhanced CT. Symptom severity, assessed using a visual analog pain scale, averaged 7.2/10 (range 6.5-9). The mean duration of symptoms was 4 months. Operative and follow-up data were collected prospectively and analyzed for symptomatic and objective evidence of improvement. RESULTS: The mean operating time was 95 minutes, and no major complications were observed. The average hospital stay was 2.9 days (range 2-7 days). At a mean follow-up of 2.8 years (range 1.5-5 years), pain relief was reported by 22 patients (change of pain score from 7.2 to 1.4). One patient had worsening of pain at 6 weeks postoperatively. Asymptomatic recurrence of the cyst was seen in two patients on the follow-up ultrasound scans. CONCLUSIONS: Retroperitoneoscopic renal-cyst decortication is a safe, minimally invasive, and efficacious procedure for the treatment of painful renal cysts, with a durable response.
BACKGROUND AND PURPOSE: During transurethral resection of the prostate (TURP) for a very large and vascular gland in a medically compromised patient, there may arise the need for quick termination of the procedure because of medical problems that develop as a result of fluid absorption or bleeding if the surgery is prolonged. In such a situation, an alternative solution proposed by us is termination of the procedure after complete resection of one lateral lobe (and the median lobe, if present) of the prostate (hemiresection). PATIENTS AND METHODS: From January 1998 to December 2001, 161 consecutive symptomatic men with prostates >50 cc and an indication for prostatectomy were randomized to receive either a standard TURP (group 1; 80 patients) or prostatic hemiresection; i.e., complete resection of one lateral lobe and the median lobe, if present (group 2; 81 patients). The two groups were comparable in terms of age and prostate size. Preoperative and postoperative parameters were compared in the two groups using Student's t-test. RESULTS: Resected tissue weight was significantly greater in group 1, while the resection time and operative blood loss were significantly lower in group 2. The two groups had comparable improvement in symptom score and flow rate. CONCLUSIONS: Hemiresection of the prostate produces short-term functional results comparable to those of standard TURP in patients with prostates >50 cc, with shorter operative duration and significantly less bleeding. It is an acceptable surgical option in medically compromised patients with significant cardiac, pulmonary, or renal comorbidity.
BACKGROUND AND PURPOSE: To evaluate the safety and efficacy of percutaneous nephrolithotomy (PCNL) for the management of complete staghorn calculi in children <or=5 years old. PATIENTS AND METHODS: The charts of 19 preschool children (15 boys, 4 girls) aged 20 months to 5 years (mean 4.2 years) with complete staghorn calculi who underwent PCNL at our center over a 3-year period were reviewed. The mean stone burden was 972 mm2 (range 870-1210 mm2). All procedures were performed with the patient in the prone position after retrograde catheterization with a 5F ureteral catheter. Fluoroscopyguided punctures were made by the urologist followed by track dilation to 24F. A 19F sheathless nephroscope passed through an Amplatz sheath was used in all cases. Flexible nephroscopy was used as an adjunct where necessary. Postoperative stone clearance was documented by plain film or, for radiolucent calculi, ultrasonography. RESULTS: The majority of children (68%; N = 13) required two tracts, while five children (26%) required only one tract and one child required three. Complete clearance with PCNL monotherapy was achieved in 17 patients (89%), which increased to 94.7% with adjunctive shockwave lithotripsy. Stone analysis revealed struvite in 1, uric acid in 3, and calcium oxalate monohydrate in 15 patients. CONCLUSION: In preschool children, PCNL for complete staghorn calculi is a safe and effective method for maximal stone clearance.
A 35-year-old man with a left ectopic pelvic kidney and a prior history of open pyelolithotomy presented with recurrent multiple stones in the pelvic kidney. Complete clearance of calculi was achieved by laparoscopy-assisted PCNL (percutaneous nephrolithotomy). To the best of our knowledge this is the first report of laparoscopy-assisted PCNL in a previously operated ectopic pelvic kidney.
INTRODUCTION: To assess the efficacy, safety and morbidity of tubeless percutaneous nephrolithotomy. MATERIALS AND METHODS: One hundred and fifty-two patients with renal and upper ureteric calculi were included in this study. Sixty-nine patients (71 renal units; group 1) in whom no nephrostomy tube was placed at the conclusion of the procedure was compared with a similar control group of 83 patients (group 2) in whom a nephrostomy tube was placed. Operating time, blood loss, analgesia requirement, puncture site urinary leakage, hospital stay and mean convalescence period were compared in both groups. RESULTS: Both groups were similar with respect to age, sex distribution and stone size. Operating time and blood loss were less in group 1 although they did not reach statistical significance. The mean analgesic requirement, puncture site urinary leakage and hospital stay were significantly less in group 1. CONCLUSION: Tubeless percutaneous nephrolithotomy is a safe and effective procedure in this selected group of patients.
BACKGROUND: Retroperitoneoscopic surgery has become an established armamentarium in the hands of urologist. We present a simple and cost-effective technique that aids in the maintenance of pneumoretroperitoneum. METHODS: Between June 2003 and December 2004, 150 retroperitoneal nephrectomies were performed with maintenance of the pneumoretroperitoneum using our technique. RESULTS: The retroperitoneal space was maintained in all patients with minimal or no leakage of carbon dioxide from the port site. CONCLUSION: Our simple, cost-effective technique is highly reliable for the maintenance of pneumoretroperitoneum.
INTRODUCTION: The treatment of large complete staghorn calculi requires a sandwich combination of percutaneous nephrolithotomy (PCNL) and shockwave lithotripsy (SWL) or sometimes open surgery. Many urologists hesitate to place more than 2-3 tracts during PCNL because of the belief that this may increase complications. We present data to support multi-tract PCNL for large (surface area >3,000 mm(2)) complete staghorn calculi. PATIENTS AND METHODS: From July 1998 to October 2003, 121 renal units (103 patients) with large complete staghorn renal calculi were treated with PCNL. All procedures were performed in the prone position after retrograde ureteral catheterization. Fluoroscopy-guided punctures were made by the urologist followed by track dilation to 34 french. When multiple tracts were anticipated all punctures were usually made at the outset and preplaced wires were put into the collecting system or down the ureter. Stones were fragmented and removed using a combination of pneumatic lithotripsy and suction. Postoperative stone clearance was documented on X-ray KUB. RESULTS: 121 renal units of 103 patients (15 women and 88 men, mean age 43 years) were treated. Six patients had associated bladder calculi that were treated simultaneously. The stone surface area was 3,089-6,012 (mean 4,800) mm(2). 10 patients (9.7%) had renal insufficiency with a mean (range) serum creatinine of 3.0 (1.5-5.5) mg/dl. The number of tracts required per patient were 2 tracts in 11, 3 tracts in 68, 4 tracts in 39, and 5 tracts in 3, giving a total of 397 tracts in 121 renal units, over a total of 140 procedures (including second-look procedures in 19 renal units). The points of entry of these tracts were 121 upper calyx (30.4%), 178 middle calyx (44.8%), and 98 lower calyx (24.6%). All 121 units had one upper polar access tract of which 92 (76%) were supracostal. Complications were blood transfusion (n = 18), pseudoaneurysm (n = 2), fever (n = 22), septic shock (n = 1) and hydrothorax (n = 3). PCNL monotherapy achieved an 84% complete clearance rate that improved to 94% with SWL in 8 renal units with small residual fragments. Stone compositions were calcium oxalate (91%), uric acid (2%) and mixed (7%). CONCLUSION: Aggressive PCNL monotherapy using multiple tracts is safe and effective, and should be the first option for massive renal staghorn calculi.