RG Stone Urology & Laparoscopy Hospital

PURPOSE: In a prospective manner we evaluated the learning experience of an endourologist inexperienced with holmium laser prostate enucleation and its impact on surgical outcome. We also reviewed the literature to document technical features of holmium laser prostate enucleation at different institutions. MATERIALS AND METHODS: Patient demographic, perioperative and followup data were analyzed. To assess the impact of the learning curve on postoperative outcome patients were divided into group 1--patients 1 to 50, group 2--51 to 100 and group 3--101 to 162. The effect of the learning curve and weight of resected tissue on enucleation and morcellation efficiency was studied. RESULTS: Holmium laser prostate enucleation was successfully completed in 93.82% of patients. Eight patients required conversion to transurethral prostate resection. Enucleation and morcellation efficiency was 0.49 and 2.75 gm per minute, respectively. Enucleation efficiency attained a plateau after 50 cases. Postoperative outcome was compared in the 3 patient groups. There was a higher incidence of capsular perforation and stenotic urethral complications in group 1. In the literature a mean of 57.09% of tissue (range -9.6 to 81.9%) was retrieved after holmium laser prostate enucleation and mean efficiency was 0.52 gm per minute (range -0.11 to 1.09). Efficiency increased proportionally with resected prostate weight. CONCLUSIONS: An endourologist inexperienced with holmium laser prostate enucleation can perform the procedure with reasonable efficiency after about 50 cases with an outcome comparable to that of experts, as described in the literature. During the learning curve conversion to transurethral prostate resection can be done without any harm to the patient.

OBJECTIVE: To evaluate, in a prospective study, the complications in 280 patients undergoing holmium laser enucleation of the prostate (HoLEP) at our institution, and to review previous reports to determine the overall incidence and types of various complications, and analyse their causes and means of prevention. PATIENTS AND METHODS: We analysed the patients' demographic, peri-operative and follow-up data, and the complications during and after surgery. RESULTS: HoLEP was completed successfully in 268 patients (95.7%); eight required conversion to transurethral resection of the prostate (TURP) during the initial experience. The morcellation device and laser malfunctioned in two patients each. A blood transfusion was required during HoLEP in one patient; other complications included capsular perforation (9.6%), superficial bladder mucosal injury (3.9%) and ureteric orifice injury (2.1%). A blood transfusion was needed after HoLEP in 1.4% of patients and cystoscopy with clot evacuation in 0.7%. Transient urinary incontinence was the commonest complication after HoLEP, in 10.7% of patients, but recovered spontaneously in all except two (0.7%). Other rare complications were re-catheterization (3.9%), urinary tract infection (3.2%), epididymitis (0.7%), meatal and submeatal stenosis (2.5%), bulbar urethral stricture (2.1%), bladder neck contracture (0.35%) and myocardial infarction (0.35%). CONCLUSIONS: There was a low incidence of complications with HoLEP; most were minor and easily managed. Our results are comparable with those published previously, and establish HoLEP as safe and reproducible procedure. While gaining experience, HoLEP can be converted to TURP with no harm to the patient.

PURPOSE: To describe the differences in the treatment and the outcomes of renal stones treated with flexible ureteroscopy (URS) either with or without the support of a ureteral access sheath (UAS). METHODS: The Clinical Research Office of the Endourological Society URS Global Study involved the collection of prospective data from consecutive patients treated with URS at centers around the world over a 1-year period. Baseline characteristics, stone location, treatment details, postoperative outcomes and complications were recorded. Inverse-probability-weighted regression adjustment (IPWRA) analyses were conducted on outcome from patients treated with or without the use of a UAS to determine the impact on stone-free rates (SFRs). RESULTS: Of 2239 patients treated with flexible URS, 1494 (67 %) patients were treated with the use of a UAS and 745 (33 %) without a UAS. The IPWRA analyses conducted on 1827 patients with complete data and based on treatment and outcome models showed that if URS procedures were performed without the use of an UAS, the average stone-free rate would be 0.504 compared with 0.753 with a UAS. This average treatment effect of 0.248 was not significant (P = 0.604). Using IPWRA analysis on only the treated population in the estimations revealed no significant difference between using and not using a UAS (31 %; ATET: 0.311; P = 0.523). CONCLUSIONS: The study showed no difference in SFR when a UAS was used or not. Whereas UAS did not increase the risk of ureteral damage or bleeding, postoperative infectious complications were reduced.

PURPOSE: To review the incidence of UTIs, post-operative fever, and risk factors for post-operative fever in PCNL patients. MATERIALS AND METHODS: Between 2007 and 2009, consecutive PCNL patients were enrolled from 96 centers participating in the PCNL Global Study. Only data from patients with pre-operative urine samples and who received antibiotic prophylaxis were included. Pre-operative bladder urine culture and post-operative fever (>38.5°C) were assessed. Relationship between various patient and operative factors and occurrence of post-operative fever was assessed using logistic regression analyses. RESULTS: Eight hundred and sixty-five (16.2%) patients had a positive urine culture; Escherichia coli was the most common micro-organism found in urine of the 350 patients (6.5%). Of the patients with negative pre-operative urine cultures, 8.8% developed a fever post-PCNL, in contrast to 18.2% of patients with positive urine cultures. Fever developed more often among the patients whose urine cultures consisted of Gram-negative micro-organisms (19.4-23.8%) versus those with Gram-positive micro-organisms (9.7-14.5%). Multivariate analysis indicated that a positive urine culture (odds ratio [OR] = 2.12, CI [1.69-2.65]), staghorn calculus (OR = 1.59, CI [1.28-1.96]), pre-operative nephrostomy (OR = 1.61, CI [1.19-2.17]), lower patient age (OR for each year of 0.99, CI [0.99-1.00]), and diabetes (OR = 1.38, CI [1.05-1.81]) all increased the risk of post-operative fever. Limitations include the use of fever as a predictor of systemic infection. CONCLUSIONS: Approximately 10% of PCNL-treated patients developed fever in the post-operative period despite receiving antibiotic prophylaxis. Risk of post-operative fever increased in the presence of a positive urine bacterial culture, diabetes, staghorn calculi, and a pre-operative nephrostomy.

PURPOSE: Renal hemorrhage is one of the most common and worrisome complications of percutaneous renal surgery. We studied the incidence of renal hemorrhage and transfusion rates in patients undergoing balloon or Amplatz fascial dilation of the nephrostomy tract. MATERIALS AND METHODS: Medical records of 143 patients who underwent 150 percutaneous renal procedures, including percutaneous nephrolithotomy, antegrade endopyelotomy and percutaneous treatment of stones in caliceal diverticula, were reviewed. The nephrostomy tract was dilated with balloon (50 patients) or Amplatz sequential (100) dilators. Perioperative decreases in hemoglobin level and blood transfusion rates were compared between the 2 groups. RESULTS: Of the 100 patients undergoing percutaneous renal Amplatz dilation 25 (25%) required a blood transfusion, compared to only 5 of 50 (10%) undergoing balloon dilation. The difference in the transfusion rates between the 2 groups was statistically significant (p = 0.048). CONCLUSIONS: Improvements in the technique of percutaneous renal surgery have decreased the morbidity associated with these procedures. In our study use of balloon tract dilators led to less renal hemorrhage and lower transfusion rates compared to Amplatz dilation. Additionally, balloon dilation appears to be more rapid and avoids renal movement away from the surgeon, which occasionally occurs during Amplatz dilation.

OBJECTIVE: To evaluate the status of tubeless percutaneous nephrolithotomy (PCNL) in managing renal and upper ureteric calculi, from initial experience and a review of previous reports. PATIENTS AND METHODS: From September 2004 to December 2004, 46 patients were scheduled for tubeless PCNL in a prospective study. Patients with solitary kidney, or undergoing bilateral simultaneous PCNL or requiring a supracostal access were also enrolled. Patients needing more than three percutaneous access tracts, or with significant bleeding or a significant residual stone burden necessitating a staged second-look nephroscopy were excluded. At the end of the procedure, a JJ ureteric stent was placed antegradely and a nephrostomy tube avoided. The patients' demographic data, the outcomes during and after surgery, complications, success rate, and stent-related morbidity were analysed. Previous reports were reviewed to evaluate the current status of tubeless PCNL. RESULTS: Of the 46 patients initially considered only 40 (45 renal units) were assessed. The mean stone size in these patients was 33 mm and 23 patients had multiple stones. Three patients had a serum creatinine level of >2 mg/dL (>177 micromol/L). Five patients had successful bilateral simultaneous tubeless PCNL. In all, 51 tracts were required in 45 renal units, 30 of which were supracostal. The mean decrease in haemoglobin was 1.2 g/dL and two patients required a blood transfusion after PCNL. There was no urine leakage or formation of urinoma after surgery, and no major chest complications in patients requiring a supracostal access tract, except for one with hydrothorax, managed conservatively. The mean hospital stay was 26 h and analgesic requirement 40.6 mg of diclofenac. Stones were completely cleared in 87% of renal units and 9% had residual fragments of < 5 mm. Two patients required extracorporeal lithotripsy for residual calculi. In all, 30% of patients had bothersome stent-related symptoms and 60% needed analgesics and/or antispasmodics to treat them. CONCLUSION: Tubeless PCNL was safe and effective even in patients with a solitary kidney, or with three renal access tracts or supracostal access, or with deranged renal values and in those requiring bilateral simultaneous PCNL. The literature review suggested a need for prospective, randomized studies to evaluate the role of fibrin sealant and/or cauterization of the nephrostomy tract in tubeless PCNL.

BACKGROUND AND PURPOSE: A nephrostomy tube is an integral part of any percutaneous renal surgery. Commonly, a nephrostomy tube that is 2F to 3F smaller than the percutaneous tract is used after percutaneous nephrolithotomy (PCNL). In our experience, quite a few patients have pain at the nephrostomy tube site, and many patients complain of a prolonged urinary leak after tube removal when a large nephrostomy tube is used. This prospective study was planned to document whether these symptoms could be attributed to the size of the nephrostomy tube and whether a small pigtail catheter could reduce these problems without increasing complications. PATIENTS AND METHODS: Forty well-matched patients in whom a one-stage PCNL was done for calculus disease were studied prospectively. Alternate patients had a 28F nephrostomy tube or a 9F pigtail catheter placed at the end of the procedure. Patients were observed for the duration of hematuria, number of analgesic injections needed, and the duration of urinary leak after tube removal. RESULTS: The groups were comparable in the amount and duration of hematuria after PCNL. There was a statistically significant difference in the analgesic need and the duration of urinary leak after tube removal, both of which were less in patients having a pigtail catheter. CONCLUSIONS: A pigtail catheter nephrostomy tube after PCNL reduces the hospital stay by reducing the duration of the urinary leak. The postoperative course is smooth, as patient has less pain and needs less analgesic support. There is no statistically significant increase in the postoperative bleeding secondary to use of a pigtail catheter. Second-look nephroscopy was easy in the one patient with a pigtail nephrostomy catheter who needed the procedure.

OBJECTIVE: To analyse the effect of prostate size on the outcome of holmium laser enucleation of prostate (HoLEP, an established procedure for treating symptomatic benign prostatic hypertrophy, BPH), in the initial 354 patients at 1 year of follow-up. PATIENTS AND METHODS: We retrospectively reviewed the records of 354 patients who had HoLEP at our institution from April 2003 to March 2007. In 235 patients the prostate weighed <60 g (group 1), in 77 it weighed 60-100 g (group 2) and in 42 >100 g (group 3). Demographic data and perioperative variables were recorded and compared among the three groups. RESULTS: The mean prostate size was 38.1, 76.4 and 133.5 g for groups 1, 2 and 3, respectively (P < 0.001), and the respective mean weight of resected prostate was 18.47, 40.8 and 82.76 g, respectively (P < 0.001). The mean procedure efficiency increased from 0.36 g/min in group 1 to 0.49 g/min in group 2 and 0.58 g/min in group 3 (P < 0.001). The decrease in haemoglobin level after HoLEP was greater in group 3 than in the other groups. Overall, HoLEP resulted in a 75% reduction in American Urologic Association symptom score, a 225% increase in peak urinary flow rate and an 86% decrease in postvoid residual urine volume at 1 year of follow-up. Perioperative complications were evenly distributed among the three groups, except for a higher incidence of superficial bladder mucosal injury and stenotic complications in group 3. CONCLUSIONS: HoLEP is a safe and effective procedure for treating symptomatic BPH, independent of prostate size, and is associated with low morbidity. The efficiency of HoLEP increases with increasing prostate size.

PURPOSE: To compare the outcome of tubeless percutaneous nephrolithotomy (PCNL) with small-bore nephrostomy drainage after PCNL. PATIENTS AND METHODS: We tested the hypothesis that tubeless PCNL is superior to small-bore nephrostomy drainage after PCNL in terms of postoperative pain, analgesic requirement, and hospital stay. To show a 10% difference in these parameters, a sample size of 30 persons per group would be needed. All patients undergoing PCNL from September 2005 to May 2006 were included in the study. Patients meeting the inclusion and exclusion criteria were then randomized to either a tubeless approach with insertion of a ureteral stent or placement of an 8F nephrostomy tube without insertion of a ureteral stent. The perioperative outcomes of patients in the two groups were compared. RESULTS: Tubeless PCNL was performed in 33 patients, and an 8F nephrostomy tube was placed in 32 patients. The two groups had comparable demographic data. The hemoglobin drop and complication rate between the two groups were comparable. Patients undergoing tubeless PCNL experienced less postoperative pain (P = 0.001), needed less analgesia (P = 0.006), and were discharged 9 hours earlier than patients in the other group. Complete stone clearance was achieved in 87.87% patients in the tubeless group and 87.5% patients in the nephrostomy group. In the tubeless group, 39.4% of patients had bothersome stent-related symptoms, of whom 61.5% needed analgesics and/or antispasmodic agents. CONCLUSIONS: Tubeless PCNL offers the potential advantages of decreased postoperative pain, analgesic requirement, and hospital stay without increasing the complications. It was associated with stent-related discomfort in 39% of patients.

OBJECTIVE: To present our experience with 454 patients who had tubeless percutaneous nephrolithotomy (TPCNL) over last 3 years. PATIENTS AND METHODS: From September 2004 to August 2007, all patients aged >14 years and undergoing PCNL were considered for TPCNL. Exclusion criteria were the presence of pyonephrosis, matrix calculi, significant bleeding or residual stone burden and need for three of more percutaneous accesses. These patients had a nephrostomy tube placed after PCNL (control group). The remaining patients undergoing TPCNL (study group) had antegrade ureteric stenting. Demographic and perioperative data were compared retrospectively. RESULTS: Of 840 patients who had PCNL during the study period, 454 had TPCNL. The two groups had comparable demographic data except for a smaller stone burden (322.8 vs 832.2 mm(2)) and fewer staghorn calculi (94 vs 154) in patients undergoing TPCNL (P < 0.001). The mean number of tracts per renal unit and operative duration were statistically higher in patients undergoing standard PCNL (1.5 vs 1.1, and 68.8 vs 52.2 min, respectively). The decrease in haemoglobin, complication and stone-free rates were comparable. TPCNL was associated with less postoperative pain, analgesia requirement and earlier discharge (P < 0.001). CONCLUSIONS: TPCNL can be used with a favourable outcome and no increase in complications in selected patients, with the potential advantages of decreased postoperative pain, analgesia requirement and hospital stay. Its application can be extended to patients with a solitary kidney, previous ipsilateral open surgery, raised serum creatinine level, in the presence of three renal accesses or supracostal access, and in patients undergoing bilateral synchronous PCNL or contralateral endourological stone treatment.

OBJECTIVE: To report experience with holmium laser enucleation of the prostate (HoLEP) simultaneously with transurethral holmium laser cystolithotripsy (HLC) for managing bladder outlet obstruction (BOO) and associated vesical calculi; we also review previously reported cases of managing vesical calculi and associated BOO. PATIENTS AND METHODS: The high-powered holmium laser is a very efficient multifunctional endourological instrument that effectively fragments calculi of all compositions and is capable of haemostatic cutting of tissue, resulting in minimal bleeding after prostatic resection. A prospective study was conducted from April 2003 that included 32 men who underwent simultaneous HoLEP with transurethral HLC at our institution. Demographic, laboratory, peri-operative and follow-up data were analysed. Complications during and after surgery were identified to assess the morbidity of procedure. RESULTS: The mean (range) size of bladder calculi was 34.6 (12-70) mm and the preoperative weight of the prostate was 51.9 (11-172) g. Combined HoLEP with transurethral HLC was technically feasible in all patients, and all were stone-free after surgery. The mean operative duration was 97.7 (40-230) min, the weight of prostate tissue removed 34.6 (5-88) g, and the duration of catheterization and hospital stay 29.3 h and 34.8 h, respectively. Complications during and after surgery occurred in 12.5% and 15.6% of patients, respectively; all complication were minor and none caused any residual disability to the patient. No patient required a blood transfusion or developed clot retention. CONCLUSIONS: Managing bladder stones and BOO with simultaneous transurethral HLC and HoLEP should be considered the treatment of choice for such cases. Stones of any size and composition, and prostates of practically any size can be treated endoscopically using the holmium laser, with acceptable morbidity once the technique is mastered. The review of previous reports suggested a need for a prospective study comparing endoscopic management of BOO and associated bladder stones, with medical management of BOO and extracorporeal shock wave lithotripsy/endoscopic lithotripsy for bladder stone.

OBJECTIVE: This study was planned to compare the risks and advantages of antegrade and retrograde ureteroscopy for impacted large upper ureteral calculi. PATIENTS AND METHODS: From September 1996 to February 1998, ureteroscopy was offered to 43 patients. Of these, retrograde ureteroscopy was done in 20 patients, while antegrade ureteroscopy was performed in 23 patients. All these patients were followed up to evaluate the immediate and long-term success of the procedure. The incidence and nature of complications were also noted. RESULTS: During retrograde ureteroscopy, complete stone clearance was achieved in 11 patients (55%), while pushback of the whole or fragmented calculus was seen in the rest. These patients with residual calculi were later treated by extracorporeal shockwave lithotripsy (SWL). The stone-free rate at the end of 3 months was 85%. Three patients developed minor ureteroscopy-related complications. Complete stone clearance was achieved in all patients with antegrade ureteroscopy. No intraoperative or postoperative complications were encountered. CONCLUSION: In this series, antegrade ureteroscopy was found to be a safe and effective option for impacted upper ureteral calculi and assured better results than retrograde ureteroscopy.

BACKGROUND: Complications after bariatric surgery are not uncommon occurrences that influence the choice of operations both by patients and by surgeons. Complications may be classified as intra-operative, early (<30 days post-operatively) or late (beyond 30 days). The prevalence of complications is influenced by the sample size, surgeon's experience and length and percentage of follow-up. There are no multicentric reports of post-bariatric complications from India. OBJECTIVES: To examine the various complications after different bariatric operations that currently performed in India. MATERIALS AND METHODS: A scientific committee designed a questionnaire to examine the post-bariatric surgery complications during a fixed time period in India. Data requested included demographic data, co-morbidities, type of procedure, complications, investigations and management of complications. This questionnaire was sent to all centres where bariatric surgery is performed in India. Data collected were reviewed, were analysed and are presented. RESULTS: Twenty-four centres responded with a report on 11,568 bariatric procedures. These included 4776 (41.3%) sleeve gastrectomy (SG), 3187 (27.5%) one anastomosis gastric bypass (OAGB), 2993 (25.9%) Roux-en-Y gastric bypass (RYGB) and 612 (5.3%) other procedures. Total reported complications were 363 (3.13%). Post-operative bleeding (0.75%) and nutritional deficiency (0.75%) were the two most common complications. Leaks (P = 0.009) and gastro-oesophageal reflux disease (P = 0.019) were significantly higher in SG, marginal ulcers in OAGB (P = 0.000), intestinal obstruction in RYGB (P = 0.001) and nutritional complications in other procedures (P = 0.000). Overall, the percentage of complications was higher in 'other' procedures (6.05%, P = 0.000). There were 18 (0.16%) reported mortalities. CONCLUSIONS: The post-bariatric composite complication rate from the 24 participating centres in this study from India is at par with the published data. Aggressive post-bariatric follow-up is required to improve nutritional outcomes.

PURPOSE: In a prospective manner we studied various factors affecting fluid absorption during HoLEP. We also simultaneously evaluated changes in serum electrolytes and hemoglobin decrease during HoLEP. MATERIALS AND METHODS: This prospective study comprised of 53 patients who underwent HoLEP at our institute. Irrigation fluid was normal saline tagged with ethanol (1% w/v). Intraoperatively a standard breath analyzer was used to monitor expired breath ethanol levels during the procedure at 10-minute intervals. Patients who absorbed irrigating fluid as indicated by positive intraoperative breath tests were considered absorbers. Serum electrolyte and hemoglobin estimations were done before and after surgery. Total irrigation time, amount of irrigation fluid used, weight of resected tissue and presence of capsular perforation were recorded. Statistical analysis was performed to observe the effects of various factors on the amount of intraoperative fluid absorption. RESULTS: Of 53 patients studied 14 (26.41%) demonstrated fluid absorption in the range of 213 to 930 ml (mean 459). Preoperative prostate weight, total irrigation time, amount of irrigation fluid used and resected tissue weight were all significantly greater in absorbers. Similarly, absorbers had a statistically significant decrease in hemoglobin level postoperatively. There was no statistically significant change in serum electrolytes between absorbers and nonabsorbers. CONCLUSIONS: Preoperative weight of prostate, total irrigation time, amount of irrigation fluid used and weight of resected tissue all directly influence the amount of fluid absorption during HoLEP. There is no significant change in serum electrolytes and no risk of the transurethral resection syndrome.

PURPOSE: We compared the characteristics and outcomes of patients treated with percutaneous nephrolithotomy in the CROES (Clinical Research Office of the Endourological Society) Global Study according to preoperative renal function. MATERIALS AND METHODS: Prospective data on consecutive patients treated with percutaneous nephrolithotomy in a 1-year period were collected from 96 participating centers. The glomerular filtration rate was estimated using the Modification of Diet in Renal Disease formula based on preoperative serum creatinine measurement. Patients were divided into 3 groups by glomerular filtration rate, including chronic kidney disease stages 0/I/II-greater than 60, stage III-30 to 59 and stages IV/V-less than 30 ml/minute/1.73 m(2). Patient characteristics, operative characteristics, outcomes and morbidity were assessed. RESULTS: Estimated glomerular filtration rate data were available on 5,644 patients, including 4,436 with chronic kidney disease stages 0/I/II, 994 with stage III and 214 with stages IV/V. A clinically significant minority of patients with nephrolithiasis presented with severe chronic kidney disease. A greater number of patients with stages IV/V previously underwent percutaneous nephrolithotomy, ureteroscopy or nephrostomy and had positive urine cultures than less severely affected patients, consistent with the higher incidence of staghorn stones in these patients. Patients with chronic kidney disease stages IV/V had statistically significantly worse postoperative outcomes than those in the other chronic kidney disease groups. CONCLUSIONS: Poor renal function negatively impacts the post-percutaneous nephrolithotomy outcome. By more aggressive removal of kidney stones, particularly staghorn stones, at first presentation and more vigilantly attempting to prevent recurrence through infection control, pharmacological or other interventions, the progression of chronic kidney disease due to nephrolithiasis may be mitigated.

PURPOSE: To evaluate the feasibility and safety of supracostal access in tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: From September 2004 to November 2005, tubeless PCNL using supracostal access was done for 72 patients at our institute. Patients requiring more than two percutaneous tracts or with significant intraoperative bleeding or residual stone burden were excluded from the study. The outcome of these patients was compared with that of a historic cohort of similar patients having supracostal access with routine placement of a nephrostomy tube. The two groups had comparable demographic data. RESULTS: The differences in the mean drop in hemoglobin concentration, transfusion requirement, and complication rate in the two groups were not statistically significant, with three patients in the study group and four patients in the control group requiring blood transfusion. Patients undergoing tubeless PCNL required less analgesia (P = 0.000) and were discharged a mean of 19 hours earlier (P = 0.000) than those in the control group. Complete stone clearance was achieved in 90.27% of the renal units in the study group and 86.11% of the renal units in the control group. Two patients in the study group and three patients in the control group had postoperative hydrothorax, all of whom, except for one in the control group, were managed conservatively. CONCLUSION: Supracostal access in tubeless PCNL appears to be feasible, safe, and effective, offering the advantages of a lower analgesic requirement and shorter hospital stay without increasing thoracic complications. Studies with larger numbers of patients are needed to confirm these initial findings.

PURPOSE: To report our initial experience with hemostatic fibrin glue as an adjuvant during tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Seventeen consecutive patients underwent tubeless PCNL with injection of 2 mL of Tisseel Vapor Heated Sealant (Baxter AG, Vienna, Austria) into the percutaneous tracts at the conclusion of the procedure. The perioperative outcomes of these patients were compared retrospectively with those of a control group of 25 consecutive patients who underwent tubeless PCNL without the use of fibrin glue. The safety and efficacy of the new approach was evaluated by comparing operative time, hemoglobin drop, transfusion requirement, length of hospitalization, postoperative pain, analgesic use, and postoperative complications in the two groups. RESULTS: There was no difference in the mean drop in hemoglobin, transfusion requirement, or complications in the two groups. However, patients undergoing Tisseel tubeless PCNL required less analgesia postoperatively (P=0.05), and they were discharged an average of 7 hours earlier than the patients in the control group. There were no major postoperative complications. CONCLUSIONS: Use of fibrin glue was safe and was associated with less analgesic requirement and a shorter hospital stay. Randomized studies are needed to evaluate its clinical role in the future.

BACKGROUND AND PURPOSE: Management of urolithiasis in a horseshoe kidney (HSK) poses a unique challenge. Although most patients can be managed by a combination of percutaneous nephrolithotomy (PCNL) and extracorporeal shockwave lithotripsy (SWL), calculi in the isthmic calix remain difficult to treat, as this area is out of reach during rigid PCNL, and, owing to the poor evacuation of the fragments, the results of SWL are suboptimal. CASE REPORT: A 59-year-old man known to have an HSK presented with right-sided lower-abdominal pain and episodes of urinary infection. In the past, he had undergone pyelolithotomy and lithotripsy for lithiasis in the kidney. Imaging studies identified a large recurrent calculus in the anteriorly directed isthmic calix. This was treated successfully by a laparoscopy-assisted transperitoneal PCNL. The laparoscopic view allowed the bowel to be retracted away from the site of the HSK, and PCNL guided by fluoroscopy and laparoscopy was performed. Complete stone clearance was achieved in a single stage. The patient remains free of symptoms and recurrence 3 months later. CONCLUSION: We believe this to be the first report describing this novel approach to lithiasis in an HSK.

BACKGROUND: Splenic injury is an uncommon complication of percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: We report herewith two cases of splenic injury that occurred during puncture of the 10th intercostal-space for PCNL. RESULTS AND CONCLUSIONS: One of these patients presented with hypotension on day 5 after discharge from the hospital. Both patients needed emergency laparotomy, and one of them required splenectomy for management of the injury. We reviewed the literature to determine the risk factors and management of splenic injury during PCNL.

Vesical calculus is a common problem that is treated traditionally with open cystolithotomy or cystolithalopaxy. Open surgery has the inherent problems of a long scar, prolonged catheterization, extended hospitalization, and risk of infection. Transurethral cystolithalopaxy also requires special instruments that carry a risk of trauma, which could lead to urethral strictures. Thirty-eight patients (15 children and 23 adults) were treated for vesical calculi by percutaneous cystolithotomy (PCCL), a minimally invasive procedure. A fluoroscopic-guided tract was made to the bladder through a small suprapubic puncture (9-10 mm) and a nephroscope was inserted via an Amplatz sheath placed suprapubically. The calculus was fragmented with ultrasound or pneumatic energy before being flushed out. A suprapubic catheter was kept in place for 48 hours postsurgery; no urethral catheter was needed. Urethral instrumentation was kept to a minimum. After 48 hours, the suprapubic catheter was clamped and removed after the patient had two or three normal voids. No significant intraoperative or postoperative complication was encountered. Given that the urethra is spared, percutaneous cystolithotomy is a preferred approach in patients with vesical calculi.