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   2005| July-December  | Volume 21 | Issue 2  
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Instrumentation, sterilization, and preparation of robot
A Bhandari, A Hemal, M Menon
July-December 2005, 21(2):83-88
The da Vinci surgical system is being used for a wide range of surgical tasks. As the applications of this robot increase, more and more surgeons would like to acquire this piece of equipment. There are a wide range of expensive and sophisticated accessories and instruments that come along with this machine, that need special care and attention. The aim of this chapter is the make the user familiar with the various parts of the robot and to provide guidelines for the safe usage of this equipment.
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Laparoscopic retroperitoneal nephrectomy: overcoming the learning curves
PR Modi, GV Kadam, S Dodia, R Jain, R Patel, A Devra
July-December 2005, 21(2):102-105
Objective: To assess the results of retroperitoneal laparoscopic nephrectomy at a single centre. Materials and methods: A retrospective study of 40 patients (group A: initial 20, group B: late 20 cases) who underwent retroperitoneal laparoscopic nephrectomy was done. Analysis of the complication rate, conversion rate to open surgery, operative time and the blood loss and analgesia requirement were studied. Results: Laparoscopic retroperitoneal nephrectomy was carried out successfully in 60% cases of group A and in 95% cases of group B cases. There was a statistically significant reduction in the blood loss and duration of surgery in group B. Analgesia requirement was not different in either group. Conclusions: Retroperitoneal laparoscopic nephrectomy has a steep learning curve. Results of the procedure improved and complications reduced significantly after the initial 20 cases.
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Robotic radical prostatectomy-a minimally invasive therapy for prostate cancer: results of initial 530 cases
A Tewari, A Bhandari, A Hemal, M Menon
July-December 2005, 21(2):93-96
Context: In 2000, the number of new cases of prostate cancer was estimated at 5 13 000 worldwide [Eur J Cancer 2001; 37 (Suppl 8): S4]. In next 15 years, prostate cancer is predicted to be the most common cancer in men [Eur J Cancer 2001; 37 (Suppl 8): S4]. Radical prostatectomy is one of the most common surgical treatments for clinically localized prostate cancer. In spite of its excellent oncological results, due to the fear of pain, risk for side effects, and inconvenience (Semin Urol Oncol 2002; 20: 55), many patients seek alternative treatments for their prostate cancer. At Vattikuti Urology institute, we have developed a minimally invasive technique for treating prostate cancer, which achieves oncological results of surgical treatment without causing significant pain, large surgical incision, and side effects (BJU Int, 2003; 92: 205). This technique involves a da Vinci™ (Intuitive Surgical®, Sunnyvale, CA) surgical robot with 3-D stereoscopic visualization and ergonomic multijointed instruments. Presented herein are our results after treating 750 patients. Methods: We prospectively collected baseline demographic data such as age, race, body mass index (BMI), serum prostate specific antigen, prostate volume, Gleason score, percentage cancer, TNM clinical staging, and comorbidities. Urinary symptoms were measured with the international prostate symptom score (IPSS), and sexual health with the sexual health inventory of males (SHIM). In addition, the patients were mailed the expanded prostate inventory composite at baseline and at 1, 3, 6, 12 and 18 months after the procedure. Results: Gleason seven or more cancer grade was noted in 33.5% of patients. The average BMI was high (27.7) and 87% patients had pathological stage PT2a-b. The mean operative time was 160 min and the mean blood loss was 153 cm3. No patient required blood transfusion. At 6 months 82% of the men who were younger and 75% of those older than 60 years had return of sexual function and 64 and 38%, respectively, had sexual intercourse. At 6 months, 96% patients were continent. Where next?: This procedure is safe and effective in managing patients with clinically localized prostate cancer. However, the surgical robot has a significant prize tag attached and not every center has access to the technology. In future, hopefully, the robot will become smaller, and cheaper to allow wide acceptance of this procedure.
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Skeletal metastases from recurrent paraganglioma of the urinary bladder.
Shikha Goyal, Tarun Puri, Gowthaman Gunabushanam, Anup Kumar Das, Pramod Kumar Julka
July-December 2005, 21(2):122-124
Paragangliomas arising from the urinary bladder are extremely rare. Most of them are benign, and are curable with surgical resection alone, but about 10% are malignant and may metastasise to regional nodes or distant sites. We present the case of a 45 year male patient who had a recurrent paraganglioma of the urinary bladder with vertebral metastases. The patient was managed using a combination of palliative chemotherapy with carboplatin, etoposide and zoledronate and radiotherapy to the spine. However, the patient's general condition rapidly deteriorated while on systemic treatment. This case demonstrates the unusually aggressive course that this disease may occasionally take.
  1 5,505 158
Ureteroscopic lithotripsy - skip the stent and spare the patient
S Kumar
July-December 2005, 21(2):116-117
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Tubularized incised plate urethroplasty (Snodgross procedure) for distal penile hypospadias - a regional centre experience
N Singh, E Sharma, R Saraf, HL Goswamy
July-December 2005, 21(2):109-111
Tubularized incised plate (TIP) urethroplasty has rapidly become the procedure of choice for repair of distal penile hypospadias (DPH) at most of the centres throughout the world. Multiple series from major institutions have reported excellent cosmetic and functional results in conjunction with low complication rates. A retrospective review of 52 new cases of DPH where TIP urethroplasty was performed in Medical College Jammu has been analysed. Age range of the patients included in the study varied between 2 and 18 years with majority 47 (97.3%) below 5 years. Ten (19.9%) patients had chordee, which got corrected by degloving of the penis except 3 (5.7%) who required tunica albuginea plication. Neourethra was covered with vascularized pedicled dartos flap from the inner prepuce. Major complications occurred in 7 (13.4%) patients [urethrocutaneous fistula-5 (11.5%) patients, meatal stenosis-1 (1.9%) patient and complete breakdown-1 (1.9%) patient]. There were also minor complications like superficial skin necrosis in 10 (19.2%) patients and haematoma formation in 1 (1.9%) patient. Functional results as judged by the urinary stream, were good in 46 (88.8%) patients. Excellent cosmetic result was seen in 44 (84.6%) patients except 2 (3.8%) who had mild torsion of the shaft. Conclusion: Tubularized incised plate urethroplasty with dartos flap cover is a simple, single stage procedure for DPH with excellent cosmetic and functional results and is associated with minimal complications.
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Predictors of patency after two-stitch invagination vaso-epididymal anastomosis for idiopathic obstructive azoospermia
G Gautam, R Kumar, NP Gupta
July-December 2005, 21(2):112-115
Objectives: Anastomotic patency with return of sperm in the ejaculate following microsurgical vasoepididymostomy (VEA) is not universal and may be delayed. The ability to predict the result of VEA based on preoperative or intra-operative parameters would enable the surgeon to offer the best treatment to the infertile couple. We used the two-stitch invagination technique of VEA in patients of idiopathic obstructive azoospermia and prospectively analyzed factors that could predict a patent anastomosis. While such studies have previously been done for patients undergoing VEA for secondary infertility following a vasectomy, to the best of our knowledge this is the first study analyzing these parameters for patients with primary infertility and idiopathic obstruction. Methods and materials: Over a 2-year period, 29 men underwent the 2-suture invagination VEA for idiopathic obstructive azoospermia. Twenty-four patients provided at least one postoperative semen sample. Preoperative and intra-operative parameters were compared between patients with a patent anastomosis with sperm in ejaculate (n = 12) and those with no sperm in the ejaculate (n = 12) using the t-test, Fisher's exact test or chi-square test, as appropriate and a multivariate statistical analysis to determine any significant difference. Results: The mean follow up of the 24 patients was 7.6 months (2-30 months). A significantly greater number of patients with patent anastomosis had motile epididymal sperms (P = 0.034) and higher surgeon's technical satisfaction with the procedure (P = 0.034). However, this difference was seen only on a univariate analysis and did not persist when a multivariate analysis was used. Conclusions: The presence of motile sperms in the epididymal fluid and a high level of technical satisfaction with the anastomosis may indicate a higher likelihood of success following a vaso-epididymal anastomosis for idiopathic obstruction. However, these parameters are not enough to prognosticate the outcome of surgery and advise early in vitro fertilization.
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Robots for minimally invasive urology
A Shrivastava, M Menon
July-December 2005, 21(2):74-78
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Carcinoma of tongue with solitary metastasis to kidney - case report
YB Thyavihally, HB Tongaonkar, AK D'Cruz, RF Chinoy
July-December 2005, 21(2):120-121
The most common tumors which metastatise to kidney are lymphoma, leukemia, and lungs. Metastatic tumors of the kidney are usually small, asymptomatic and occasionally cause flank pain and hematuria. Distinction from renal cell carcinoma is difficult to differentiate and a tissue diagnosis is imperative. Solitary metastasis to kidney from carcinoma tongue is rare. We report a case of isolated renal metastases from tongue cancer to show at the possibility of tumor metastasis, although rare, should always be considered in the differential diagnosis of renal mass.
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Nitin S Kekre
July-December 2005, 21(2):69-69
  - 3,218 93
Evaluation of endorectal magnetic resonance imaging and magnetic resonance spectroscopic imaging in diagnosing and staging prostate cancer - a prospective pilot study.
M Dholakia, N Patil, P Shetty, A Khandkar, V Srinivas
July-December 2005, 21(2):106-108
Aims: The main objective of our study was to evaluate the efficacy of End. MRI and MRSI in (1) detecting and (2) staging prostate cancer by correlating it with histopathological results. Methods: In a double blind prospective study of 20 patients were divided into two groups. In group A with 10 patients, the inclusion criteria were elevated PSA and/or a palpable nodule. All 10 patients with undiagnosed prostate cancer underwent End. MRI and MRSI followed by TRUS guided ten quadrant biopsy. In group B, 10 patients with already proven carcinoma prostate were included. All these patients underwent End. MRI and MRSI followed by radical prostatectomy. Results: The mean S.PSA was 19.8 ng/ml (1.9-52) and the mean Gleason score was 6.8 (5-8). In group A End. MRI/MRSI revealed a diagnosis of prostate cancer in 10 patients, but only six were positive on biopsy. In group B, End. MRI/MRSI showed eight patients to have periprostatic extension but only three were confirmed on final histology. Out of the eight patients that showed periprostatic spread on End. MRI/MRSI, seven patients showed seminal vesicle invasion, and one patient showed capsular infiltration. But on histopathology study seminal vesicle involvement was confirmed in only one patient and only two patients had capsular infiltration. Conclusions: This pilot study reveals that End.MRI/MRSI, although a relatively well-established investigation in the west, has not shown the same degree of accuracy in our setup.
  - 4,213 189
Robotic dismembered pyeloplasty for the treatment of ureteropelvic junction obstruction.
Vipul Patel
July-December 2005, 21(2):97-101
Objective: Laparoscopic pyeloplasty has been shown to have equivalent surgical outcomes with less surgical morbidity when compared to the open approach. The laparoscopic approach has traditionally been performed in a few specialized training centers because of the advanced technical skills required to perform this complex reconstructive procedure. The introduction of robotic technology into the modern day operating suite has brought on a new era and has simplified complex urologic reconstructive procedures. The daVinci robot provides the advantages of three-dimensional vision, magnification, and a robotic articulating wrist. These features allow precise dissection and suturing capabilities. We used the daVinci robot to perform robotic assisted laparoscopic pyeloplasty. We studied its feasibility, utility, and efficacy. Methods: Between July 2002 and April 2003, 12 patients with a mean age of 29.2 years (16-56) underwent robotic assisted laparoscopic dismembered pyeloplasty. Each patient had presented with flank pain (six left and right) and had been diagnosed with a ureteropelvic junction (UPJ) obstruction by either IVP or MAG3 renal scan. A retrograde pyelogram was performed preoperatively to delineate the anatomy and a stent was placed. Robotic dismembered pyeloplasty was performed. Eight of 12 patients had crossing vessels only five of which were shown on preoperative CT scan. The crossing vessels were preserved in all cases. The UPJ was dismembered at the point of obstruction and the scar excised. The ureter was spatulated medially and the renal pelvis fashioned appropriately. Ureteropelvic reconstruction was performed with eight-interrupted 4-0 monocryl sutures on an RB-1 needle in the first five cases. In the other seven cases the anastomosis was performed with two running semicircular sutures. Stents were removed at 14-28 days. An IVP was performed prior to stent removal and a renal scan at 3 and 6 months. Results: Each patient underwent a successful procedure without open conversion, transfusion or complication. Estimated blood loss was minimal at 52 cm3. Each patient was discharged home on the first postoperative day, average 18 h. Operative times fell quickly as experience with the daVinci robot increased. Operative time averaged 201 min. The first five patient's average or time was 262 vs. 158 min for the last seven. Time for the anastomosis averaged 42 min (100-20). The initial five cases were performed with an interrupted anastomosis. These took longer averaging 65.4 min (100-33). The subsequent seven cases were performed with two running hemi-circumferential stitches with anastomotic time averaging 25 min (30-20). Intraoperatively no complications were noted. Postoperatively the average hospital stay measured from the time of surgery to the time of discharge averaged 18 h (24-16). No postoperative complications have been noted. Average return to work is 10.9 days, and clearance for full activity at 17 days. Duration of the stent has averaged 18 days (24-13). The initial five patients with the interrupted anastomosis had longer stent times of 22.2 days (28-17) while the patients with a running anastomosis has average stent times of 17.6 days (22-13). Average follow up is currently 4.9 months (2-10). Each patient is doing well with no signs of recurrent obstruction. Follow up has been documented with MAG3 renal scan with Lasix at 3, 6 and 9 months. Conclusion: The adoption of robotic technology into today's modern operating rooms has stimulated a new era in urologic surgery. The daVinci robot provides magnified three-dimensional vision and a miniature robotic articulating wrist that allows precise dissection and laparoscopic suturing. Robotic dismembered pyeloplasty is an excellent technique with very good results. As experience with the robotic instrumentation increases operative times fall quickly. Blood loss and pain are minimal, allowing early discharge home and quick recovery. The short-term results are promising. Longer follow-up is needed.
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Evidence-based urology
J Chandra Singh
July-December 2005, 21(2):70-73
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Robotic-assisted laparoscopic surgery in urology:a historical perspective
Nikhil L Shah, AK Hemal, Mani Menon
July-December 2005, 21(2):79-82
Significant improvements in the surgical approaches and management of disease have been made since the advent of antiseptic surgical technique and the widespread use of antibiotics. During the last quarter century, especially in the last decade, however, there has been an indisputable paradigm shift toward the use of minimally invasive surgery for treatment of a variety of diseases. This has benefited the patient in terms of lower morbidity and mortality through less violation of the body's natural protective boundaries. The morbidity in terms of pain, discomfort, and disability often associated with open surgery is due to the process of gaining access to the specific organ or region of interest as opposed to the actual procedure itself. Put another way, the move toward minimally invasive approaches for surgical disease has resulted in superior outcomes, fewer complications, and an overall improvement in health-related quality of life (HRQOL).
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Telerobotic surgery
Prokar Dasgupta, Ben J Challacombe
July-December 2005, 21(2):89-92
With continued advances in medical robotic technology and global telecommunications, the concept of remote telerobotic surgery continues to develop. The ultimate goal of an experienced specialist operating remotely using a robot controlled by high-speed audiovisual connections has been shown to be feasible but is limited by local resources and a lack of evidence from randomised controlled trials. This article looks at the development of this exciting field and its impact on modern urology.
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Emphysematous pyelonephritis
A Karthikeyan, S Kumar, G Ganesh
July-December 2005, 21(2):118-119
  - 8,105 494
Diclofenac suppository administration in conjunction with lidocaine gel during transrectal ultrasound-guided prostate biopsy
J Chandra Singh, Nitin S Kekre
July-December 2005, 21(2):125-126
  - 5,111 143
Does testicular hypotrophy correlate with grade of adolescent varicocele?
J Chandra Singh, Nitin S Kekre
July-December 2005, 21(2):126-127
  - 5,314 134
Stress urinary incontinence: TVT or TOT?
J Chandra Singh, Nitin S Kekre
July-December 2005, 21(2):127-128
  - 14,399 380
Alpha blockers or antibiotics in chronic prostatitis/ chronic pelvic pain syndrome - what is the evidence?
J Chandra Singh, Nitin S Kekre
July-December 2005, 21(2):128-129
  - 5,183 163
Stenting the urethra after Snodgrass repair for distal hypospadias - is it necessary?
J Chandra Singh, Nitin S Kekre
July-December 2005, 21(2):129-130
  - 4,606 151
Donor evaluation: CT angiogram or MR angiogram?
J Chandra Singh, Nitin K Kekre
July-December 2005, 21(2):130-130
  - 3,310 138
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