Icahn School of Medicine at Mount Sinai Hospital
New York, New York | United States
Main Specialties: Urology
Additional Specialties: Urology
Primary Affiliation: Icahn School of Medicine at Mount Sinai Hospital - New York, New York , United States
Int Braz J Urol. 2015;41:1014-9.
We have read the technique titled “A novel method of ensuring safe and accurate dilatation during percutaneous nephrolithotomy” by Javali et al (1) with great interest. We compliment the authors on this novel technique of placing guide wire in difficult situation. We would like to draw the attention of the authors to a few points and make a few comments. A well-placed guide wire is a corner stone to the success of percutaneous access. Failure of guide-wire access may result in potential complications such as loss of tract, bleeding due to parenchymal injury that might lead to abandonment of procedure (2). Although wire down the ureter in every case would be ideal, but it is not necessary to be very rigid about that. We feel adequate and secure length of the wire in the pelvi-calyceal system is all that is needed for a satisfactory and safe tract making. The common causes of guide-wire not going up the renal pelvis or down the ureter (3) are: • Large calculus occupying and/or blocking the calyx or infundibulum, • Puncture of the anterior calyx instead of the posterior calyx. If a large obstructing calculus is the cause of wire not progressing, there may be a need to fragment the calculus to create space for the wire to proceed. The authors have not mentioned any incidence of need for fragmentation in this large series. The lower pole calyces usually have a complex arrangement. The typical anterior and posterior arrangement of calyces is seen only in 58% of cases in the lower pole (3). Eisner et al have found that in 31% of cases, the arrangement of calyces in the lower pole is such that no calyx is truly posterior. In such kidneys both the calices in the lower pole are anterior with one of the calyx being less anterior as compared to the other (4). If the anterior calyx is punctured then the glide wire would have difficulty in entering the pelvis (2). In this situation, gaining access to renal pelvis and upper ureter using an ureteroscope would torque the lower pole. This can be traumatic.
Asian Pac. J. Health Sci., 2016; 3(1):96-98
Purpose: To access bladder functions or exact degree of outflow obstruction in patients undergoing TURP. Material and Methods: PF studies performed in 100 patients undergoing TURP between Aug 2012 to Aug 2014 before and 3 months after TURP. Results:The mean age of the patients was 70.29 (45-84) years. All patients enrolled in the study were having Serum PSA below 4 ng/ml with average being 1.3 ng/ml. Out of 100 patients, 42 presented with refractory retention and 58 with high AUA score. All patients with refractory retention had stable filling phase; Pdet@Qmax> 79 cm/H2O, with average Qmax -8ml/sec and AG No. >40. 35 patients were happy with outcomes of surgery. Out of 58 patients with high AUA Score, 29 patients were having predominant voiding symptoms, 17 patients were having predominant storage symptoms and 12 patients were having both storage and voiding symptoms. Patients with predominant voiding symptoms and both storage and voiding symptoms had urodynamically stable filling phase with high detrusor pressure and reduced flow rate. All of these had good surgical outcome.13 patients with predominant storage symptoms had detrusor over activity of which 3 were happy with outcomes of surgery; 7 patients had persistent LUTS, 3 lost to follow up. Conclusions: Patients having high AUA symptom score with predominant storage symptoms had detrusor instability (85%) and 45% were unhappy and hence in these patients PF studies could help us to counsel about the results of TURP.
Journal of Clinical and Diagnostic Research. 2016 Feb, Vol-10(2): PC04-PC06
Journal of Clinical and Diagnostic Research
Introduction: Children with urolithiasis are associated with considerable morbidity and commonly associated with metabolic abnormalities. By treating these abnormalities stone formation is prevented. Objectives: To study the metabolic risk factors of urolithiasis in children and compare them with literature. Materials and Methods: In open, prospective and observational study, 75 children were evaluated from August 2010 to June 2014. In all patients’ dietary history, water intake and results of laboratory findings were recorded. All urine samples obtained from patients were without dietary restrictions. Reference paediatric 24 hour urinary parameter was used according to western literature. Results: We investigated 75 patients with urolithiasis. Low urine volume was found in 49 patients which is comparable with previous studies indicating simple intervention as to increase water intake. Low calcium intake was found in 44 patients suggesting that low calcium intake is associated with higher incidence of urolithiasis due to increased intestinal oxalate absorption. Hypocalcaemia was found in 32 patients and 24 hour urinary abnormality was found in only 16 patients’. Both these finding does not support previous literature. Stone analysis finding does not correlate with urinary finding. Conclusions: Low urine volume secondary to low water intake is predominant finding. Hypocalcaemia is major metabolic abnormality in contradiction to western literature. There are no nomograms for urinary excretion of Calcium, uric acid, oxalate and citrate in Indian children. Keeping the optimum blood calcium level & increased fluid intake can prevent stone formation in children.
Year : 2016 Month : January Volume : 5 Issue : 1 Page : 54 - 55
International Journal of Anatomy, Radiology and Surgery
Isolated renal penetrating injury requiring exploration is rare. Kidney is retroperitoneal organ with strong muscular and rib cage support. Added to this Gerota�s fascia prevent direct injury to renal parenchyma. Here we have presented an interesting case of renal stab injury in young man who had completely divided kidney due to knife. Patient managed with nephrectomy. He fared well the procedure as well as post-operative recovery. We discussed this case with literature review but isolated renal stab injury was not found. We also presented elegant images of this case.
Year : 2016 | Volume : 32 | Issue : 1 | Page : 71-73;DOI: 10.4103/0970-1591.173113
Indian Journal Of Urology
A 30-year-old lady underwent a Boari flap repair for post-hysterectomy mid-ureteric stricture. The upper end of the double J stent inserted during the procedure was misplaced in the supra-renal inferior venal cava. Cystoscopic stent removal could be performed uneventfully, while the stricture was managed by endoureterotomy.
Journal of Clinical and Diagnostic Research
Introduction: India is the country with the highest burden of TB, an estimated incidence figure of 2.1 million cases of TB for India out of a global incidence of 9 million according to World Health Organization (WHO) statistics for 2013. Renal impairment in these patients is slow and due to continuous infection causing destruction of renal mass. Reconstruction of urinary tract which is frequently required for patients with Urinary TB poses significant challenges. This paper analyses these challenges. Aim: To analyse challenges in reconstruction of urinary tract in patients with urinary tuberculosis and renal failure. Materials and Methods: Thirty-one patients with renal tuber-culosis were seen from August 2011 to August 2013. We faced major problem in outcomes of surgery in patients with multifocal disease. Results: Out of 31 patients 18 patients were males and 13 were females. Total 11 patients had serum creatinine more than 2mg/dl (1.5 mg/dl being upper normal range of our laboratory) at the time of presentation. These patients had simultaneous kidney, ureter and bladder involvement or with bilateral disease. Four of these patients underwent uretero-calicostomy, five patients underwent augmentation cystoplasty with bilateral ureteric reimplantation and two patients underwent ileal conduit as they were having serum creatinine of more than 2.5 mg/dl. All patients who underwent ureterocalicostomy had re stricture and failure of surgery and augmentation cystoplasty had raised creatinine requiring second procedure in the form of percutaneous nephrostomy. Patients with ileal conduit remained stable with overnight bladder drainage at bed time. Conclusions: Though renal failure is not considered contrain-dication for augmentation cystoplasty, reconstruction using large segment of bowel predisposes them to metabolic complications and sepsis. Use of short segment of ileal conduit with continued drainage at night in creatinine above 2.5 mg% is reasonable option to augmentation to avoid further metabolic complications.
Arab Journal of Urology
Sir, We read with keen interest an interesting point of technique by Ratkal and Sharma  about a ‘pull and push’ technique of antegrade JJ stent placement after percutaneous renal procedures. The authors need to be complimented for a very interesting technique. Based on our experience of the ‘Reverse Zebra Technique’ of stent placement , we have a few comments on the presented technique. In the present technique, the ureteric catheter is gradually pulled until the lower end of the ureteric catheter is seen above the pubic symphysis. Through this catheter the guidewire is coiled in the bladder and the stent placed over it in an antegrade fashion. The major problem with this technique is that the lower part of the ureteric catheter is usually in the non-sterile zone of the surgical field. Due to the prone positioning of the patient, the lower end can become unsterile. By pulling the catheter up, the unsterile end of the catheter is being brought not only in the ureter but also in the kidney and out through the Amplatz sheath. In contrast, in the reverse zebra technique, the lower end remains out of the sterile field hence maintaining asepsis better.
Year : 2015 | Month : December | Volume : 9 | Issue : 12 | Page : PD01 - PD02.DOI: 10.7860/JCDR/2015
Journal of Clinical and Diagnostic Research
Placenta percreta presents as life threatening complications with bladder invasion. A condition of placenta invading urinary bladder presented with differential diagnosis of gestational trophoblastic neoplasia on imaging and responded to chemotherapy. A 35-year-old primi-gravida presented at term with per vaginal bleeding. During caesarian section placental mass totally invading uterine myometrium was found. She was given single dose of Methotrexate. After 2 months she presented with gross haematuria with clot retention two times. Her MRI was suggestive of gestational trophoblastic neoplasia of size 19 X 10 X 13cm. Her beta-Human Chorionic Gonadotropin levels were 691.23 mIU/ml. She was given total four doses of methotrexate. At present size of mass was 1.6 X1.3X 1.1cm. Her beta Human Chorionic Gonadotropin level dropped down to 2mIU/ml. Patient was not willing for further intervention or for follow up.
Year : 2015 | Month : Nov | Volume : 9 | Issue : 11.DOI : 10.7860/JCDR/2015/14207.6709.
Journal of Clinical and Diagnostic Research
Introduction Early diagnosis and expeditious management of coronary artery disease (CAD) has a rewarding survival benefit. Aim To study whether erectile dysfunction (ED) serves as a surrogate marker for CAD in a young patient. Settings and Design Males (n=207) between ages 20-60 years with ED were evaluated prospectively for risk factors for CAD. Materials and Methods Blood Glucose Levels (BGL) fasting and post meal), lipid profile (LP) and 12 lead electrocardiogram (ECG) was done in all of them. International Index of Erectile Function-5 (IEF-5) was used for the evaluation of ED. Those with abnormal parameters were assessed by cardiologists by echocardiography, stress test and if necessary coronary angiography (Non-Invasive or Invasive). Statistical Analysis All the data were analysed using SPSS. 16 statistical software (SPSS Inc., Chicago, IL, USA). All data are expressed as mean and standard deviation. The Student’s t-test was used to compare means between groups, and the chi-square test was used to compare proportions between the groups. P-value <0.05 was considered statistically significant. All confidence intervals (CIs) are two tailed and calculated at the 0.05 level. Results Out of 207, 149 patients had at least one abnormal screening parameter. All underwent cardiology consultation and 2D ECHO and Stress test. Thirty six patients underwent coronary angiography. CAD was found in 22 patients. Of these, 19 patients had severe ED. Nine patients were between 20-40 years of age (13.23%). All 9 young patients had deranged LP; severe ED. Six patients were smokers while nobody was hypertensive. Conclusion ED serves as a surrogate marker for CAD in young patients (p=0.001). Presence of risk factors and lab abnormalities in young patients with ED warrants a cardiology referral to detect CAD.
Open Access ORIGINAL RESEARCH Int J Med Sci Public Health. 2015; 4(8): 1098-1102doi: 10.5455/ijmsph
International Journal of Medical Science and Public Health
Background: Transurethral resection of prostate (TURP) to treat benign enlargement of prostate (BEP) has been the gold standard for decades. It has been demonstrated to be efficient, cost-effective and durable with low long-term complication and retreatment rates. Objective: To evaluate the results and financial implications of surgical therapy in a subset of BEP patients who underwent TURP with relative indications, after an initial medical therapy. Materials and Methods: In this open-prospective study, we assessed 100 patients with BEP who were initially on medical therapy but later on opted for TURP based on various reasons. Preoperative financial expenditure on the medications and perioperative expenses were analyzed. The financial implication of an operative procedure against the long-term medical treatment was evaluated. The paired T test was applied wherever possible. Results: The mean age of the patients was 67.29 (48–84) years; 56% of patients were dependent on their siblings for financial support. Rest 44% possessed monthly average income between Rs. 4,000 and 6,000. There was mean improvement of 17.13 in American Urological Association symptom score, mean increment of 6.68 mL/s in maximum flow rate, and mean decrease of 54.36 mL in postvoid residue post-TURP. Majority (84%) of the patients were happy with TURP when compared with 35% with medical management. Conclusion: In a public hospital setup with subsidized operative charges, a long-term medical management (>2 years) would prove more expensive compared with an earlier surgical intervention, which would thus be worthwhile in patients with economic constraints.
Journal of Case Reports
Background: Imperforate hymen though most common female genital tract malformation, remains an uncommon cause of acute urinary retention and abdominal pain in children. Case Report: We present a case of 13 year old pre-menarchal female who presented with acute urinary cyclical suprapubic pain and a lump in abdomen in emergency department. Foleys catheterization was done to relief her urinary retention. On detail examination, she was diagnosed with imperforate hymen and palpable lump in abdomen. Ultrasonography showed it to be hematometrocolpos. Patient underwent hymenotomy and passive drainage of collected menstrual blood. Discussion: Imperforate hymen presents as amenorrhea, recurrent cyclical lower abdominal/pelvic pains, acute urinary retention or palpable lump due to hematometrocolpos. Conclusion: It is a diagnosis that can easily be overlooked in the fast paced setting of the Emergency Department. It must be included, particularly, in the differential diagnosis of every pre-pubertal young female with abdominal pain or acute urinary retention.
Year : 2015 | Month : May | Volume : 9 | Issue : 5.DOI : 10.7860/JCDR/2015/13912.5875
Journal of Clinical and Diagnostic Research
Bilateral congenital mid ureteric stenosis is a very rare entity causing hydroureteronephrosis. The pathophysiology and aetiology of this condition is uncertain. Congenital functional obstruction of the mid ureter has only 17 reported cases, that too of unilateral pathology. We report a case of an 11-year-old male child who was presented with left sided lump in abdomen since one year. On bilateral retrograde ureteropyelography (RGP), bilateral mid ureteric stenosis was documented at the level of pelvic brim. Tc99m Diethylene Triamine Pentacaetic Acid (DTPA) scan showed non functioning left kidney and decreased function and retention on right side. We did a left nephroureterectomy and uretero-ureterostomy without tapering over a Double-J stent (DJ), with excision of stenosed segment on right side. Pathological review of the ureteric segments of both sides revealed proximal dilatation with non-specific thickening of the muscular wall of the stenosed segments of ureter. The differential diagnosis must additionally include ureteral valves and fibro epithelial polyps. Important role of intravenous pyelography in such cases must be emphasized to localize the pathology site. In addition, retrograde ureteropyelography is essential in management of this anomaly to delineate the stenosed segment of the ureter preoperatively, so that the surgeon can be well prepared with final plan of management.
http://www.bhj.org.in/journal/2015-5702-april/original-articles.htm.Bombay Hospital Journal, Vol. 57
Bombay Hospital Journal
We studied 44 consecutive patients with UPJ obstruction at our institute to assess their functional outcome of pyeloplasty by analysing their GFR and drainage pattern in preoperative and postoperative renal scan. The postoperative renal function was found to remain static in substantial proportion of the patients (72%) with only 6% showing a post-operative improvement in renal function. Drainage improved in 76% of the patients on post-operative diuretic scintigraphy as evaluated using various parameters. However a majority (88%) of the patients experienced an improvement in symptoms and relief of pain which appears to be the most crucial outcome rather than the improvement in renal function. There was no correlation found between age, preoperative serum creatinine, degree of hydronephrosis i.e. parenchymal thickness, preoperative GFR and postoperative functional improvement.