AZF microdeletions associated with idiopathic and non-idiopathic cases with cryptorchidism and varicocele

AIM

To identify submicroscopic interstitial deletions in azoospermia factor (AZF) loci in idiopathic and non-idiopathic cases of male infertility in Indians.

METHODS

One hundred and twenty two infertile males with oligozoospermia or azoospermia were included in this study. Semen analysis was done to determine the sperm density, i.e., normospermia (>20 million/mL), oligozoospermia (<20 million/mL) or azoospermia. They were subjected to detailed clinical examination and endocrinological and cytogenetic study. Thirty G-banded metaphases were analyzed in the 122 cases and polymerase chain reaction (PCR) microdeletion analysis was done in 70 cytogenetically normal subjects. For this genomic DNA was extracted using peripheral blood. The STS primers tested in each case were sY84, sY86 (AZFa); sY127, sY134 (AZFb); sY254, sY255 (AZFc). PCR amplifications found to be negative were repeated at least 3 times to confirm the deletion of a given marker. The PCR products were analyzed on a 1.8 % agarose gel.

RESULTS

Eight of the 70 cases (11.4 %) showed deletion of at least one of the STS markers. Deletions were detected in cases with known and unknown aetiology with bilateral severe testiculopathy and also in cryptorchid and varicocele subjects.

CONCLUSION

AZF microdeletions were seen in both idiopathic and non-idiopathic cases with cryptorchidism and varicocele. The finding of a genetic aetiology in infertile men with varicocele and cryptorchidism suggests the need for molecular screening in non-idiopathic cases.

Mesonephroid adenocarcinoma of the bladder and urethra: a case report

Mesonephric or mesonephroid adenocarcinoma of the bladder may be a malignant form of nephrogenic adenoma or nephroid metaplasia. The lesion is rare, and to the best of our knowledge only 9 cases have been reported in the world literature. We report another case of mesonephroid adenocarcinoma of the bladder and urethra which was treated with transurethral resection and subsequent chemotherapy.

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.

Laparoscopic radical cystectomy with intracorporeal ileal conduit diversion: five cases with a 2-year follow-up

OBJECTIVE

To assess the feasibility and intermediate-term outcome of laparoscopic radical cystectomy (LRC) with ileal conduit urinary diversion in patients with organ-confined muscle-invasive carcinoma of the urinary bladder, the entire procedure undertaken intracorporeally only using laparoscopic techniques.

PATIENTS AND METHODS

Five patients (four men and one woman) underwent LRC with intracorporeal ileal conduit diversion in February 2000, using a six-port transperitoneal technique. LRC, ileal conduit exclusion, restoration of ileo-ileal continuity, and bilateral stented uretero-ileal anastomoses were completed intracorporeally in all patients. The follow-up data up to 2 years are reported.

RESULTS

All procedures were completed laparoscopically with no open conversion or intraoperative complications. The mean duration of surgery was 7.5 h; the blood loss was 360 mL and no patient required perioperative blood transfusion. The mean (range) hospital stay was 7 (6-22) days; the specimen weight was 225-400 g. The surgical margins of the bladder specimen were negative in each patient. One patient developed intestinal obstruction after surgery, requiring a diverting ileostomy for 12 weeks. At a follow-up of 2 years, two patients died, both from unrelated causes (myocardial infarction and septicaemia from pulmonary infection in one each). The three surviving patients are asymptomatic with normal upper tracts and no evidence of local recurrence or metastatic disease.

CONCLUSION

LRC with ileal conduit diversion undertaken completely intracorporeally is a feasible option for muscle-invasive organ-confined carcinoma of the urinary bladder, with good outcomes over a 2-year follow-up.

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.

Colour duplex Doppler ultrasonography evaluation of non-vasculogenic male erectile dysfunction: An Indian perspective

We present the study of colour duplex Doppler ultrasonography on Indian patients with non-vasculogenic erectile dysfunction. Patients with a history suggestive of psychogenic impotence along with a normal clinical response to intracavernosal papaverine were presumed to have non-vasculogenic erectile dysfunction. In our patients, the incidence of psychogenic impotence was much higher and the mean age of patients presenting with erectile dysfunction was lower as compared to patients from developed countries reported in research. The Doppler flowmetry showed much higher mean peak systolic velocities (PSVs) with a negative correlation between age and PSV. End diastolic velocity, resistive index and acceleration time values conformed to the literature.

Management of renal angiomyolipoma in complex clinical situations

Renal angiomyolipoma (AML) is associated with complex clinical situations such as tumour in a solitary kidney, bilateral, large or multicentric tumours or those associated with tuberous sclerosis (TS) or pregnancy. Management in these situations may be challenging. Fifteen patients (20 kidneys) were admitted with symptomatic AML over last 10 years. Eleven patients had one or the other complicating factor. Ten patients had a tumour of >10 cm, 4 had TS, 5 had multiple and bilateral tumours, 1 patient was pregnant and 1 had a solitary functioning kidney. With the newer imaging modalities correct diagnosis was possible in 12 cases and renal cell carcinoma (RCC) was suspected in 3 cases. Selective angioembolization (SAE) was done in 3 patients, which successfully controlled bleeding in all. Nephron-sparing surgery (NSS) was performed in 5 patients. Total nephrectomy was done in 4 cases, in 3 due to suspicion of RCC and in 1 due to extensive involvement of the kidney. Three patients with multiple and bilateral tumours were chosen for conservative treatment and none developed recurrence of bleeding on strict follow-up. In a pregnant patient, bleeding was successfully controlled with angioembolization. However, 1 patient with a solitary functioning kidney with large-sized tumour (20 x 18 cm) underwent NSS. In conclusion, the basis of management of AML is preservation of renal tissue, which can be effectively achieved with SAE or NSS. In a solitary functioning kidney, NSS or SAE is the ideal treatment, if feasible. The patients in the TS group are usually more complicated and require life-long follow-up after initial management with NSS or SAE. Pregnant AML patients can be safely managed with SAE. Conservative treatment without any intervention and regular follow-up may be more helpful in some patients with multiple, bilateral extensive tumours.

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.

Evaluation of laparoscopic retroperitoneal surgery in urinary stone disease

PURPOSE

To assess the safety and effectiveness of laparoscopic retroperitoneal surgery and attempt to define its role in the management of urolithiasis.

PATIENTS AND METHODS

Laparoscopic retroperitoneal surgery (LRS) was undertaken in 72 male and 42 female patients with calculous disease from March 1994 to April 2000 for variety of indications that otherwise would have made them candidates for conventional open surgery. Some of these patients were subjected to retroperitoneoscopic ureterolithotomy (RPUL) (40 patients) and retroperitoneoscopic pyelolithomy (RPPL) (7 patients). Retroperitoneoscopic nephrectomy (RPN) and nephroureterectomy (RPNUT) for a nonfunctioning renal unit secondary to renal and or ureteral calculi was done in 53 and 14 patients, respectively. Most of the procedures were performed with three 10-mm ports. In some cases, an additional 5-mm port was used.

RESULTS

The procedure was successful in 75%, 71%, 90.5%, and 86% of cases subjected to RPUL, RPPL, RPN, and RPNUT, respectively. The mean operating time for RPUL was 106.3 minutes and for RPPL was 108.2 minutes, whereas it was 99.7 minutes for RPN and 147 minutes for RPNUT of nonfunctioning kidneys secondary to calculous disease. The major complications encountered were colon injury in one patient with calculous pyonephrosis who had dense adhesions and injury to the external iliac artery in another patient having RPUL. The mean blood loss was 69.8, 127.2, 135.6, and 206.5 mL, respectively, for RPUL, RPPL, RPN, and RPNUT. The average hospital ranged from 3 to 4 days.

CONCLUSIONS

Laparoscopic retroperitoneal surgery has a definite role in the management of patients requiring open surgery for calculous disease. It is safe and feasible in spite of the dense adhesions that are frequently encountered in such patients. Often, previous attempts at treatment with shockwave lithotripsy or endourologic procedures also lead to inflammation and adhesions, making surgery difficult. However, these problems can be dealt with by LRS with good results.

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.

Complications of retroperitoneoscopic surgery at one centre

OBJECTIVE

To evaluate the complications of retroperitoneoscopic urological surgery at one centre and to analyse their causes and means of prevention.

PATIENTS AND METHODS

The procedural details and complications were analysed retrospectively in 316 patients (aged 4-88 years) who underwent retroperitoneoscopic urological surgery between March 1994 and January 2000 at our centre. Nephrectomies and nephroureterectomies for benign and malignant diseases were the most common procedures. Other indications included urolithiasis, adrenal diseases, pelvi-ureteric junction obstruction, chyluria, retrocaval ureter and malignant retroperitoneal lymph node enlargement. The specimens were retrieved intact by enlarging the port sites.

RESULTS

The mean (range) operative duration was 104.9 (30-400) min, the blood loss 130.86 (25-1200) mL and the hospital stay 3.2 (1-10) days; 3.5% of the patients had a major complication, including seven vascular injuries, five of which required immediate conversion to open surgery. Four patients (1.2%) had other major complications including colonic injury, retroperitoneal collections and incisional hernia. There were 50 minor complications (15.8%) of which peritoneal tears (17) were the commonest. Port-site infections and subcutaneous emphysema contributed 2.2% each.

CONCLUSIONS

As the stages of retroperitoneoscopic surgery become standardized and the outcome predictable, it is rapidly becoming accepted as an important method of treatment. The complications are few and predominantly minor. Increasing experience leads to a decrease in the complication rates. Individual surgeons can identify the common complications in their practice, ascertain the possible causes and devise methods of prevention.

Retroperitoneoscopic ureterolysis and reconstruction of retrocaval ureter

We report a case of circumcaval ureter in a symptomatic young man who was managed successfully by retroperitoneoscopic ureterolysis and ureteroureteral reconstruction using three-port technique.

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.

Primary obstructive megaureter in adults: need for an aggressive management strategy

PURPOSE

Primary obstructive megaureter (POM) is an uncommon disease in adults. We reviewed our experience with this disease to determine the clinical profile, management and prognosis of this disease in adults.

METHODS

We studied 37 adults with POM who presented from January 1989 to December 1998. Their clinical presentation, renal function, radiologic data, complications, treatment as well as the results and follow-up were studied.

RESULTS

The patients' age ranged from 13 to 52 years. Male:female ratio was 27:10. Seven patients had bilateral disease. All patients were symptomatic excepting 2. Complications at presentation were loin pain (26 cases), urinary infection (15 cases), calculus disease (17 cases), azotaemia (5 cases), and obstructive jaundice (1 case). Associated congenital anomalies included contralateral renal agenesis (2 cases), posterior urethral valve (1 case) and exstrophy of bladder (1 case). Thirty-four patients required surgical intervention. Of these, 26 patients underwent ureteroneocystostomy (UNC) with ureteral tailoring in 18 patients; 4 patients were treated endoscopically by ureteric meatotomy and stenting, 2 patients with nonfunctioning kidney by nephroureterectomy, 2 patients in advanced renal failure by percutaneous nephrostomy alone. In 4 out of 5 patients uraemia did not improve despite adequate drainage.

CONCLUSION

The majority of adults with POM are symptomatic, have complications and require surgical correction. Complications of stone formation (46%) and renal failure (13.5%) are unusually common in adults. Once renal failure is advanced, intervention appears futile, therefore, it is imperative to treat these patients as soon as possible. Surgical correction by ureteric re-implantation is effective and has low morbidity.

Spontaneous perirenal hematoma. A case report and review of literature

Spontaneous perirenal hematoma (SPH) is a clinical entity that poses a diagnostic and therapeutic challenge. We report a case of SPH in an adult where the cause could not be determined at first presentation, even with computed tomography (CT) of the abdomen and angiography. He was under close follow-up, and it was only with a repeat CT scan after 3 months that a mass lesion in the kidney was identified as the underlying cause. We also present a review of the literature so that a logical approach can be adopted for this problem.

Polymerase chain reaction in clinically suspected genitourinary tuberculosis: comparison with intravenous urography, bladder biopsy, and urine acid fast bacilli culture

OBJECTIVES

To evaluate the role of urinary polymerase chain reaction (PCR) in the detection of Mycobacterium tuberculosis (MTb) in patients with a clinical suspicion of genitourinary tuberculosis (GUTB) and to compare its sensitivity with intravenous urography (IVU), bladder biopsy, and urine culture for acid fast bacilli (AFB).

METHODS

The study was carried out between September 1997 and December 1998 in 42 patients with a clinical suspicion of GUTB. Their clinical features, organ involvement, and investigation results were studied. The diagnostic yield of urinary PCR for MTb and its sensitivity in comparison with routine urine AFB culture, bladder biopsy, and IVU were assessed.

RESULTS

There were 25 male and 17 female patients, with a mean age of 31.04 years. Patients suspected of having GUTB most often presented with irritative voiding symptoms. Two patients had abnormal renal parameters. Of the 42 patients clinically suspected of having GUTB, radiologic abnormalities suggestive of GUTB were found in 37 (88.09%); MTb was isolated in the urine AFB culture in 13 (30.95%); bladder biopsy was positive in 11 (45.83%); and urinary PCR for MTb was positive in 34 cases (80.95%). Of 35 cases of proven GUTB, IVU was suggestive of the diagnosis in 32 (91.42%) and MTb was isolated in the urine AFB culture in 13 cases (37.14%). Bladder biopsy was positive in 11 (45. 83%) of 24 patients in whom biopsy was taken, and urinary PCR for MTb was positive in 33 (94.29%).

CONCLUSIONS

A high index of suspicion is necessary for a diagnosis of GUTB. In clinically suspected cases, IVU may be suggestive of GUTB, but it is not specific. In the present study, IVU was suggestive in 88.09% of patients. MTb was isolated in the urine AFB culture in only 37.14% of patients, and bladder biopsy was positive in 45.83%. Urinary PCR for MTb was the most sensitive indicator and was positive in 94.29% of patients. It is evident from this series that PCR provides a much faster diagnosis of urinary MTb. It is a rapid, sensitive, and specific diagnostic method and avoids a delay in starting treatment.

Ureterovaginal fistula following laparoscopic-assisted vaginal hysterectomy--a case report with review of literature

The authors present a case of ureterovaginal fistula following laparoscopy-assisted vaginal hysterectomy, which was successfully managed by ureteroneocystostomy with bladder psoas hitch.

Marjolin's ulcer of the suprapubic cystostomy site infiltrating the urinary bladder: a rare occurrence

We report a case of a 40-year-old man who had presented with a spontaneous suprapubic urinary leak from a well-healed suprapubic cystostomy tract scar, 20 years following a successful scrotal tube substitution urethroplasty done for a post-traumatic urethral stricture. Preoperative contrast studies suggested a recurrent bulbomembranous urethral stricture. Excision biopsy of the suprapubic fistulous tract revealed scar cancer infiltrating the bladder wall. Of 3 similar cases reported in the past, only 1 had bladder involvement. Ours is the second such case with bladder involvement.

Comparison of retroperitoneoscopic nephrectomy with open surgery for tuberculous nonfunctioning kidneys

PURPOSE

We describe, define and evaluate the role of retroperitoneoscopic nephrectomy for tuberculous nonfunctioning kidneys, and compare the results with those of open nephrectomy in similar cases in a nonrandomized study.

MATERIALS AND METHODS

Beginning in July 1994, 9 patients underwent retroperitoneoscopic nephrectomy for tuberculous nonfunctioning kidneys at our center. Data obtained from the records of these patients were compared with those of 9 who underwent open nephrectomy for a similar indication during the same period. Retroperitoneoscopic nephrectomy was initially performed by kidney dissection followed by ligation of the hilar vessels. The technique was subsequently modified and the vessels controlled before dissecting the kidney. Various parameters were compared and statistical analysis was done.

RESULTS

The 2 groups were similar in regard to patient age, gender and side of disease. Retroperitoneoscopic nephrectomy was successful in 7 of the 9 patients. Although 2 of our initial patients required conversion to open surgery, the remaining 7 successfully underwent retroperitoneoscopic nephrectomy after modifying the technique. Mean operative time was slightly greater in the retroperitoneoscopy than in the open surgery group (103.3 versus 92.2 minutes). Mean blood loss was less in the retroperitoneoscopy group (101.4 versus 123.3 ml.), mean hospital stay plus or minus standard deviation was significantly shorter (3.2 +/- 0.83 versus 8.88 +/- 3.37 days) and mean time to return to work was significantly less (3 versus 7 weeks). Mean analgesic requirement for opioids and diclofenac sodium was also lower in the retroperitoneoscopic nephrectomy group (0 versus 1.44 +/- 0.72 and 3.8 +/- 1.3 versus 4.3 +/- 1.2 doses, respectively). Minor complications developed in only 2 retroperitoneoscopy cases.

CONCLUSIONS

Tuberculosis has been considered a contraindication to retroperitoneoscopic nephrectomy due to a high conversion rate. However, we believe that our modified technique of retroperitoneoscopic nephrectomy is a viable option for managing tuberculous nonfunctioning kidneys. The conversion rate is lower than previously reported. Comparing our results with those of open nephrectomy shows that retroperitoneoscopic nephrectomy is beneficial in all respects except for slightly longer operative time. Because of the benefits of minimally invasive surgery, this approach should be considered in such cases.

Open thumb forceps. An unusual foreign body in the urethra: technique of its removal

A great variety of foreign bodies in the urethra have been reported in the literature. Mostly, these cases were reported to emphasize the unusual nature of the objects requiring technical modifications for their removal. We report an interesting case of self introduced open thumb forceps into the urethra and technique of its retrieval.

Lower ureteral obstruction due to a persistent umbilical artery

A 32-year-old lady presented with primary infertility and a 1-year history of recurrent left-flank pain. She was found to have left lower ureteric obstruction on intravenous urography. No specific cause for the obstruction could be determined preoperatively. The patient underwent open extraperitoneal surgery to determine the cause and to treat the obstruction. A 4-mm vessel was seen crossing over the ureter at the site of narrowing. It was the persistent umbilical artery traced in continuity from the internal iliac artery. The vessel was resected, and the ureter was reimplanted into the bladder. Extrinsic obstruction of the distal ureter because of aberrant or persistent vessels has been infrequently reported. Such reports predominantly refer to children, and the diagnosis is usually made at laparotomy, frequently following previous failed attempts at endourological management.