Initial experience of laparoscopic retroperitoneal partial nephrectomy in an academic hospital in Malaysia

Laparoscopic retroperitoneal partial nephrectomy (LRPN) is a technically demanding kidney surgery due to the limited space and unfamiliar approach in the retroperitoneal space. The aim of this study is to review the outcome of our initial experience in performing this procedure. All patients who underwent LRPN between 2019 to 2022 were included in this retrospective review. A total of 23 patients underwent LRPN. The mean operating time was 178±43 minutes and mean warm ischemia time was 20±5 minutes. The average estimated blood lost was 89±68ml and the mean postoperative hospital stay was 3.6±0.8 days. Two patients (11.1%) had positive margin and no local recurrence was seen after mean follow up of 15.8±12.0 months. Our initial experience on LRPN showed promising results to perform partial nephrectomy safely and effectively.

Multiwall carbon nanotube polyvinyl alcohol-based saturable absorber in passively Q-switched fiber laser

In this work, we demonstrated a compact Q-switched erbium-doped fiber laser capable of generating high-energy pulses using a newly developed multiwall carbon nanotube (CNT) polyvinyl alcohol (PVA) thin film based saturable absorber. Q-switched pulse operation is obtained by sandwiching the thin film between two fiber ferrules forming a saturable absorber. A saturable absorber with 1.25 wt. % of PVA concentration shows a consistency in generating pulsed laser with a good range of tunable repetition rate, shortest pulse width, and produces a high pulse energy and peak power. The pulse train generated has a maximum repetition rate of 29.9 kHz with a corresponding pulse width of 3.49 μs as a function of maximum pump power of 32.15 mW. The maximum average output power of the Q-switched fiber laser system is 1.49 mW, which translates to a pulse energy of 49.8 nJ. The proposed method of multiwall CNT/PVA thin film fabrication is low in cost and involves uncomplicated processes.

Tunable single Stokes extraction from 20 GHz Brillouin fiber laser using ultranarrow bandwidth optical filter

The individual extraction of a Brillouin Stokes line from a 20 GHz comb generated from the compact configuration of a multiwavelength Brillouin fiber ring laser configuration has been achieved using an ultranarrow bandwidth (UNB) optical filter. The narrowest bandwidth transmission of a UNB optical filter that is 50 pm is used in order to get particular Stokes. The Stokes filtered is in the wavelength range of 1549.768-1551.016 nm. High SNR within the range of 54.97-11.73 dB with almost nil peak power loss being obtained was monitored by a 0.16 pm optical spectrum analyzer, giving convincing results. Relatively, the proposed configuration could provide wide tunability and narrow selection of the Brillouin Stokes.

Closely spaced dual-wavelength fiber laser using an ultranarrow bandwidth optical filter for low radio frequency generation

A dual-wavelength (DW) fiber laser with a closely spaced single longitudinal mode (SLM) output is proposed and demonstrated. The proposed fiber laser utilizes a conventional fiber Bragg grating with a center wavelength of about 1546.8 nm in conjunction with an ultranarrow bandwidth tunable optical filter to generate the desired DW SLM output. Observations with a very high resolution optical spectrum analyzer, which was capable of achieving resolutions up to 0.16 pm, revealed detailed spectral characteristics not characteristically seen before. A channel spacing of up to 58 nm was realized, and spacing as small as 2 pm was achieved. The minimum channel spacing and its resulting beat frequency are the narrowest observed yet to the best of our knowledge for a DW fiber laser at room temperature.

Urinary bladder characteristics via ultrasound as predictors of acute urinary retention in men with benign prostatic hyperplasia

OBJECTIVE

To determine the clinical utility of urinary bladder and prostate characteristics measured by ultrasound scan in predicting acute urinary retention (AUR) for men with bladder outlet obstruction with an underlying benign prostate hyperplasia (BPH).

MATERIALS AND METHODS

Consecutive men aged ≥50 years presenting with lower urinary tract symptoms (LUTS) or AUR were prospectively recruited in this cross-sectional study. International prostatic symptom score (IPSS) and serum prostate-specific antigen (PSA) were recorded. High-resolution ultrasound was used to measure bladder detrusor thickness (DT, mm), prostatic volume (PV, cm3), intravesical prostatic protrusion (IPP, mm), bladder wall thickness (BWT,mm), intravesical volume and bladder radius. The latter two parameters were used to estimate bladder weight (UEBW, g), assuming a spherical bladder.

RESULTS

Among selected patients, thirty had AUR while 32 men presented with LUTS only. There were significant differences between those with and without AUR in their age (70.5 vs 66.0, p=0.017), IPSS (24.0 vs 18.5, p=0.009), serum PSA (6.18 vs 1.77, p=0.002), PV (56.7 vs 32.4, p=0.006), BWT (5.0 vs 4.4, p=0.034) and UEBW (39.1 vs 25.0, p=0.0003). Multivariate analysis revealed high IPSS and UEBW to be predictors for AUR. UEBW was the strongest predictor of AUR: area under ROC curve was 0.767, with sensitivity and specificity of 63.3% and 87.5%, respectively, at cut-off point of 35 g. The likelihood ratio for AUR was also best with UEBW≥35 g.

CONCLUSIONS

Combined with IPSS, ultrasound determined bladder characteristic, particularly UEBW, is a useful tool in predicting AUR in men with BPH.

Bilateral emphysematous pyelitis: a rare encounter in urology

Gas-forming infection of the kidneys can affect either the parenchyma or the collecting system. They are known as emphysematous pyelonephritis (EPN) and emphysematous pyelitis (EP) respectively. Bilateral EPN is a fairly established entity and numerous articles about this condition have been published. However, much less is known about bilateral EP. We report a rare case of bilateral EP and a literature review of this disease. A 66-year-old woman with long-standing bilateral staghorn calculi presented with bilateral EP and severe sepsis. She was treated with antibiotics and bilateral double-J stents to drain the upper urinary tracts. She recovered after 1 month of intensive care and medical therapy. Percutaneous nephrolithotomy (PCNL) had been scheduled to treat her staghorn calculi. A literature search on MEDLINE and Google Scholar with the terms "bilateral emphysematous pyelitis" only found 1 case report in English and another 2 reports in the Korean language that discussed bilateral EP. The collective experience of these few cases, including the present case, suggests that bilateral EP runs a more benign course than bilateral EPN. It should be diagnosed as soon as possible with computed tomography (CT) scans of the renal system. Current evidence shows that can be treated successfully with timely antibiotics. Drainage of the collecting system either percutaneously or with placement of double-J stents might facilitate recovery.

An unusual cause of a penetrating injury to the anterior urethra: a thorny situation

Concurrent penetrating injury to the male external genitalia and the anterior urethra is uncommon. This case illustrates an unusual cause of such an injury, and its subsequent management and outcome. A 69-year-old man had his scrotum and anterior urethra pierced by a long thorn when he fell in his farm. He presented with urine leakage from the scrotal wound each time he micturated. Cystoscopic examination confirmed the cause and extent of the injury, and also facilitated the extraction of the thorn. The injury was allowed time to heal by urinary diversion with a urinary catheter. There were no stricture or fistula formations and the patient remained symptom-free at 3 months follow-up. Careful cystoscopic examination was both diagnostic and therapeutic in this case. A conservative approach is a feasible option in the management of selected cases of penetrating anterior urethral injury.

S-band multiwavelength ring Brillouin/Raman fiber laser with 20 GHz channel spacing

We propose and demonstrate a tunable S-band multiwavelength Brillouin/Raman fiber laser (MBRFL) with a tuning range of between 1490 to 1530 nm. The proposed MBRFL is designed around a 7.7 km long dispersion compensating fiber in a simple ring configuration, acting as a nonlinear medium for the generation of multiple wavelengths from stimulated Brillouin scattering (SBS) and also as a nonlinear gain medium for stimulated Raman scattering (SRS) amplification. A laser source with a maximum power of 12 dBm acts as the Brillouin pump (BP), while two 1420 nm laser diodes with a total power of 26 dBm act as the Raman pumps (RPs). The MBRFL can generate a multiwavelength comb consisting of even and odd Stokes at an average power of -12 dBm and -14 dBm respectively, and by separating the even and odd Stokes outputs, a 20 GHz channel spacing is obtained between two consecutive wavelengths. Due to the four-wave mixing (FWM) effect, anti-Stokes lines are also observed. The multiwavelength comb generated is not dependent on the BP, thus providing high stability and repeatability and making it a highly potential source for many real-world applications. This is the first time, to the knowledge of the authors, that a tunable MBRFL has been developed using SRS to obtain gain in the S-band region.

Evaluation of power Doppler ultrasonography for prostate biopsy in men with elevated serum prostate specific antigen levels

OBJECTIVES

To evaluate power doppler ultrasonography (PDU)-directed prostate biopsy in patients with elevated serum prostate specific antigen (PSA) levels.

MATERIALS AND METHODS

Men with serum total PSA levels of more than 4 ng/ml undergoing biopsy for the first time were included. Grey-scale transrectal ultrasound (TRUS) and PDU were performed. PDU signal on vascularity accumulation and perfusion characteristics were recorded and graded as normal or abnormal in the peripheral zone of the prostate. Abnormalities were defined on transverse image as radial or arc hypervascularities. A biopsy regime based on Vienna-normogram was performed in all patients.

RESULTS

Overall, prostate adenocarcinoma detection rate was 21.4% and abnormal accumulation on PDU signal was identified in 96.7% of those patients (p = 0.01). PDU directed prostate biopsies were positive in 66.7% of the patients with prostate cancer. The sensitivity, specificity, positive predictive value and negative predictive value of PDU signal alone for prostate cancer detection was 96.7%, 24.5% and 96.4% respectively, and PDU guided biopsies were 66.7%, 24.5%, 19.4% and 73% respectively.

CONCLUSIONS

The high sensitivity and negative predictive value of PDU makes it useful as an aid for TRUS biopsy in selected patient with previous negative biopsies at risk of harbouring prostate cancer.

Ureteric stone in the presence of existing backache: lessons to learn

Incidence of urolithiasis is on the rise due to climatic changes especially global warming.The pain due to presence of ureteric stone is a well known identity but many times it may be asymptomatic or even masked by concurrent presence of backache. In the present article, we describe the case of a 43-year-old male who came to the clinic for treatment of backache persisting for more than two years. The patient complained of backache two years back for which he was treated with analgesics and physiotherapy which relieved his pain. No X-ray was taken earlier because the attending clinician thought the backache to be musculo-skeletal in origin. Recently, one day a sudden episode of backache in the midst of night compelled him to seek medical treatment. However, this time a X-ray was performed and it showed the presence of calculi in the right upper pelvis of ureter which measured 1.9 cm vertically. An ultrasound confirmed the diagnosis. The patient was treated with two episodes of shock wave therapy which failed to crush the stone. A Double-J stent was inserted under general anaesthesia. The stone was crushed using a ureteroscope guided laser. The present case report describes how backache in professionals cannot be lightly attended. Even the characteristic groin to loin pain may be absent. All cases of backache should be properly investigated with an X-ray to rule out renal or ureteric calculi.

Clinicopathological features and survival of testicular tumours in a Southeast Asian university hospital: a ten-year review

INTRODUCTION

Testicular cancer mainly affects young men worldwide. There is lack of published data on patients with this malignant condition from the Southeast Asian region. The aim of this study was therefore to determine the clinicopathologic features of testicular cancer patients treated in a Southeast Asian university hospital and their overall survival rate.

MATERIALS AND METHODS

This was a retrospective study of testicular cancer patients treated between January 2001 and February 2011. Their epidemiological data, clinical presentation, pathologic diagnosis, stage of disease and treatment were gathered and the overall survival rate of this cohort was analyzed.

RESULTS

Thirty-one patients were included in this study. The majority of them were of Malay ethnicity. The average age at presentation was 33.7 years. The commonest testicular cancer was non-seminomatous germ cell tumour, followed by seminoma, lymphoma and rhabdomyosarcoma. More than half of all testicular germ cell tumour (GCT) patients had some form of metastasis at diagnosis. All the patients were treated with radical orchidectomy. Adjuvant chemotherapy was given to those with metastatic disease. Four seminoma patients received radiotherapy to the para-aortic lymph nodes. The 5-year survival rate for all testicular cancers in this cohort was 83.9%. The survival rate was 88.9% in 5 years when GCT were analyzed separately.

CONCLUSION

GCT affects patients in their third and fourth decades of life while lymphoma patients are generally older. Most of the patients treated for GCT are of Malay ethnicity. The majority have late presentation for treatment. The survival rate of GCT patients treated here is comparable to other published series in other parts of the world.

Proptosis: a rare presentation of metastatic renal cell carcinoma

We present a case of a middle-aged man who was incidentally found to have right renal solid mass while investigating for his left eye proptosis. Computerised tomography (CT) scan confirmed the diagnosis of renal cell carcinoma and the tumour was successfully excised via open surgery. The histopathology examination revealed the 10x7x8 cm mass to be a clear cell type renal cell carcinoma. The rare presentation of this metastatic renal cell carcinoma, its diagnosis and management will be discussed.

Retrograde intrarenal surgery for renal stones smaller than 2 cm

INTRODUCTION

Extracorporeal shock wave lithotripsy (ESWL) is accepted as the gold standard treatment for renal stones that are smaller than 2 cm. Recently, retrograde intrarenal surgery (RIRS) has been introduced as another form of treatment. We report our experience in dealing with renal stones smaller than 2 cm using RIRS as the primary treatment and following failed ESWL.

METHODS

A retrospective analysis was conducted over a five-year period on patients with stone(s) measuring less than 2 cm each and who had undergone RIRS. The patients were divided into two groups: RIRS as the primary procedure and RIRS post-ESWL.

RESULTS

A total of 46 patients underwent RIRS in our institute. The total stone clearance rate was 61 percent. The clearance rate was better for RIRS as the primary procedure when compared to RIRS as an adjunct procedure (70 percent versus 52 percent; p-value is 0.23). Patients with mid-pole stones achieved an 80 percent stone clearance rate as compared to 60 percent for those with lower pole stones. The clearance rate for upper pole stones was only 29 percent. When RIRS was the primary procedure for lower pole stones, the success rate was 75 percent, compared to 56 percent when it was used as an adjunct procedure post-ESWL.

CONCLUSION

For renal stones measuring less than 2 cm, the stone clearance rate for RIRS was as good as that for EWSL as a primary procedure and achieved a good clearance rate following the failure of ESWL.

Granulomatous prostatitis: a reminder to clinicians

Granulomatous Prostatitis (GnP) is a heterogenous entity classified into specific infections, non-specific infections, post surgical i.e. post-transurethral resection of prostate (TURP) and rare secondary (systemic) causes. A total of 1388 reports of prostatic biopsy and prostatic chips from TURP were reviewed from 1995 and 2007. The results which showed granulomatous prostatitis were analyzed and retrospective data collected from the patient's records. A total of 9 cases with granulomatous prostatitis were identified. There are 3 types of entities which are the non-specific (NSGnP), post-TURP and the specific type. The incidence of GnP in our center is lower than reported by Stillwell et al. The majority of the patients were Malays.

Hand-assisted laparoscopic nephrectomy and nephroureterectomy: our experience in Hospital Universiti Kebangsaan Malaysia

Hand-assisted laparoscopic nephrectomy (HAL-N) and nephroureterectomy (HAL-NU) were introduced to bridge the gap between open and laparoscopic surgery. This newer technique has the benefits of both laparoscopic and open surgical approaches but has a shorter learning curve and decreased operative time compared to laparoscopic surgery. A review of our 2-year experience showed that for the seventeen cases of HAL-N that was performed, the mean operative time was 187.8 minutes while the mean length of hospital stay was 4.1 days. For the two HAL-NU cases, the mean operative time was 415 minutes while the mean length of hospital stay was 5.5 days. Only one complication occurred and it was an incisional hernia at the hand-port site. There was no recurrence for the carcinoma cases. Our experience shows that this technique is feasible and safe.

Metastatic penile cancer presenting as hypercalcemia and pathological fracture of the humerus: a rare event

Distant haematogenous metastasis in penile cancer is rare. A patient who had total penectomy and bilateral inguinal lymphadenectomy for penile cancer but later presented with hypercalcemia of malignancy and pathological fracture of the humerus is reported.

A review of day care ureteroscopy of a teaching hospital in Malaysia

This is a retrospective review of 200 day-care ureteroscopies performed between April 1998 and October 2002. The aim was to determine the feasibility and safety of this procedure. The mean age was 38.8 years and 75% of them were male. Eighty-three percent were ASA 1 and the remainders were ASA 2. The side of procedure were 48.5% right, 2.5% left and 6% both sides. Fentanyl and proprofol were used during induction. Calculi were found in 82.5% of cases. Rigid and flexible scope were used in 91.5% and 10.5% of cases. There were 33% upper, 23% mid and 44% distal ureteric stones. The mean stone size was 9.37 X 6.93mm. Seventy-four percent required a ureteric stent insertion. The mean operative time was 58.3 minutes. Four percent of patients experienced pain post-operatively relieved by NSAID injection. Repeat ureteroscopy performed in 30% of patients. There were zero admission rates. This study suggests day-care ureteroscopy is effective, safe and well tolerated by patients.