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A K Hemal

Publications and source records attributed to A K Hemal.

At least 19 recordsLinked to original sources
PubMed2007

Transrectal ultrasound-guided biopsy of prostate voxels identified as suspicious of malignancy on three-dimensional (1)H MR spectroscopic imaging in patients with abnormal digital rectal examination or raised prostate specific antigen level of 4-10 ng/ml.

Results of the evaluation of transrectal ultrasound (TRUS) guided needle biopsy of voxels identified as suspicious of malignancy on magnetic resonance spectroscopic imaging (MRSI) in a large cohort of men (n = 83) with abnormal digital rectal examination (DRE) [prostate specific antigen (PSA) 0-4 ng/ml] or PSA less than 10 ng/ml, are reported. Three-dimensional (1)H MRSI was carried out at 1.5 T using a pelvic-phased array coil in combination with an endorectal surface coil. Voxels were classified as suspicious of malignancy based on Cit/(Cho + Cr) metabolite ratio. TRUS-guided biopsy of suspicious voxels was performed using the z- and x-coordinates obtained from MR images and two to three cores were taken from the suspected site. A systematic sextant biopsy was also carried out. MRSI showed voxels suspicious of malignancy in 44 patients while biopsy revealed cancer in 11 patients (25%). Patients who were negative for malignancy on MRSI were also negative on biopsy. An overall sensitivity of 100%, specificity of 54%, negative predictive value of 100% and accuracy of 60% were obtained. The site of biopsy was confirmed (n = 20) as a hypo-intense area on repeat MRI while repeat MRSI revealed high choline and low citrate. The overall success rate of MRI-directed TRUS-guided biopsy of 25% was higher compared with a 9% success rate achieved without MR guidance in another group of 120 patients. Our results indicate that TRUS-guided biopsy of suspicious area identified as malignant from MRSI can be performed using the coordinates of the voxel derived from MR images. This increases the detection rate of prostate cancer in men with PSA level <10 ng/ml or abnormal DRE and also demonstrates the potential of MR in routine clinical practice.

Adenocarcinoma↗
PubMed2007

Apparent diffusion coefficient of the prostate in men prior to biopsy: determination of a cut-off value to predict malignancy of the peripheral zone.

Determination of the apparent diffusion coefficient (ADC) of the prostate in men (n = 60) with raised prostate-specific antigen (PSA) or an abnormal digital rectal examination (DRE) prior to transrectal ultrasound (TRUS) guided biopsy using endorectal DWI is reported. Patients were categorized into different groups based on their PSA levels. The mean ADC was calculated from a number of regions of interest (ROIs) for the whole of the peripheral zone (PZ) and the central gland (CG). A total of 1108 ROIs were analyzed from 60 patients. The mean ADC value of the PZ was higher than that of the CG in controls. A total of 23 out of 60 patients were positive for malignancy on biopsy, and the mean ADC of the PZ was lower in these patients compared with those who were negative. Moreover, the mean ADC obtained for the whole of the PZ of the prostate in different groups of patients and controls showed a decreasing trend. A plot between PSA and mean ADC for the PZ showed non-linear association with logarithmic decrease in ADC. The mean ADC of the CG was not significantly different in patients who were positive or negative for malignancy in biopsy. In addition, a cut-off value of 1.17 x 10(-3) mm2/s (sensitivity = 73% and specificity = 74%, area under the curve = 0.83) for the mean ADC for the whole of the PZ of patients was determined by using the receiver operating characteristic curve (ROC) to predict malignancy of the PZ.

Adult↗
PubMed2006

Laparoscopic nephroplication and nephropexy as an adjunct to pyeloplasty in UPJO with giant hydronephrosis.

Giant hydronephrosis due to uretero-pelvic junction obstruction (UPJO) is rare and usually the treatment is nephrectomy. When renal salvage is required, reconstruction of the UPJ alone is usually inadequate to improve drainage from the pelvicalyceal system. Various open surgical techniques have been described to improve gravity-assisted drainage from the giant hydronephrotic kidney. We describe, for the first time, a complete laparoscopic approach for pyeloplasty combined with nephroplication and nephropexy.

Adult↗
PubMed2006

Reconstructive surgery for the management of genitourinary tuberculosis: a single center experience.

PURPOSE: We evaluated the role of surgery for genitourinary tuberculosis with special emphasis on reconstructive procedures. MATERIALS AND METHODS: Case records of 241 patients with genitourinary tuberculosis who underwent surgery at our center during a period of 17 years were reviewed. Clinical features, organ involvement, investigations, treatment and outcome of therapy were studied. RESULTS: There were 129 males and 112 females with a mean age of 34.6 years. The most common presentation was irritative voiding symptoms. Azotemia was seen in 54 (22.4%) cases. The most commonly involved organ was the kidney in 130 (53.94%) cases. Preoperative bacteriologic diagnosis was confirmed in 70 (29%) cases. All patients received antitubercular drug therapy for 9 months. A total of 248 procedures, including 33 endoscopic, 87 ablative and 128 reconstructive, were performed with some patients requiring more than 1 procedure. Early complications, which mainly involved the bowel, were seen in 19 (7.88%) cases. Bacteriologic cure was achieved in all culture positive cases. Renal functional parameters stabilized or improved in 44 of 54 patients (81.5%) in whom they were deranged at presentation. CONCLUSIONS: Genitourinary tuberculosis is common in developing countries. Diagnosis is often delayed because of late presentation and many patients present with cicatrization sequelae. A combination of antitubercular drug therapy and judicious surgery achieves satisfactory results in the majority of cases. With improved antitubercular drug therapy and experience with the use of bowel segments in the urinary tract, more reconstructive procedures are being performed with satisfactory outcomes. In patients who undergo reconstructive procedures, a rigorous and prolonged followup is necessary.

Adolescent↗
PubMed2006

Beware! Fungal urosepsis may follow endoscopic intervention for prolonged indwelling ureteral stent.

We present a 38-year-old lady with a prolonged indwelling ureteral stent that had been placed for pain relief after development of Steinstrasse following extracorporeal lithotripsy for a 2.5-cm left renal calculus. The patient developed candidal urosepsis within 6 hours after ureteroscopy and percutaneous nephrolithotomy (PCNL) for the removal of residual fragments. She subsequently recovered on systemic antifungal therapy in the form of intravenous amphotericin B and achieved complete stone clearance after repeat ureteroscopy and PCNL. Fungal urosepsis is known to complicate the postoperative course in chronically debilitated patients with poor nutritional status or those with diabetes or other significant comorbities. To our knowledge, this is the first reported case of a patient with no significant comorbities developing fungal urosepsis after endoscopic intervention for a long-term indwelling ureteral stent.

Adult↗
PubMed2004

Hand assisted laparoscopic radical cystectomy for cancer bladder.

AIM: To evaluate the efficacy, safety and feasibility of hand assistance in performing laparoscopic radical cystectomy and to describe our point of technique of hand assisted laparoscopic radical cystectomy (HALRC) with extra-corporeal ileal conduit reconstruction for muscle invasive bladder cancer. This is the second case report of HALRC in the world literature. METHODS: A five-port transperitoneal laparoscopic approach with an indigenous hand port was used to perform the radical cystectomy in a patient with muscle invasive TCC of bladder. After specimen retrieval, ileal conduit reconstruction was performed extra-corporeally through the site of hand port incision. RESULTS: HALRC was successfully completed in 4.3 hrs and the patient was discharged on the 7th day. The blood loss was 500 ml, and patient was transfused 2 units of blood, as the pre operative hemoglobin was 9 gms%. The analgesic requirement was 350 mgs of Pethidine (equivalent to 35 mgs of Morphine) and 450 mgs of oral Diclofenac Sodium. It took about 23 days for patient to resume normal activity. The histopathology was reported as T3b, left perivesical margin was positive and 2/5 of left pelvic lymph nodes were also involved. However, 7 lymph nodes removed from the right side did not show any disease. In view of histopathology report patient was given 4 cycles of postoperative chemotherapy, At the current follow up of 25 months the patient is free of any recurrence of disease. CONCLUSION: This case demonstrates the applicability of hand port assistance in to the laparoscopic field inside the abdomen, which helps in retraction and performing blunt dissection coupled with tactile sensation. It is feasible to use hand during laparoscopic radical cystectomy. Its usefulness has to be weighed against the standard laparoscopic radical cystectomy and additional time required for set up and the added cost. The technical success rate currently for standard laparoscopic radical cystectomy clearly demonstrates that hand assistance is not necessary. But, just as its applicability is being investigated, its role should be assessed in larger series of laparoscopic radical cystectomy.

Aged↗
PubMed2004

The technique of apical dissection of the prostate and urethrovesical anastomosis in robotic radical prostatectomy.

OBJECTIVE: To describe the technique of dissecting the apex of the prostate and a modified single running-suture urethrovesical anastomosis in patients undergoing robot-assisted radical prostatectomy for organ-confined prostate cancer. PATIENTS AND METHODS: Over 550 robot-assisted radical prostatectomies have been undertaken using Vattikuti Institute Prostatectomy (VIP) technique in patients with localized carcinoma of the prostate. We present a critical analysis of the first 120 procedures by one surgeon (M.M.) at our institution using this newly developed technique of urethrovesical anastomosis preceded by dissecting the apex of the prostate. RESULTS: The mean time for the urethrovesical anastomosis was 13 min. All but 24 patients had their catheter removed 4 days after surgery, as indicated by a cystogram. The catheter was removed successfully at 7 days in the remaining 24 patients who had a mild leak on cystography. Two patients had urinary retention within a week of removing the catheter and had to be re-catheterized. Continence was evaluated using standardized criteria before and after the procedure. The patients also replied to a mailed validated questionnaire survey; 96% were continent at 3 months and the remaining 4% used a thin pad for security. CONCLUSIONS: We report a technique of dissecting the apex of the prostate and prostatovesical junction for dividing the bladder neck, and a modified single running-suture urethrovesical anastomosis, in patients undergoing robot-assisted radical prostatectomy for organ-confined cancer of the prostate. The same principles can also be applied for the anastomosis during pure laparoscopic procedures and for urethro-neovesical anastomosis in patients undergoing robotic radical cystoprostatectomy for carcinoma of the bladder.

Anastomosis, Surgical↗
PubMed2004

Renal metastasis from primary hepatocellular carcinoma. A case report and review of the literature.

Secondary malignant tumors of the kidney are uncommon. These secondary tumors are usually the result of hematogenous spread from solid or hematologic malignancies. These tumors are almost always discovered at autopsy, with only 40 cases diagnosed prior to death reported in the literature. Primary tumors of the lung, breast and gastrointestinal tract are the most common sources of renal metastases. The occurrence of a renal secondary from a primary hepatocellular carcinoma is the subject of this presentation. To the best of our knowledge, such an occurrence has not been reported previously.

Aged↗
PubMed2003

Symptomatic and complicated adult and adolescent primary obstructive megaureter--indications for surgery: analysis, outcome, and follow-up.

OBJECTIVES: Primary obstructive megaureter is an uncommon presentation in adult patients. Although not reported frequently in published studies, the anomaly exists and warrants aggressive surgical management in contrast to its presentation in children. METHODS: This study was composed of 55 patients (47 with unilateral and 8 with bilateral megaureters) with adult primary obstructive megaureter who were treated from January 1989 to December 2001. Their clinical presentation, renal function, radiologic data, treatment, complications, and follow-up were studied. RESULTS: Of the 55 patients, 36 were male and 19 were female (age range 13 to 52 years). All patients were symptomatic except two. Forty-four patients (50 renoureteral units) required ureteral reimplantation, with tailoring in 33. Five patients were treated with endoscopic techniques (ureteral meatotomy in 3 and ureteroscopic retrieval of ureteral calculi in 2). Four patients required nephroureterectomy for nonfunctioning kidneys. Associated renal calculi were managed by extracorporeal shock wave lithotripsy and pyelolithotomy and ureteral calculi by endoscopic methods or calculi removed at the time of ureteroneocystostomy. All but 4 patients showed improvement in hydroureter and hydronephrosis and developed no complications during the follow-up period of 1 to 12 years (mean 7). Five patients with bilateral megaureters had uremia. Only one improved after surgery with adequate drainage and 2 patients died despite reimplantation. CONCLUSIONS: Most adult patients with megaureter are symptomatic. Complications such as stone formation and deranged function of the affected kidney are common and almost all require surgical intervention. Surgery in those with bilateral megaureters with advanced renal failure is mostly unrewarding.

Adolescent↗
PubMed2003

Laparoscopy for the diagnosis and treatment of radiologically occult but symptomatic hypoplastic kidneys.

OBJECTIVES: To evaluate the efficacy of different imaging modalities for visualization of small poorly functioning hypoplastic and dysplastic kidneys and to assess the role of laparoscopy in localization and treatment. METHODS: Between 1998 and 2002, 10 female patients who presented with urinary incontinence, flank pain, or hypertension secondary to small, poorly functioning hypoplastic or dysplastic kidneys were treated at our institute. We reviewed the results of the imaging studies, cystoscopy, and evaluation under anesthesia for these patients. After the diagnosis, all patients were treated with laparoscopic retroperitoneal or transperitoneal nephroureterectomy or nephrectomy. RESULTS: Intravenous urography and ultrasonography failed to visualize the affected renal units in all 10 cases. Computed tomography could locate small dysplastic renal units in only 5 patients (50%). Dimercaptosuccinic acid renal scintigraphy was diagnostic in all 10 cases (100%). Magnetic resonance urography was done in 2 cases only, and the affected renal units were identified in both. Cystoscopy and vaginoscopy were inconclusive in all but 2 cases. Laparoscopy efficiently located the offending renal units in all 10 cases. In 9 cases, the affected renal units were located in the lumbar region, and in 1 case it was situated ectopically in the pelvis. All 10 patients underwent laparoscopic retroperitoneal or transperitoneal nephroureterectomy or nephrectomy and were asymptomatic after surgery. CONCLUSIONS: Dimercaptosuccinic acid scintigraphy is an accurate and specific imaging modality for visualization of small hypoplastic renal units that are not visualized by conventional radiologic imaging techniques. Laparoscopy can be recommended as the ideal method of management, because it provides a minimally invasive technique for detecting the kidney and simultaneously correcting the problem.

Adolescent↗
PubMed2003

Impact of primary tumour characteristics on the survival of patients with lymph node metastases in bladder cancer following radical cystectomy.

BACKGROUND AND OBJECTIVE: Patients with carcinoma urinary bladder with metastasis to the lymph nodes have been believed to have a poor prognosis. The various factors affecting survival in this subset of patients are not well understood. To analyze, these factors, we retrospectively analyzed patients who had undergone radical cystectomy at our center in the last 10 years. METHODS: From Jan. 1991 to May 2001, 158 patients underwent radical cystectomy at our center. 38 of these were found to have metastasis in the regional lymph nodes (i.e. stage D). A multivariate regression analysis was done to look for factors, which predict a better survival in this group of patients. Patients were studied for age, sex, morphology of tumour (papillary or nodular), grade of tumour, local extent of the disease (T1 T3A OR T3B), lymph nodal involvement, chemotherapy (whether received or not) and no. of TUR resection before radical cystectomy. SPSS software was used and the actuarial disease specific survival calculated for each variable. RESULTS: There were 33 males and 5 females with an age range of 34-75 years (mean 56). Overall survival was 7 months to 84 months with mean of 32 months. Patients with polypoidal disease had better survival (66 months vs 15 months). Also patients with organ-confined disease (T2, T3a) had better survival than those with perivesical spread (T3b). The mean survival in N1 and N2 disease was 36 and 10 months respectively. The benefits of adjuvant chemotherapy (methotrexate and cisplatin) could not be assessed as most of the patients received chemotherapy. CONCLUSION: Patients with positive lymph nodes for metastases have fairly good survival with radical cystectomy especially those who have a lower T stage (organ confined), papillary morphology and N1 disease.

Adult↗
PubMed2003

Evaluation of role of retroperitoneoscopic pyelolithotomy and its comparison with percutaneous nephrolithotripsy.

OBJECTIVES: To evaluate the role of retroperitoneoscopic pyelolithotomy (RPPL) for the management of renal pelvic calculus and its comparison with percutaneous nephrolithotripsy (PCNL). PATIENTS AND METHODS: Eighteen RPPLs were performed between March 1995 and March 2002, and 16 out of these were compared retrospectively with 12 cases of PCNL performed in the year 2000 for solitary renal pelvic stone more than 3-cm in size. Laparoscopic pyelolithotomy was carried out with retroperitoneal approach and subsequent to stone removal pyelotomy was sutured with intracorporeal interrupted sutures. RESULTS: The two groups were similar as regards the patient age and sex. The mean stone sizes in RPPL and PCNL groups were 3.6 and 4.2 cm respectively (p < 0.006). There were 2 conversions in the RPPL group due to stone migration into calyx and dense perirenal adhesions making dissection difficult. The mean operating time was 142.18 min for RPPL as compared to 71.6 min for PCNL (p < 0.000). The blood loss was 173.1 ml in RPPL as compared to 147.9 ml for PCNL (p NS). The mean hospital stay was 3.8 and 3-days in RPPL and PCNL groups respectively. CONCLUSIONS: Laparoscopic pyelolithotomy takes longer to perform, more invasive, less cosmetic and requires more skills at present as compared to PCNL. In this limited study it is clearly demonstrated that PCNL is the better treatment modality for renal stones and laparoscopy should be offered to those who needs adjunctive procedure such as pyeloplasty or puncture during PCNL under vision.

Adult↗
PubMed2003

Stone fragility: its therapeutic implications in shock wave lithotripsy of upper urinary tract stones.

OBJECTIVE: To analyse the impact of stone composition on stone fragility (fragmentation) and clearance of upper urinary tract stones after shock wave lithotripsy (SWL). MATERIAL AND METHODS: Between 1st July 1998 and 31st July 2001, 300 renal and ureteric units of 290 patients (10 being bilateral) underwent SWL for upper urinary tract calculi. The degree of fragmentation was divided into four types: (I) Excellent, (II) Good, (III) Fair and (IV) No fragmentation. Stone composition was done by X-ray diffraction crystallography. A statistical comparison was made between degree of fragmentation, number of shock waves delivered, voltage setting, number of sessions required and requirements of adjuvant procedures according to the stone composition. RESULTS: Stone analysis revealed that 90% of the patients had calcium oxalate stones. Of these 80% were calcium oxalate monohydrate (COM) and 20% calcium oxalate dehydrate (COD). Struvite, apatite and uric acid stones comprised of 6%, 3% and 1% respectively. Type-I fragmentation was achieved up to 63.96%, 50% and 100% in COD, struvite and uric stones respectively as compared to 44.9% and 44.44% for COM and apatite stones. Type-III fragmentation was seen up to 8.79% and 33.3% respectively in COM and apatite as compared to 5.55% or less in other types of the stones suggesting that COM and apatite stones produce larger fragments. The mean number of shock waves, voltage and number of treatments was significantly higher for COM and apatite stones (p value < 0.005) with a stone free rate of only 65-66% and 65-68% respectively at three months (p value < 0.001). Similarly the number of adjuvant procedures required in COM alone was more, i.e. 31 as compared to 17 procedures in rest of the other kinds of stones (p value < 0.05). CONCLUSION: Stone composition in Indian subcontinent is different from the western world. Fragility of a stone varies with the composition of the stone and affects the therapeutic results.

Adolescent↗
PubMed2003

Pseudohypospadias with bilateral vesicoureteric reflux: consequences of inappropriate management of stricture urethra.

A 17-year-old male boy presented with clinical features of pseudohypospadias (small penile stump with absent distal penile urethra) associated with very small capacity bladder and bilateral grade IV vesicoureteric reflux following suprapubic urinary diversion for multiple urethro-cutaneous fistula and periurethral abscess which developed as a consequence of inappropriate initial management of urethral trauma. This case highlights the importance of the initial management of urethral trauma and the management of its rare complication.

Abscess↗
PubMed2003

Giant hydronephrotic kidney mimicking intestinal obstruction.

We describe a case of small bowel obstruction in a thirty-year-old adult male, which was discovered to be on account of a large hydronephrotic nonfunctioning kidney. An emergency percutaneous nephrostomy alleviated the massive abdominal distension and symptoms of small bowel obstruction. We have reviewed the causes, differential diagnosis and discussed the manner of such a unique and rare presentation.

Abdominal Pain↗
PubMed2003

Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion.

OBJECTIVE: To develop a technique of nerve-sparing robot-assisted radical cystoprostatectomy (RRCP) for patients with bladder cancer. PATIENTS AND METHODS: Robotic assistance should enhance the ability to preserve the neurovascular bundles during laparoscopic radical cystectomy. Thus we undertook RRCP and urinary diversion using a three-step technique. First, using a six-port approach and the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), one surgeon carried out a complete pelvic lymphadenectomy and cystoprostatectomy using a technique developed specifically for robotic surgery. The neurovascular bundles were easily identified and dissected away, the specimen entrapped in a bag and removed through a 5-6 cm suprapubic incision. Second, a different surgical team exteriorized the bowel through this incision and created a neobladder extracorporeally. Third, the neobladder was internalized, the incision closed and the primary surgeon completed the urethro-neovesical anastomosis with robotic assistance. RESULTS: RRCP was carried out in 14 men and three women by the primary surgeon (M.M.). The form of urinary reconstruction was ileal conduit in three, a W-pouch with a serosal-lined tunnel in 10, a double-chimney or a T-pouch with a serosal-lined tunnel in two each. The mean operative duration for robotic radical cystectomy, ileal conduit and orthotopic neobladder were 140, 120 and 168 min, respectively. The mean blood loss was < 150 mL. The number of lymph nodes removed was 4-27, with one patient having N1 disease. The margins of resection were free of tumour in all patients. CONCLUSIONS: We developed a technique for nerve-sparing RRCP using the da Vinci system which allows precise and rapid removal of the bladder with minimal blood loss. The bowel segment can be exteriorized and the most complex form of orthotopic bladder can be created through the incision used to deliver the cystectomy specimen. Performing this part of the operation extracorporeally reduced the operative duration.

Blood Loss, Surgical↗
PubMed2003

Laparoscopic radical cystectomy and ileal conduit reconstruction: preliminary experience.

PURPOSE: We present our preliminary experience with laparoscopic radical cystoprostatectomy for muscle-invasive carcinoma of the urinary bladder. Patient and operative data and the surgical technique are presented. PATIENTS AND METHODS: Laparoscopic radical cystoprostatectomy and bilateral pelvic lymph node dissection were performed using five or six ports by a transperitoneal approach. An ileal conduit urinary diversion was constructed at the site of specimen retrieval. RESULTS: The procedure was successful in nine of ten patients with a mean blood loss of 533 mL and an average transfusion of 1.3 units per patient. The mean operating time was 6.48 hours and an average of 33 mg of morphine equivalents was required for analgesia. The mean hospital stay was 10.8 days. One patient had surgical margins positive for cancer, while none had histologic evidence of pelvic nodal metastasis. There were five minor and major intraoperative and postoperative complications. The remaining patient, treated early in our experience, developed hypercarbia necessitating conversion to open surgery. No metastases have been seen after a mean duration of follow-up of 19 months. CONCLUSIONS: Laparoscopic radical cystoprostatectomy with open ileal conduit urinary diversion is a feasible alternative to traditional open radical cystectomy. Urinary diversion can be performed through the small incision necessary to extract the surgical (radical cystoprostatectomy) specimen from the abdomen. With our modified technique, it also is feasible to reduce the cost.

Adult↗