Browsing by Author "Luitel, BR"
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Publication A Rare Case of Synchronous Renal Cell Carcinoma and Adrenocortical Carcinoma(Institute of Medicine, 2014) Gupta, DK; Chapagain, S; Subedi, PP; Luitel, BR; Maskey, P; Chalise, PR; Sharma, UK; Gyawali, PR; Shrestha, GK; Joshi, BRAbstract We report a rare case of synchronous adrenocortical carcinoma and renal cell carcinoma. A 60 year male, a known diabetic and hypertensive under treatment, while undergoing routine investigations and ultrasonography of abdomen, was incidentally detected to have adrenal as well as renal masses. On computed tomograghy scan right adrenal mass measured about 10 x 8 cm while the renal mass was 4.6 x 3.8 cm in size, Urinary vanillylmandelic acid and 24 hr urine metanephrine were within normal limits. Similarly, serum cortisol and dihydroepiandrosterone were in normal range. Patient underwent right adrenalectomy with right partial nephrectomy. Histopathological examination of adrenal mass revealed adrenocortical carcinoma while that of renal mass revealed clear cell renal cell carcinoma. Keywords: Adrenalectomy, adrenocortical carcinoma, renal cell carcinomaPublication Anatomical Variations of Renal Artery in Nepalese Live Kidney Donors(Institute of Medicine, 2015) Thakur, DK; Sedhain, S; Luitel, BR; Chalise, PR; Sharma, UK; Gyawali, PRAbstract Introduction: Donor nephrectomy is unique surgery to predispose the surgeon on stress as healthy donors have major surgery purely for others’ benefit. Renal vessels are known with the wide range of variations which can lead to major complications or life threatening events if unrecognized. A thorough knowledge of anatomic variations in renal artery facilitates surgeons to anticipate and manage these potential risks and prevent the complications. Here we present anatomical variations in RA in Nepalese live kidney donors. Methods: This prospective observational study was conducted at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Live kidney donors over a period of 17 months (From June 2013 to October 2014) presenting for donation were evaluated for renal vasculature with 64- slice multidetector computed tomography and the findings were correlated with intraoperative findings during donor nephrectomy. Results: Sixty three donors were enrolled in the study. Male & female ratio was 1:2.1. Age ranged from 18 years to 64 years (Mean 44.58 years).Anomalous RA was seen in 25 cases (39.7%). Fifty six percentages of anomalies were seen in female and 44% in male. Majority of anomalies were on left side (22.2%). The most common anomaly was supernumerary RA seen in 16 cases (25.5%) Accessory RA was seen in 11 cases (17.5%). Prehilar bifurcation was seen in 11 cases (17.5%). Aberrant RA was seen in 5 cases (8%). Preoperative CT angiographic findings correlated with intraoperative findings in all cases (r = 1, p = 0). Polar branch was transected accidentally in two cases which were repaired at bench surgery. Conclusion: Anatomical variations of renal artery in Nepalese donors are comparable with other populations. Thorough knowledge of the variations can minimize complications and improve outcome during nephrectomy. Keywords: CT renal angiography, Donor nephrectomy, Renal arteryPublication Comparison of Different Estimating Equations for Prediction of Glomerular Filtration Rate in Living Kidney Donors(Institute of Medicine, 2017) Poudyal, S; Pradhan, M; Chapagain, S; Luitel, BR; Chalise, PR; Sharma, UK; Gyawali, PRAbstract Introduction: Assessment of renal function is a crucial step in evaluation of living kidney donors. The standard method for determining renal function is measurement of glomerular filtration rate (GFR) using I-123 iothalamate, Tc-99m Diethylene Triamine Pentaacetic Acid (DTPA) and 51Cr-Ethylene Diamine Tetraacetic Acid. As these methods are expensive and cannot be used in all clinical settings, it is common practice to estimate GFR by creatinine-based equations. The objective of this study is to compare commonly used estimating equations for the prediction of GFR in Living Kidney Donors. Methods: In 75 healthy kidney donors, GFR estimated by Modification of Diet in Renal Disease Study equation (MDRD), Cockcroft-Gault formula(CG), Chronic Kidney Disease Epidemiology Collaboration(CKD- EPI) equation and 24 hour urinary creatinine clearance were compared to GFR measured by Tc-99m DTPA. Statistical analysis was done using Dunnett’s test and Bland-Altman plot. Similarly, accuracy, precision and bias of each equation were assessed. Results: Mean GFR calculated by DTPA clearance, CG, MDRD, CKD-EPI equations and 24 hour urine creatinine clearance were 83.35±8.59, 78.99±17.17, 93.30±17.12, 96.34±13.36 and 137.96±43.65 ml/min/1.73m2 respectively. Applying Dunnett’s test, GFR by CG equation minimally underestimated GFR measured by DTPA (p=0.612) whereas GFR estimated by MDRD (p=0.034), CKD-EPI(p=0.03) and 24 hour urine creatinine clearance(p<0.001) were statistically significant. CG equation had the highest accuracy. Using Bland-Altman plot, the precision of CKD-EPI equation was the highest among all. Conclusion: There is no single creatinine-based estimating equation to assess GFR with utmost accuracy and precision at the same time. Keywords: creatinine clearance, Diethylene Triamine Pentaacetic Acid, living kidney donorsPublication Does Stone Culture Predict Systemic Inflammatory Response after Percutaneous Nephrolithotomy?(Institute of Medicine, 2014) Luitel, BR; Chalise, PR; Gyawali, PR; Sharma, UK; Shrestha, GK; Joshi, BRAbstract Introduction: Systemic inflammatory response syndrome (SIRS) is a common and important complication after percutaneous nephrolithotomy (PNL). This study was carried out with the objective of finding out the association between stone culture and PostPNL- SIRS. Methods: A prospective study was done in the urology unit, Tribhuvan University Teaching Hospital from July 2009 to June 2011. Preoperative midstream urine, intraoperative pelvic urine and stone fragments were sent for culture in all patients undergoing PNL. The primary outcome was SIRS on second postoperative day. Data analysis was done using Statistical Package for Social Sciences (SPSS) 17.0 version. Results: Out of 47 patients 22 (46.8%) patients developed SIRS on second postoperative day. Stone and pelvic urine culture positivity rate was 8(17%) and 6(12.8%) respectively with P. aeruginosa E. coli and Proteus spp being the common organisms isolated, most of which were sensitive to amikacin. Positive stone culture was the significant risk factor for SIRS (P=0.018). Conclusion: Positive stone culture is an important risk factor for SIRS after PNL. Routine stone culture is beneficial in patients undergoing PNL for the subsequent postoperative management. Keywords: Percutaneous nephrolithotomy, Stone culture, Systemic Inflammatory Response Syndrome (SIRS)Publication Factors affecting stone clearance in Percutaneous Nephrolithotomy(Institute of Medicine, 2018) Poudyal, S; Rai, BDK; Dhital, P; Pradhan, M; Chapagain, S; Luitel, BR; Chalise, PR; Sharma, UK; Gyawali, PRAbstract Introduction: Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large and complex renal stones. It is of paramount importance to deliver the maximum clearance with minimal morbidity. There are different anatomical, stone-related and patient-related factors affecting the stone-free rate. This study is conducted to delineate the factors predicting stone clearance in PCNL. Methods: A prospectively maintained database of 114 cases, who underwent PCNL between January to October 2016 in Tribhuvan University Teaching Hospital, was analysed. Age, gender, body mass index, surgical and medical history, renal anomalies, American Society of Anesthesiologists score, tract size, type of tract dilatation, fluoroscopy time, stone density, stone location and burden, skin to stone distance, presence of hydronephrosis, and duration of surgery were correlated with the stone clearance. Stone clearance was evaluated with either X-ray or ultrasound of the kidneys, ureters and bladder up to three months of PCNL. Result: Stone clearance rate was 85.96%. Stone burden(p<0.001), stone location(p=0.03), number of calyces involved by stone(p<0.001) and presence of hydronephrosis(p=0.005) were statistically different between stone-free and stone-residue group. Multifactorial analysis showed that stone burden, location and no. of calyces involved by stone were the only factors effecting stone free rate. Area under curve for the stone burden was 0.842 (p<0.001). Conclusion: Stone burden, location and number of calyces involved by the stone are the principal factors determining the stone clearance in PCNL. Keywords: Percutaneous Nephrolithotomy, Renal calculi, Stone clearancePublication Intraurethral Instillation of Ketamine and Lidocaine versus Lidocaine for Male Rigid Cystoscopy: A Prospective Randomized Controlled Trial(Kathmandu University, 2023) Pradhan, U; Chalise, PR; Luitel, BR; Kriti, S; Devkota, SABSTRACT Background Male rigid cystoscopy is one of the most common outpatient procedures in urology because of it lower cost, better optical area and better orientation compared with flexible devices. However, performing rigid cystoscopy is not only painful but equally apprehensive in awake male patients. Objective The study was conducted to evaluate the efficacy of lidocaine gel and ketamine solution together compared with lidocaine gel alone during male rigid cystoscopy. Method A total of 76 male patients who visited the hospital for rigid cystoscopy were randomized into two groups before undergoing cystoscopy. The experimental group received 15 ml lidocaine with 2 ml (100 mg) Ketamine solution while the control group received 15 ml lidocaine gel with 2 ml Normal saline. Patient’s heart rate and mean arterial pressure were recorded in five minutes interval till twenty minutes after completion of the procedure. The level of pain perception of all the patients was measured with Visual analogue scale (VAS) score, at the beginning, during and after cystoscopy. Independent sample t-test was used to compare outcome measures and p value of < 0.05 was considered statistically significant. Result Out of the total 70 patients analyzed at the end of study with 35 patients in each group, the VAS score in each stage were lower in lidocaine plus ketamine group compared to lidocaine gel alone. The difference was significant at the commencement and middle of the procedure (p < 0.05). Conclusion Intraurethral instillation of ketamine and lidocaine is more effective in reducing mean pain score during cystoscopy as compared to lidocaine alone. KEY WORDS Cystoscopy, Ketamine, Lidocaine, Visual analogue scale scorePublication Open Anderson Hynes Pyeloplasty in Ureteropelvic Junction Obstruction: An Institutional Experience(Institute of Medicine, 2015) Subedi, PP; Chapagain, S; Thakur, DK; Poudyal, S; Luitel, BR; Chalise, PR; Sharma, UK; Gyawali, PR; Shrestha, GKAbstract Introduction: Ureteropelvic junction obstruction (UPJO) is one of the common causes of hydronephros is in children and adults. The cause may be congenital or acquired. The standard management of UPJO has classically been an open Anderson-Hynes (A-H) dismembered pyeloplasty. This study is an audit of A-H pyeloplasty done for patients with UPJO presenting to our institution. Methods: A retrospective analysis was done in the Urology unit, Tribhuvan University Teaching Hospital from July 2013 to November 2014. All patients undergoing A-H pyeloplasty were included for review. Preoperative data regarding the demographics, presentation, diagnostic tools used, details of the surgery, postoperative complications, duration of hospital stay and follow up findings were reviewed. Initial follow up was scheduled at two weeks, then at three months and at one year. At 3 months, DTPA renogram was obtained to assess the function and clearance of the treated kidney. Results: The age of the patients ranged from 5 months to 69 years. Flank pain was the most common presenting complain. Most of the patients were males and left sided obstruction was common. The most common diagnostic modality used was USG and excretory urography. CT urography was done in cases of secondary UPJO. DTPA scan was used in select cases for baseline documentation of the function of the involved kidney. The average duration of surgery was 2 hours and 30 minutes. The mean duration of hospital stay was 5 days. The most common complication was urinary tract infection. Conclusion: Open A-Hpyeloplasty is the most common surgery done for UPJO at our institution. The outcome can be improved by attention to the principles of A-H pyeloplasty. Keywords: hydronephrosis, A-H pyeloplasty, ureteropelvic junction obstructionPublication Pattern of Renal Cell Carcinoma – A Single Center Experience in Nepal(Kathmandu University, 2011) Sidharth; Luitel, BR; Gupta, DK; Maskey, P; Chalise, PR; Sharma, UK; Gyawali, PR; Shrestha, GK; Sayami, G; Joshi, BRABSTRACT Background Renal tumor is the 13th most common malignancy in the world and more than 90% of renal tumors are renal cell carcinomas. As there is no data available on renal cell carcinoma in Nepal, hence this study was undertaken to analyze the patterns of renal cell carcinoma in patients with renal mass at a tertiary level hospital in Nepal. Objectives To analyze the patterns of renal cell carcinoma in patients with renal mass at a tertiary level hospital in Nepal. Methods The case records of 50 consecutive patients with renal cell carcinoma presenting at the Tribhuvan University Teaching Hospital, Kathmandu from July 2006 to June 2011 were retrospectively evaluated for presenting symptoms, physical finding, investigation and histopathology report. Results Out of 50 patients, 64% were male and 36% were female. The age ranged between 11 to 78 years (mean ± SD: 55 ± 15 years). Fifty four percent of patients were smokers. Incidentally tumor was detected in 40% cases by ultrasonography and the typical triad was present in only 4%. The tumor was occupying upper pole in 40% of cases. The tumor size ranged from 3 to 15 cm (mean ± SD: 7.3 ± 2.9 cm). Histopathologically, 76% of the patient had organ confined renal cell carcinoma (T1- 2 N0 M0). Clear cell was the most common type seen in 86%. Fuhrman’s nuclear grade 2 was found in 50%. Conclusion Many of the renal cell carcinoma are detected incidentally, at an early stage and are of clear cell subtype. KEY WORDS Incidental renal tumor, Nepal, Renal cell carcinoma.Publication Phaeochromocytoma in Nepal – A Single Centre Experience(Kathmandu University, 2012) Maskey, P; Shrestha, GK; Luitel, BR; Gupta, DK; Sidarth; Chalise, PR; Sharma, UK; Gyawali, PR; Joshi, BRABSTRACT Background Phaeochromocytomas are rare tumors of chromaffin cells of neural crest that classically present with symptoms of catecholamine excess such as palpitations, headache and sweating. They are diagnosed by measuring plasma or urinary levels of catecholamines or their metabolites. Anatomic localization is done by computed tomographic scan or magnetic resonance imaging, or meta-iodobenzyl guanidine scan in certain cases. Adequate preoperative catecholamine blockade prevents perioperative hemodynamic instability. Objectives To study the clinical spectrum and management of phaeochromocytomas in a tertiary care centre, Tribhuvan University Teaching Hospital, in Nepal. Methods Retrospective review of case records of histologically proven cases of phaeochromocytomas from 2008 -2011 was done, and data collected on clinical spectrum, diagnostic modalities, perioperative management and follow-up. Results Tweleve cases of phaeochromocytomas were operated. The mean age was 36.41±14.07 years. There were 2 bilateral phaeochromocytomas and 1 extra- adrenal paraganglioma. Apart from the common symptoms of catecholamine excess, patients had atypical presentations like psychiatric manifestations and blurred vision. A combination of urinary Vanillyl Mandelic Acid and computed tomographic scan was used for diagnosis, and open surgery was done in all cases. Pre-operative blood pressure control was achieved by prazocin or calcium channel blockers. Ten patients had intraoperative surge in blood pressure. There were no major morbidity or mortality. Three patients had high blood pressure post- operatively, but were effectively managed with antihypertensives. Conclusion Phaeochromocytomas can have variable presentation. Good preoperative preparation and perioperative management can result in an excellent outcome. KEY WORDS Hypertension, Paraganglioma, Phaeochromocytoma, Prazocin, Vanillyl Mandelic AcidPublication Risk-based Management of Non-muscle Invasive Bladder Cancer: Experience from Tribhuvan University Teaching Hospital(Kathmandu University, 2016) Luitel, BR; Chalise, PR; Sidharth; Gupta, DK; Subedi, P; Chapagain, S; Sharma, UK; Gyawali, PR; Shrestha, GK; Joshi, BRABSTRACT Background Most of the recent evidences suggest for risk-based management of non muscle invasive bladder cancer (NMIBC) to reduce the risk of recurrence and progression. Objective This study was conducted to assess the recurrence and progression of non muscle invasive bladder cancer in Nepalese patients using European Organization for Research and Treatment of Cancer (EORTC) risk tables and to assess the effectiveness of intravesical therapy to reduce the risk of recurrence. Method A prospective observational single centre study was conducted at Tribhuvan University Teaching Hospital from January 2010- December 2012. Forty six patients with non muscle invasive bladder cancer who underwent transurethral resection of bladder tumor and completed two years follow up were included. According to the European Organization for Research and Treatment of Cancer (EORTC) risk table, the patients were divided into low, intermediate and high risk groups. The patients received postoperative adjuvant therapy and surveillance as per the European Association of Urology guidelines. Result Among the 46 patients, the overall two year recurrence and progression rate was 8 (17%) and 1 (2%) respectively. Out of seven patients in low risk category, none of them developed recurrence or progression of disease. Out of 15 patients in intermediate risk category the one year and two year recurrence rate was 13% and 20% respectively. Out of 24 patients in high risk category the one and two year recurrence rate was 17% and 21% respectively. The risk reduction by use of intravesical Bacillus Calmette Guerin (BCG) for recurrence in high risk category was 58% and 60% in first and second year respectively. In our study, the overall and individual risk group, the one and two year recurrence rate was lower than that predicted by European Organization for Research and Treatment of Cancer risk table. Conclusion Risk-based management of non muscle invasive bladder cancer by using the European Organization for Research and Treatment of Cancer risk table is a useful method of management, though its prediction rates are lower in Nepalese population. KEY WORDS EORTC, intravesical therapy, NMIBC, progression, recurrence, risk table