Diagnosis and treatment of urethral prolapse in children: 16years’ experience with 89 Chinese girls Publication date: Available online 22 April 2017 Source:Arab Journal of Urology Author(s): Yi Wei, Sheng-de Wu, Tao Lin, Da-wei He, Xu-liang Li, Guang-hui Wei ObjectiveTo review our experience and results in the diagnosis and treatment of urethral prolapse (UP) in Chinese girls.Patients and methodsWe conducted a retrospective chart review of 89 consecutive girls (aged <16years) with UP and without other complications, who received treatment for UP from January 1999 to January 2015 (a study period of 16years) at the Children’s Hospital of Chongqing Medical University, China. Data analysed included: age, symptoms, clinical findings, predisposing factors, management, and outcomes.ResultsThe presenting symptoms in the 89 girls were: mass (54 girls), bleeding (34), and dysuria/straining at micturition (one). In all, 14 patients received conservative treatment as their symptoms were mild, and 75 were successfully treated by excision of the prolapsed urethral mucosa or ligation over a Foley catheter, as their symptoms were severe and recurred too frequently to be managed conservatively. The mean postoperative length of stay for ligation was 7.76days and for excision was 4.57days. Ligation over a Foley catheter had a longer hospital stay.ConclusionsUP is a rare condition occurring in prepubertal girls, evidenced by a urethral mass and bleeding. Increased physician awareness and early recognition of UP avoids unnecessary examinations and patient anxiety.
Medical expulsive therapy for ureteric stones: Analysing the evidence from systematic reviews and meta-analysis of powered double-blinded randomised controlled trials Publication date: Available online 18 April 2017 Source:Arab Journal of Urology Author(s): Tarik Amer, Banan Osman, Allan Johnstone, Martin Mariappan, Ameet Gupta, Nikolaos Brattis, Gareth Jones, Bhaskar K. Somani, Francis X. Keeley, Omar M. Aboumarzouk ObjectiveTo conduct a systematic review and meta-analysis investigating the efficacy and safety of medical expulsive therapy (MET) in low risk of bias (RoB) randomised controlled trials (RCTs).MethodsA Cochrane style systematic review was conducted on published literature from 1990 to 2016, to include low RoB and a power calculation. A pooled meta-analysis was conducted.ResultsThe MET group included 1387 vs 1381 patients in the control group. The analysis reveals α-blockers increased stone expulsion rates (78% vs 74%) (P<0.001), whilst calcium channel blockers (CCBs) had no effect compared to controls (79% vs 75%) (P=0.38). In the subgroup analysis, α-blockers had a shorter time to stone expulsion vs the control group (P<0.001). There were no significant differences in expulsion rates between the treatment groups and control group for stones <5mm in size (P=0.48), proximal or mid-ureteric stones (P=0.63 and P=0.22, respectively). However, α-blockers increased stone expulsion in stones >5mm (P=0.02), as well as distal ureteric stones (P<0.001). The α-blocker group developed more side-effects (6.6% of patients; P<0.001). The numbers needed to treat for α-blockers was one in 14, for stones >5mm one in eight, and for distal stones one in 10.ConclusionThe primary findings show a small overall benefit for α-blockers as MET for ureteric stones but no benefit with CCBs. α-blockers show a greater benefit for large (>5mm) ureteric stones and those located in the distal ureter, but no benefit for smaller or more proximal stones. α-blockers are associated with a greater risk of side-effects compared to placebo or CCBs.
A naked-eye comparison of image quality between a portable versus a fixed camera system for digital flexible ureterorenoscopy – A single centre experience Publication date: Available online 12 April 2017 Source:Arab Journal of Urology Author(s): Mohamed El Howairis, Noor Buchholz ObjectiveTo assess the image quality using the portable OTV-SI (Olympus, Southend, UK) light source system compared to a dedicated fixed standard stack system for flexible ureterorenoscopy (URS) as judged by the human eye.MethodsWe compared two differing flexible URS set-ups. The first was our normal completely digital fixed set-up, comprising a flexible ureteroscope and matching digital stack system (CLV-S40 PRO-6E, Olympus). The second set-up comprised the same digital ureteroscope but with a conventional non-digital stack system and the OTV-SI portable light source. Seven experienced urologists were asked to subjectively assess the quality of the video sequences with the naked eye. The image qualities assessed were as follows: colour, distortion, graininess, depth perception, contrast, and glare. Finally, they were asked to guess whether they were observing images from the normal fixed set-up or the portable set-up. Fisher’s exact test was used to compare the two sets of nominal variables.ResultsThere were no significant differences in the observation ratings between the fixed and portable systems, independent of observer or image settings. Also, the surgeons were not able to correctly guess which stack system had been used.ConclusionFor flexible URS imaging, the combination of a digital ureteroscope with a conventional non-digital stack system together with the OTV-SI portable light source was subjectively found not to be inferior to the completely digital fixed set-up. Thus, the cheaper and smaller portable system could be considered as an economical option without substantial loss of image quality, especially useful in developing countries.
Effects of previous unsuccessful extracorporeal shockwave lithotripsy treatment on the performance and outcome of percutaneous nephrolithotomy Publication date: Available online 7 April 2017 Source:Arab Journal of Urology Author(s): Hakan Türk, Mehmet Yoldaş, Tufan Süelözgen, Cemal Selcuk İşoğlu, Mustafa Karabıçak, Batuhan Ergani, Sıtkı Ün ObjectiveTo evaluate the effects of previous unsuccessful extracorporeal shockwave lithotripsy (ESWL) treatment on the performance and outcome of percutaneous nephrolithotomy (PCNL).Patients and methodsOf 1625 PCNL procedures performed in our clinic, 393 renal units with similar stone burden and number of accesses was included in the present study. We categorised the study patients into two groups according to whether they underwent ESWL within 1year prior to PCNL or not. Accordingly, Group 1 comprised 143 (36.3%) ESWL-treated patients and Group 2 comprised 250 (63.7%) non-ESWL-treated patients.ResultsResidual stones were detected in 36 (25.1%) of the ESWL-treated patients (Group 1) and in 60 (24%) of non-ESWL-treated patients (Group 2). There were no statistically significant differences between the groups for length of hospital stay (LOS), nephrostomy tube removal time, and the presence of residual stones. When we evaluated the groups for both the preoperative and postoperative haemoglobin (Hb) drop and blood transfusion rate, manifest Hb declines and more transfusions were required in the ESWL-treated patients (both P=0.01).ConclusionsIn our study, previous ESWL treatment had no influence on the PCNL stone-free rate, operation time, incidence of postoperative complications, and LOS, in patients with similar stone burdens. However, bleeding during PCNL was more prevalent in the ESWL-treated patients, so close attention should be paid to bleeding in patients who have been pretreated with ESWL.
The prevalence of an excessive prepuce and the effects of distal circumcision on premature ejaculation Publication date: Available online 7 April 2017 Source:Arab Journal of Urology Author(s): Luigi Gallo ObjectiveTo investigate the prevalence of an excessive prepuce in patients with premature ejaculation (PE) and to evaluate the effectiveness of distal circumcision in reducing the penile hypersensitivity, which is thought to be a cause of PE.Patients and methodsMen were considered to have an excessive prepuce if the foreskin exceeded the external urethral meatus by ≥1cm in the flaccid state. The diagnosis of PE was based on the Premature Ejaculation Diagnostic Tool (PEDT) questionnaire score and on the intravaginal ejaculatory latency time (IELT). These features were evaluated at baseline and at 6months after circumcision.ResultsLifelong PE was diagnosed in 352 patients of whom 208 (59.1%) had an excessive prepuce. We offered those with an excessive prepuce a circumcision, as a potential definitive treatment for their PE, and 27 (13%) men accepted. At 6months after circumcision, there was an increase in the mean (SD) IELT from 40.4 (16.5) to 254 (66.8)s (P<0.001) and the mean (SD) PEDT score decreased from 17 (2) to 6.6 (1.9) (P<0.001). Overall, 26 of the 27 (96%) patients that had a circumcision reported an IELT increase.ConclusionsAn excessive prepuce is very common in patients affected by PE. Although accepted by only 13% of our patients, distal circumcision was shown to be a very effective surgical treatment for definitive treatment of PE. We therefore recommend assessing patients complaining of lifelong PE for an excessive prepuce and if they have an excessive prepuce to suggest that they undergo distal circumcision.
The impact of coexisting sperm DNA fragmentation and seminal oxidative stress on the outcome of varicocelectomy in infertile patients: A prospective controlled study Publication date: Available online 7 April 2017 Source:Arab Journal of Urology Author(s): Shabieb A. Abdelbaki, Jehan H. Sabry, Ahmed M. Al-Adl, Hanan H. Sabry ObjectivesTo study the relationship between sperm DNA fragmentation (SDF) and reactive oxygen species (ROS) levels in infertile patients with varicocele, and to examine the beneficial effect of varicocelectomy and elucidate predictors of improvement after repair.Patients, subjects and methodsWe prospectively studied 60 patients with varicocele and abnormal semen variables who attended the outpatient clinic complaining of infertility for ≥12months. In all, 25 patients (41.7%) had bilateral varicoceles and 35 (58.3%) had left varicoceles. The DNA fragmentation index (DFI%, percentage of sperm with denatured nuclei), ROS and total non-enzymatic antioxidant capacity (TAC) were measured. Inguinal varicocelectomy was performed in all patients. At 3–6months postoperatively, all measurements were repeated. A control group, comprised of 20 normozoospermic fertile men, was included. Regression analysis was used to examine predictors of improvement.ResultsThe mean (SD) DFI% in the 60 infertile patients with varicocele was 29.9 (8.3) and 7.56 (2.84)% in the controls; ROS levels were 4.49 (0.9) in patients and 2.62 (0.8)photons/min in controls; and the TAC was 0.97 (0.4) in patients and 1.5 (0.5)mM in controls; with highly significant differences between the patients and controls. The DFI% showed a positive correlation with ROS levels, whilst the total motile sperm count (TMSC) had a significant negative correlation with DFI%, ROS levels and grade of varicocele, whilst there was significant positive correlation with TAC. The grade of varicocele and duration of infertility were related to the presence of higher levels of ROS and increased of DFI%. Postoperatively, improvement (measured as a >50% increase in TMSC) occurred in 40 of 55 (73%) patients available at follow-up, with a significant reduction in the mean (SD) DFI% from 29.49 (8.58) to 18.78 (7.23)%, ROS levels from 4.49 (0.88) to 3.27 (1.3)photons/min (both P<0.001), and a significant increase in the mean (SD) TAC from 1.01 (0.44) to 2.05 (0.51)mM (P<0.001). Responders had a shorter infertility duration and lower preoperative DFI% and ROS levels. Regression analysis showed that DFI% is a predictor of improvement after varicocelectomy.ConclusionSDF was shown to have a negative impact on improvement after varicocelectomy. Hence, DFI% could be recommended as a prognostic test in infertile patients with varicocele to help decision-making as regards the necessity and the anticipated outcome of varicocelectomy in patients with infertility.
Simulators in the urological training armamentarium: A boon or a bane? Publication date: Available online 3 April 2017 Source:Arab Journal of Urology Author(s): Gaurav Aggarwal, Samiran D. Adhikary Simulation devices have grasped the attention of almost all industries worldwide and the medical field has not been exempt. With technological advancement, it becomes important to assess whether medical simulators are the way forward as an adjunct or as a replacement to traditional training approaches by assessing their safety, efficacy and cost-effectiveness, and whether they should be made mandatory in the curriculum of urology training.The present review aims to clarify some of these issues, as well as assess their role in urological training and present both the pros and cons of this simulation-based training.
A practical guide and decision-making protocol for the management of complex renal cystic masses Publication date: Available online 30 March 2017 Source:Arab Journal of Urology Author(s): Peter Weibl, Milan Hora, Boris Kollarik, Kristina Kalusova, Tomas Pitra, Mesut Remzi, Wilhelm Hübner, Pascal Balzer, Tobias Klatte ObjectivesTo analyse the management, pathology and outcomes of complex renal cystic masses (CRCM) and to develop a decision-making tool for daily clinical care using the Bosniak classification system for CRCM.Patients and methodsA comprehensive dataset of 185 patients with 188 CRCM and a minimum follow-up of 3years were analysed for management, pathology and outcomes.ResultsWe analysed 35 Bosniak II, 34 Bosniak IIF, 58 Bosniak III, and 61 Bosniak IV lesions. The overall incidence of renal cell carcinoma was 8.6%, 29.4%, 62.1%, and 78.7% for each category. Based on our surveillance strategy of Bosniak IIF masses, we recommend computed tomography (CT)/magnetic resonance imaging (MRI) every 2years after the initial examination. We also recommend performing one MRI (as an adjunct to CT) during the early follow-up period (<4years). The use of MRI correlation for differential diagnostic purposes has proven useful for marginal Bosniak II, IIF and III cases.ConclusionsFrom our data, we have created a decision-making protocol to guide urologists in planning a safe and effective diagnostic and treatment strategy for CRCM. The Bosniak classification is a useful tool for clinical decision-making. Uncertainties still remain for Bosniak IIF and III lesions. Our protocol shows that individualised decision-making is necessary in a significant proportion of CRCM.
Management of penile cancer in a Singapore tertiary hospital Publication date: Available online 30 March 2017 Source:Arab Journal of Urology Author(s): Teck Wei Tan, Sing Joo Chia, Kian Tai Chong ObjectivesTo present our experience of managing penile squamous cell carcinoma (SCC) in a tertiary hospital in Singapore and to evaluate the prognostic value of the inflammatory markers neutrophil–lymphocyte ratio (NLR) and lymphocyte–monocyte ratio (LMR).Patients and methodsWe reviewed our prospectively maintained Institutional Review Board-approved urological cancer database to identify men treated for penile SCC at our centre between January 2007 and December 2015. For all the patients identified, we collected epidemiological and clinical data.ResultsIn all, 39 patients were identified who were treated for penile SCC in our centre. The median [interquartile range (IQR)] follow-up was 34 (16.5–66)months. Although very few (23%) of our patients with high-risk clinical node-negative underwent prophylactic inguinal lymph node dissection (ILND), they still had excellent 5-year recurrence-free survival (RFS; 90%) and cancer-specific survival (CSS; 90%). At multivariate analysis, higher N stage was significantly associated with worse RFS and CSS. Patients with a high NLR (≥2.8) had significantly higher T-stage (P=0.006) and worse CSS (P<0.001) than those with a low NLR. Patients with a low LMR (<3.3) had significantly higher T-stage (P=0.013) and worse RFS (P=0.009) and CSS (P<0.022) than those with a high LMR.ConclusionsAlthough very few of our patients with intermediate- and high-risk clinical node-negative SCC underwent prophylactic ILND, they still had excellent 5-year RFS and CSS. However, survival was poor in patients with node-positive disease. The pre-treatment NLR and LMR could serve as biomarkers to predict the prognosis of patients with penile cancer.
Does sacral pulsed electromagnetic field therapy have a better effect than transcutaneous electrical nerve stimulation in patients with neurogenic overactive bladder? Publication date: Available online 29 March 2017 Source:Arab Journal of Urology Author(s): Lamyaa A. Fergany, Husain Shaker, Magdy Arafa, Mohamed S. Elbadry ObjectiveTo compare the effectiveness of pulsed electromagnetic field therapy (PEMFT) and transcutaneous electrical nerve stimulation (TENS) on neurogenic overactive bladder dysfunction (OAB) in patients with spinal cord injury (SCI).Patients and methodsIn all, 80 patients [50men and 30 women, with a mean (SD) age of 40.15 (8.76)years] with neurogenic OAB secondary to suprasacral SCI were included. They underwent urodynamic studies (UDS) before and after treatment. Patients were divided into two equal groups: Group A, comprised 40 patients who received 20min of TENS (10Hz with a 700s generated pulse), three times per week for 20 sessions; Group B, comprised 40 patients who received PEMFT (15Hz with 50% intensity output for 5s/min for 20min), three times per week for 20 sessions.ResultsIn Group B, there was a significant increase in the maximum cystometric capacity (P<0.001), volume at first uninhibited detrusor contraction (P<0.002), and maximum urinary flow rate (P<0.02).ConclusionThe UDS showed that the effects of PEMFT in patients with neurogenic OAB secondary to suprasacral SCI was better than TENS for inducing an inhibitory effect on neurogenic detrusor overactivity.
Posterior urethral valves: Impact of low birth weight and preterm delivery on the final renal outcome Publication date: Available online 7 March 2017 Source:Arab Journal of Urology Author(s): Osama M. Sarhan ObjectiveTo investigate the relationship between low birth weight (LBW; <2.5kg) and preterm delivery (<37weeks gestational age) and final renal outcome in infants with posterior urethral valves (PUVs), emphasising the risk factors for the development of chronic kidney disease (CKD).Patients and methodsA retrospective review was performed for all infants with PUVs who were treated between 1990 and 2010. In all, 52 infants were identified to have LBW and/or delivered preterm (Group 1). Infants in Group 1 were compared with a matching group (Group 2) of 60 full-term normal birth weight (NBW) infants with PUVs managed during the same period. The outcome of both groups was analysed.ResultsDuring follow-up, CKD developed in 17 (32.5%) and 22 patients (36.5%) in Groups 1 and 2, respectively (P=0.812). Patients with LBW or delivered preterm had significantly higher incidence of oligohydramnios (P=0.009), increased risk of vesicostomy (P<0.001), longer hospital stay (P<0.001), and higher incidence of vesico-ureteric reflux (VUR, P=0.024). In the LBW patients, initial serum creatinine, nadir serum creatinine, oligohydramnios and Neonatal Intensive Care Unit (NICU) length of stay were significant predictors of final renal outcome (P<0.001, P=0.002, P=0.004 and P=0.012, respectively).ConclusionIn our cohort of LBW and preterm delivery infants with PUVs, outcomes were similar to those of NBW full-term infants with PUVs but with an increased risk of vesicostomy, longer hospital stay, and higher incidence of VUR. LBW was associated with oligohydramnios, longer NICU admission, high initial and nadir serum creatinine, which were associated with a poor prognosis.
A novel algorithm for the non-invasive detection of bladder outlet obstruction in men with lower urinary tract symptoms Publication date: Available online 6 March 2017 Source:Arab Journal of Urology Author(s): Fawzy Farag, Mohamed Elbadry, Mohammed Saber, Abdelbasset A. Badawy, John Heesakkers ObjectiveTo determine the ability of bladder wall thickness (BWT) in combination with non-invasive variables to distinguish patients with bladder outlet obstruction (BOO).Patients and methodsPatients completed the International Prostate Symptom Score (IPSS) questionnaire and prostate size was measured by transrectal ultrasonography (US). Pressure-flow studies were performed to determine the urodynamic diagnosis. BWT was measured at 250-mL bladder filling using transabdominal US. Recursive partition analysis (RPA) recursively partitions data for relating independent variable(s) to a dependent variable creating a tree of partitions. It finds a set of cuts of the dependent variable(s) that best predict the independent variable, by searching all possible cuts until the desired fit is reached. RPA was used to test the ability of the combined data of BWT, maximum urinary flow rate (Qmax), post-void residual urine volume (PVR), IPSS, and prostate size to predict BOO.ResultsIn all, 72 patients were included in the final analysis. The median BWT, voided volumes, PVR, mean Qmax, and IPSS were significantly higher in patients who had an Abrams/Griffiths (A/G) number of >40 (55 patients) compared to those with an A/G number of ≤40 (17 patients). RPA revealed that the combination of BWT and Qmax gave a correct classification in 61 of the 72 patients (85%), with 92% sensitivity and 65% specificity, 87% positive predictive value, and 76% negative predictive value (NPV) for BOO (area under the curve 0.85). The positive diagnostic likelihood ratio of this reclassification fit was 2.6.ConclusionsIt was possible to combine BWT with Qmax to create a new algorithm that could be used as a screening tool for BOO in men with lower urinary tract symptoms.
Minimally invasive basilic vein transposition in the arm or forearm for autogenous haemodialysis access: A less morbid alternative to the conventional technique Publication date: Available online 6 March 2017 Source:Arab Journal of Urology Author(s): Ankush Jairath, Abhishek Singh, Ravindra Sabnis, Arvind Ganpule, Mahesh Desai ObjectiveTo devise a minimally invasive, less morbid yet effective alternative technique for basilic vein transposition (BVT) in the arm/forearm and to compare perioperative outcomes with the conventional technique.Patients and methodsPatients undergoing BVT in the last two years (June 2013 to June 2015) were included in the study and the results were analysed. All patients were preoperatively evaluated using colour Doppler ultrasonography performed by the operating surgeon himself. For minimally invasive BVT, two or three small 1–2cm incisions were made to completely mobilise the basilic vein, transposed in an anterolateral arm/forearm tunnel, and then anastomosed to the brachial or radial artery in the forearm and arm, respectively. The incision in the conventional technique was along the full length of the basilic vein, with the rest of the procedure remaining the same. Complications, pain, analgesic use, maturation and primary patency rates were compared between the techniques.ResultsIn all, 30 patients underwent minimally invasive BVT and 34 patients underwent conventional BVT, with mean age of 52 and 55years, respectively. The complications of wound haematoma (one vs four) and wound infection/dehiscence (two vs six) were less common in the minimally invasive BVT group compared to the conventional group. The analgesic requirement and visual analogue scale pain score was significantly less in the minimally invasive BVT group. All other variables assessed, such as maturation and primary patency rate at 1year, were not significantly different between the groups.ConclusionMinimally invasive dissection of the basilic vein for vascular access transposition is a safe, reliable procedure with patency and functional outcomes comparable with those of conventional BVT.
Photodynamic diagnosis in upper urinary tract urothelial carcinoma: A systematic review Publication date: Available online 6 March 2017 Source:Arab Journal of Urology Author(s): Elsawi Osman, Ziad Alnaib, Nitya Kumar ObjectiveTo assess the diagnostic accuracy and safety of photodynamic diagnosis (PDD) in upper urinary tract urothelial carcinoma (UUTUC).Materials and methodsA systematic literature search was conducted. Included studies were assessed for the risks of bias and quality using appropriate tools. Dedicated data extraction forms were used. Diagnostic accuracy in terms of sensitivity and specificity were quoted whenever provided by individual studies. A combined toxicity profile of 5-aminolevulinic acid (5ALA) was given after reviewing individual studies.ResultsIn all, 17 studies were identified. After screening seven studies were included involving a total of 194 patients. None of the studies were randomised. All the available studies were of low-to-moderate quality. The largest available study, with 106 patients, reported a sensitivity of 95.8% and 53.5% for PDD and white-light (WL) ureterorenoscopy (URS) respectively, with a statistically significant difference. The specificity was 96.6% for PDD and 95.2% for WL-URS with no statistical significance. PDD showed better ability in detecting carcinoma in situ and dysplasia. One study compared PDD to computed tomography urogram (CTU) and found PDD to have better sensitivity and statistically significantly better specificity. 5ALA-associated toxicity was minor in nature and hypotension was the most common adverse event.ConclusionPDD in UUTUC appears to be more accurate than WL-URS and CTU, with no significant toxicity. Larger scale randomised trials are needed.
Can percutaneous nephrolithotomy be performed as an outpatient procedure? Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Ahmed Fahmy, Hazem Rhashad, Omer Algebaly, Wael Sameh ObjectivesTo examine the safety and effectiveness of percutaneous nephrolithotomy (PCNL) as an outpatient procedure, as in most centres PCNL is performed as an inpatient procedure that necessitates postoperative hospital admission.Patients and methodsOur study included 186 patients undergoing PCNL for renal calculi. Only those who met strict inclusion criteria were discharged home on the same day. Preoperative eligibility criteria for outpatient management included no complex medical problem, normal renal function, and easy access to an emergency room. Patients were divided into two groups. The outpatient group (Group 1) included those patients discharged on the same day as the PCNL and the hospitalised group (Group 2) included those who were considered appropriate for outpatient management but needed to be hospitalised.ResultsIn all, 162 patients (87%) fulfilled the inclusion criteria for outpatient management and 146 of these patients (90.1%) planned for outpatient management were discharged on the same operative day (Group 1). The mean time to discharge home was 8.97h. In all, 16 patients who opted for the outpatient approach subsequently required hospitalisation (Group 2). In the hospitalised group the mean operative time was longer, which was probably related to its higher stone burden.ConclusionPCNL can be safely performed with excellent outcomes as an outpatient procedure. Outpatient PCNL offers several advantages including a more rapid patient convalescence, reduced healthcare expenditure, decreased postoperative nosocomial infections with no additional morbidity for the patient, and with no compromising of the stone-free rate.
How practical is the application of percutaneous nephrolithotomy scoring systems? Prospective study comparing Guy’s Stone Score, S.T.O.N.E. score and the Clinical Research Office of the Endourological Society (CROES) nomogram Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Anurag Singla, Nikhil Khattar, Rishi Nayyar, Shibani Mehra, Hemant Goel, Rajeev Sood ObjectiveTo prospectively compare the Guy’s Stone Score (GSS), S.T.O.N.E. [stone size (S), tract length (T), obstruction (O), number of involved calices (N), and essence or stone density (E)] score and the Clinical Research Office of the Endourological Society (CROES) nephrolithometric nomogram to predict percutaneous nephrolithotomy (PCNL) success rate and assess the correlation with perioperative complications.Patients and methodsWe prospectively evaluated all consecutive PCNL patients at our institute between 1 November 2013 and 31 May 2015. The above scoring systems were applied to preoperative non-contrast computed tomography and the practical difficulties in such applications were noted. Perioperative complications and the stone-free rate (SFR) were also recorded. Receiver operating characteristic curves were drawn and the areas under curves were compared and appropriate statistical analysis done.ResultsIn all, 48 renal units were included in the study. The overall SFR was 62.2%. The presence of staghorn stones (β=27.285, 95% confidence interval 1.19–625.35; P=0.039) was the only significant variable associated with the residual stones on multivariate analysis. Stone-free patients had significantly lower median GSS (2 vs 4) and S.T.O.N.E. scores (6 vs 10) and higher median CROES scores (83% vs 63%) (all P<0.001) compared to residual-stone patients. All scoring systems were significantly associated with SFR (all P<0.001). There was no significant difference in the areas under curves of the scoring systems (0.858, 0.923, and 0.931, respectively). Furthermore, all scoring systems had weak correlations with Clavien–Dindo classified complications (r=0.29, P=0.045; r=0.40, P=0.005 and r=−0.295, P=0.04, respectively). We found no standardisation for the measurement of stone dimensions, tract length, Hounsfield units, and staghorn definition.ConclusionsAll scoring systems equally predicted SFR and had a weak correlation with Clavien–Dindo complications. Standardisation is needed for the variables in which they have been found deficient.
Extending indications of micropercutaneous nephrolithotomy: It is not just about cracking stones Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Arvind P. Ganpule, Jaspreet Singh Chhabra, S.B. Sudharsan, Ankush Jairath, Mohankumar Vijaykumar, Ravindra Sabnis, Mahesh R. Desai ObjectiveTo describe our experience and results of using the MicroPerc™ micropercutaneous nephrolithotomy armamentarium (PolyDiagnost, Germany) for unusual indications unexplored using this modality.Patients and methodsWe used the MicroPerc™ system for stone clearance in three ureteric calculi, two bladder calculi, one case of urethral calculus, for antegrade biopsy in a case of upper tract urothelial carcinoma, for Deflux® (dextranomer/hyaluronic copolymer, Salix Pharmaceuticals, Uppsala, Sweden) injection in three cases of vesico-ureteric reflux (VUR), and three cases of posterior urethral valve (PUV) fulgurations. A 4.85-F ‘All-Seeing Needle®’ (PolyDiagnost) was used in most of the cases. An 8-F mini-micro sheath was used where stability was deemed necessary. Clinical data were collected in a dedicated database. Intraoperative variables, postoperative complications, and outcomes were assessed.ResultsAll patients were successfully treated with complete stone clearance at 1month with no residual fragments. The antegrade biopsy confirmed a high-grade papillary neoplasm. There were no technical difficulties with injection of Deflux or PUV fulgurations. Follow-up at 1year revealed no stone recurrence, resolved reflux in all three cases, and all the children that had had PUVs were voiding well. The small sample and retrospective nature of the analysis are the limitations of this study.ConclusionMicroPerc™, besides its usual use for minimally invasive percutaneous nephrolithotomy, can also be feasibly used for ureteric, bladder and urethral stones, and for treating non-calculus diseases such as PUVs and VUR. True to its name, it may be an ‘All-Seeing Needle’ in reality with much more to offer and harvest from.
Percutaneous nephrolithotomy; alarming variables for postoperative bleeding Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Shakhawan H.A. Said, Mohammed A. Al Kadum Hassan, Rawa H.G. Ali, Ismaeel Aghaways, Fahmi H. Kakamad, Khalid Q. Mohammad ObjectivesTo evaluate factors contributing to bleeding after percutaneous nephrolithotomy (PCNL) and ways of managing this complication, as bleeding is a serious sequela that requires prompt management.Patients and methodsThe demographic and procedural data of 200 patients, who underwent unilateral PCNL during a 20-month period, were prospectively collected. Preoperative, operative, and postoperative details were recorded. The preoperative variables analysed included: age, sex, body mass index (BMI), the presence of hypertension, diabetes mellitus, serum creatinine, degree of hydronephrosis, previous ipsilateral open renal surgery, stone size and complexity. The operative variables analysed included: number of tracts, operative time, size of Amplatz sheath, type of anaesthesia, and complications such as calyceal and pelvic perforation.ResultsThe variables of age, sex, BMI, diabetes, hypertension, and a preoperative creatinine level of >1.4mg/dL had no significant effect on blood loss (all P>0.05). However, the rate of bleeding was significantly higher (P⩽0.05) in patients who had a history of previous open renal surgery, intraoperative pelvicalyceal perforations, and Guy’s Stone Score (GSS) grade 3 and 4 complex stones; however, absence of hydronephrosis, larger stone size, operative time (>83min), more than one puncture, and size of the Amplatz sheath (26–30 F) did not maintain their significance in multivariate analysis.ConclusionAccording to our present results stone complexity (GSS grade 3 and 4), history of ipsilateral renal stone surgery, and occurrence of intraoperative pelvicalyceal perforation are alarming variables for post-PCNL bleeding.
Immediate versus delayed shockwave lithotripsy for inaccessible stones after uncomplicated percutaneous nephrolithotomy Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Esam A.E. Desoky, Amr M. Fawzi, Ahmed Sakr, Ahmed Eliwa, Ehab R. El Sayed, Diab El Sayed, Asharf M.S. Shahin, Emad A. Salem, Hussien M. Kamel, Waleed Shabana, Mostafa Kamel ObjectiveTo evaluate the efficacy and safety of immediate versus delayed shockwave lithotripsy (SWL) for inaccessible stones after uncomplicated percutaneous nephrolithotomy (PCNL).Patients and methodsBetween December 2011 and June 2014, patients with residual inaccessible stones after uncomplicated PCNL were prospectively randomised into two treatment groups; Group I, immediate SWL and Group II, delayed SWL at 1week after PCNL. Patients with residual stones of ⩾1.5cm, a stone density of >1000 Hounsfield units and body mass index of >40kg/m2 were excluded from the study. The following data were reported: patients’ demographics, stone characteristics after PCNL, hospital stay, perioperative complications, stent duration, and stone-free rate (SFR).ResultsIn all, 84 patients (51males and 33females) with mean (SD) age of 39 (8.5) years were included in the study. Group I included 44 patients, whilst Group II included 40 patients. There was no statistically significant difference amongst the groups for patients’ demographics, stone characteristics, and perioperative complications. The hospital stay was significantly shorter in Group I, at a mean (SD) of 34 (3.7) vs 45 (2.9)h (P<0.001). The duration of ureteric stenting was significantly lower in Group I as compared to Group II, at a mean (SD) of 12 (4.2) vs 25 (3.5)days (P<0.001). The SFR was 93.2% and 95% in Groups I and II, respectively (P=0.9).ConclusionsImmediate SWL after PCNL is as effective and safe as delayed SWL with a lesser hospital stay and duration of ureteric stenting.
Tubeless mini-percutaneous nephrolithotomy versus retrograde intrarenal surgery for lower calyceal stones of ⩽2cm: A prospective randomised controlled study Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Amr S. Fayad, Mohamed G. Elsheikh, Waleed Ghoneima ObjectiveTo assess the safety, efficacy, and stone-free rate (SFR) of mini-percutaneous nephrolithotomy (mini-PCNL) and retrograde intrarenal surgery (RIRS) for the management of lower calyceal stones of ⩽2cm, and to determine the advantages and disadvantages of each.Patients and methodsIn all, 120 patients with lower calyceal stones of ⩽2cm were randomly divided into two equal groups: Group A were managed by mini-PCNL and Group B by RIRS using flexible ureteroscopy and laser. The mean age, sex, stone size, operating time, complications, hospital stay, and SFR were compared between the groups. The success of the procedure was defined as the absence of residual stones or small residuals of ⩽0.2cm on computed tomography at 12weeks postoperatively.ResultsBoth groups were comparable for preoperative parameters. The mean (SD) operating time was statistically significantly longer in Group B [109.66 (20.75)min] as compared to Group A [71.66 (10.36)min]. Although the hospital stay was longer in Group A as compared to Group B this was not statistically significant (P=0.244). The SFR for Group A was 92.72% and for Group B it was 84.31%, which was not significantly different (P=0.060).ConclusionFor treating lower calyceal stones of ⩽2cm mini-PCNL and RIRS are comparable. Mini-PCNL had a better SFR than RIRS but the hospital stay was longer and there were more intraoperative complications, whilst, RIRS had a significantly longer operating time compared with mini-PCNL and a higher incidence of postoperative fever, and a lower SFR.
Percutaneous nephrolithotomy in complete supine flank-free position in comparison to prone position: A single-centre experience Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Nadeem Sohail, Amjad Albodour, Khalid Mohammed Abdelrahman ObjectivesTo assess the outcomes of performing percutaneous nephrolithotomy (PCNL) in a modified supine position, more feasible for surgeons, anaesthetists, and operating theatre staff, as well as for the patient himself, and evaluating it in comparison to the standard prone position.Patient and methodsA retrospective, case-control study was conducted between January 2011 and December 2015. In all, 197 patient’s records were reviewed. The initial 101 patients were operated upon in prone position. From mid-2013, 96 patients were operated upon in a complete supine, flank-free position. The groups were compared in terms of operation time, calculated from positioning the patient after anaesthesia induction, insertion of ureteric catheter, puncture of renal system, until the end of procedure; stone-free rate; hospital stay; and postoperative complications, such as transfusion rate, fever, and urinary leakage.ResultsThere were two significant differences between the groups. Firstly, the operation time was a mean (SD) 32.3 (6.6) min shorter for the supine versus the prone position (P<0.001). Secondly, hospital stay was a mean (SD) 1.2 (0.75) days shorter for the supine vs the prone position (P<0.001). The complete stone clearance rate (85.4% for supine vs 79.2% for prone; P=0.2) and postoperative complications (7.3% for supine vs 17.8% for prone; P=0.02) were comparable in both groups.ConclusionSupine PCNL is a feasible procedure with similar outcomes in terms of stone-free rate as well as postoperative complications, to the standard prone PCNL. It reduces unnecessary delay that occurs during change of position resulting in significant shortening of the total operation time and surgeons can perform supine PCNL whilst sitting.
Laparoscopic re-implantation of refluxing ureter in children: A feasibility study Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Haytham E. Badawy, Khaled Refaai, Ashraf S. Soliman, Samir S. Orabi ObjectiveTo report our initial experience in the application of laparoscopy in the management of children with unilateral vesico-ureteric reflux (VUR) using the laparoscopic extravesical transperitoneal approach following the Lich–Gregoir technique, and to evaluate the results and benefits of this technique for such patients.Patients and methodsBetween February 2013 and August 2014, 17 children [13 girls and four boys, with a median (range) age of 60 (24–120)months] presented with recurrent febrile urinary tract infections and were diagnosed with unilateral VUR. They underwent transperitoneal extravesical laparoscopic ureteric re-implantation following the Lich–Gregoir technique. Postoperatively abdomino-pelvic ultrasonography was done at 1month after surgery and voiding cystourethrography (VCUG) at 3months after surgery, and in cases with persistent VUR or de novo contralateral VUR another VCUG was done at 6months after surgery.ResultsThe median (range) operative time was 90 (80–120)min and the postoperative hospital stay was 2 (2–5)days. Intraoperative and postoperative complications were minimal. Patients were followed-up for a median (range) of 6 (3–21)months. All the children had complete resolution symptomatically and on VCUG, without further intervention.ConclusionsThe laparoscopic extravesical transperitoneal approach for ureteric re-implantation, following the Lich–Gregoir technique, is feasible and very effective in the management of VUR. Prospective randomised studies are eagerly awaited to define the benefits of this technique to patients, as well as to determine the cost-effectiveness of this approach.
Sildenafil citrate in combination with tamsulosin versus tamsulosin monotherapy for management of male lower urinary tract symptoms due to benign prostatic hyperplasia: A randomised, double-blind, placebo-controlled trial Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Amr Fawzi, Mostafa Kamel, Emad Salem, Esam Desoky, Mohamed Omran, Hazem Elgalaly, Ahmed Sakr, Aref Maarouf, Salem Khalil ObjectiveTo assess the additive effect of sildenafil citrate to tamsulosin in the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) in men with or without erectile dysfunction (ED).Patients and methodsIn all, 150men with untreated LUTS/BPH with or without ED were randomised to receive sildenafil 25mg once daily (OD) or placebo OD (night time) combined with tamsulosin 0.4mg OD (day time) for 6months. Changes from pre-treatment scores in International Prostate Symptom Score (IPSS), IPSS-quality of life (QoL) score, maximum urinary flow rate (Qmax), and the five-item version of the International Index of Erectile Function questionnaire (IIEF-5) were assessed at 3 and 6months. Safety profiles were assessed by physical examination and monitoring clinical adverse events.ResultsGroup A comprised of men who received tamsulosin and sildenafil (75men), whilst those in Group B received tamsulosin and placebo (75). The IPSS was significantly improved in Group A compared to Group B, at −29.3% vs −13.7% (P=0.039) at 3months and −37% vs −19.6% (P=0.043) at 6months after treatment. Qmax significantly improved in both groups compared with before treatment (P<0.001). The IIEF-5 scores improved more in Group A than in Group B, at 58.7% vs 11.7% at 3months and 62.4% vs 12.4% at 6months after treatment (both P<0.001).ConclusionSildenafil citrate combined with tamsulosin improved LUTS, erectile function, and patient QoL more than tamsulosin monotherapy with the merit of a comparable safety profile in patients with LUTS/BPH.
The value of extended good quality transurethral resection of bladder tumour in the treatment of the newly diagnosed bladder cancer Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Mohamed Adel Atta, Ahmed Fouad Kotb, Mohamed Sharafeldeen, Ahmed Elabbady, Mohamed Mohie Hashad ObjectiveTo report our experience for the initial management of patients with newly diagnosed bladder tumours using our team approach for each case and using an aggressive extended transurethral resection of bladder tumour (TURBT) in order to investigate the real need for a routine ‘second-look’ cystoscopy in the current era.Patients and methodsThe study included 50 consecutive patients admitted to the urology department, of our tertiary care centre, for management of newly diagnosed bladder cancer. Exclusion criteria included past history of bladder tumour, palpable mass on bimanual examination under anaesthesia, presence of residual tumour at the end of resection, and patients with tumours of the bladder dome as thorough resection is difficult to achieve in this area without an attendant risk. Patients that had pathologically confirmed carcinoma in situ were also excluded. White-light cystoscopy was used in all of the cases. Extended TURBT was defined as resection of the whole tumour, resection of the tumour base and 1cm of apparently normal bladder wall around the circumference of the tumour.ResultsThe median (range) age of the patients was 52 (39–60)years. After initial TURBT, 10 patients (20%) were identified as having muscle-invasive bladder cancer. Of the remaining 40 patients, three had low-grade Ta disease, and so second biopsies were not taken. The remaining 37 patients had T1, grade 2–3 disease and none of them had evident residual disease at the site of tumour resection.ConclusionRe-staging TURBT could be safely omitted for select groups of patients. An experienced surgeon and teamwork, together with an extended TURBT can accurately achieve complete tumour resection, with accurate tumour staging, on initial resection.
Transurethral resection versus open bladder cuff excision in patients undergoing nephroureterectomy for upper urinary tract carcinoma: Operative and oncological results Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Charalampos Fragkoulis, Athanasios Pappas, Georgios I. Papadopoulos, Georgios Stathouros, Aristodimos Fragkoulis, Konstantinos Ntoumas ObjectivesTo evaluate the impact of distal ureter management on oncological results after open nephroureterectomy (ONU) comparing transurethral resection of the intramural ureter to conventional open excision, as controversy still exists about the method of choice for managing the distal ureter and bladder cuff during ONU.Patients and methodsWe retrospectively collected data from 378 patients who underwent ONU for upper urinary tract transitional cell carcinoma (UUT-TCC) from 1988 to 2009. Patients were divided into two subgroups according to the type of operation performed. Group A comprised 192 patients who had ONU with open resection of the bladder cuff from 1988 to 1997. Group B comprised 186 patients in whom transurethral resection of the intramural ureter plus single incision ONU was performed between 1998 and 2009. The mean operative time, hospital stay, duration of catheterisation, bladder recurrence rates, and cancer-specific survival (CSS) were assessed.ResultsThe total operative time was statistically significantly less in the endoscopic group (Group B). For catheterisation, patients treated with an open approach (Group A) had a statistically significantly shorter duration of postoperative catheterisation. There was no statistical difference between Groups A and B for the bladder recurrence rate (Group A 24% vs 27% in Group B, P=0.51). There was no difference in CSS at the 5-year follow-up.ConclusionsONU with transurethral resection of the intramural ureter up to the extravesical fat followed by ureter extraction is an oncologically safe and technically feasible operation.
Reference range of flaccid and stretched penile lengths of adult males in Baghdad: A cross-sectional study Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Naser S. Hussein, Ammar F. Abid, Ahmed S. Alnuaimi ObjectivesTo establish a baseline reference range for flaccid (FPL) and stretched penile lengths (SPL) in adult males and to compare with reports from different nationalities, as concerns over penile size are common among men and currently the number of men seeking help for the perceived problem of a ‘short’ penis is increasing.Subjects and methodsOver a 1-year period, FPL and SPL measurements were taken from males undergoing medical examination in the outpatient clinic of the Al-Karama Teaching Hospital, using a rigid centimetre ruler. The correlation between penile length and age was investigated.ResultsIn all, 223 apparently healthy males were included in this study with a mean (SD; range) age of 41.3 (15.0; 20–77)years. The mean (SD; range) FPL was 9.8 (2.0; 5–17)cm and the SPL was 12.6 (1.9; 7.5–19.5)cm. Statistical analysis showed that penile length is increased in older age (>55years). A penile length nomogram was constructed, showing that the 50th percentiles of FPL and SPL were 9.0 and 12.5cm, respectively.ConclusionOur data establish a baseline reference range for adult male penile lengths in the Capital of Iraq (Baghdad), which should be useful for urologists when counselling patients.
Varicocelectomy: Modified loupe-assisted versus microscopic technique – A prospective comparative study Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Mohammad H. Alkandari, Adel Al-Hunayan Abstract objectiveTo compare our novel loupe-assisted varicocelectomy (LV) technique to the ‘gold standard’ demanding microscopic varicocelectomy (MV) technique for the management of varicoceles.Patient and methodsOur LV technique, featuring testicular delivery and proximal spermatic cord occlusion using a tourniquet, has not been used before nor to our knowledge has it been reported in the literature. In the LV group, inguinal incision was done prior to testicular delivery and spermatic cord occlusion. Pampiniform and gubernacular veins were identified then tackled. Proximal spermatic cord occlusion helped in identifying those veins, and not confusing them with other cord structures that should be preserved. In all, 95 infertile men were included in this prospective, comparative study; and divided into LV and MV groups. They were followed-up for 1year, pregnancy achievement, improvements in semen parameters, and complication rates were assessed.ResultsBoth groups had statistically significant pregnancy rates and negligible complication rates. However, LV cost 33% less than MV and was quicker to perform. We did not find that the MV technique was better than our simple, more cost-effective, less time-consuming LV technique.ConclusionOur novel LV technique has similar success and complication rates as the ‘gold standard’ MV technique for the management of varicoceles, and is more cost-effective and less time consuming.
High single scrotal-incision orchidopexy as the standard technique in infants aged 6–24months Publication date: March 2017 Source:Arab Journal of Urology, Volume 15, Issue 1 Author(s): Ahmed Mohey, Tarek M. Gharib, Rabea G. Omar, Ahmed Sebaey, Basheer N. Elmohamady, Wael Kandeel ObjectiveTo prospectively investigate the effectiveness of high single scrotal-incision orchidopexy (HSSIO) for palpable undescended testis (PUDT) in infants aged 6–24months.Patients and methodsFrom March 2012 to July 2014, 46 age range-restricted (6–24months) infants with 57 PUDT underwent HSSIO after obtaining written consent from their parents. The exclusion criteria were ectopic, retractile testes and recurrent cases. All infants were examined before surgery in the outpatient department and after anaesthesia induction immediately before surgery. All infants had general anaesthesia with a caudal block. The operative time, intraoperative and postoperative complications, and follow-up of the infants at 0.5, 3 and 6months were recorded and analysed.ResultsThe mean (SD; range) operative time was 23.45 (3.28; 18–29)min. A hernia sac was found in 39 (68.4%) UDTs. For postoperative complications, only one infant developed a scrotal haematoma that was managed conservatively. The procedure was successful in 56/57 PUDT (98%). An auxiliary procedure was needed in one case, to obtain more length of the cord by extension of the incision to the external ring.ConclusionHSSIO is a safe and feasible technique, with many benefits, and as such should be considered as the standard technique for orchidopexy in infants aged 6–24months.
The world’s contribution to the field of urology in 2015: A bibliometric study Publication date: December 2016 Source:Arab Journal of Urology, Volume 14, Issue 4 Author(s): Ahmad Majzoub, Khalid Al Rumaihi, Abdulla Al Ansari ObjectiveTo explore factors associated with a successful research atmosphere by investigating the distribution of articles published in the field of urology in 2015 amongst different world regions, as research is undoubtedly a valuable tool that can help shape the future of human health.MethodsThe Scopus® database was searched for publications made by Urology journals enlisted in the SCImago journal and country rank website. Details about each article type, language, and country of origin were collected. Journals’ bibliometric measures, as well as their country of origin and the number publications since the year 1996 were also collected. Countries were divided according to the United Nations geoscheme.ResultsIn all, 80 of 93 registered Urology journals publishing a total of 10,181 articles were included in the study. Results reveal that the highest contribution came from North America (37.4%) followed by Europe (29.4%), Asia (26.5%), South America (2.2%), Africa (1.9%), and Oceania (1.7%). Bibliometric analysis of the published articles showed significantly higher impact measures amongst North American publications, followed by those from Europe, Oceania, South America, Asia, and Africa (P<0.001). A slight drop in the number of publications was noted in 2015. Finally, a statistically significant regional correlation was detected between the corresponding authors’ affiliation and the journals’ publishing region (P<0.001).ConclusionNorth America had the highest contribution to the field of urology in 2015. A significant correlation exists between the origin of the published article and the publishing journal’s region.
Adrenal masses: A urological perspective Publication date: December 2016 Source:Arab Journal of Urology, Volume 14, Issue 4 Author(s): Amr F. Fergany Adrenal masses have become increasingly common due to widespread use of sectional imaging. Urologists are commonly faced with management decisions in patients with adrenal masses. Systemic review of available literature related to surgical adrenal disease was performed to summarise the most pertinent information related to adrenal masses, diagnostic evaluation and surgical treatment. Detailed hormonal evaluation of adrenal disease was not included, being part of endocrinological rather than urological practice. Adrenal masses exhibit a wide spectrum of presentation and pathology, and treatment requires different surgical techniques. Full understanding of the pathology and management of such masses should be completely familiar to practicing urologists.
Are magnetic resonance imaging undetectable prostate tumours clinically significant? Results of histopathological analyses Publication date: December 2016 Source:Arab Journal of Urology, Volume 14, Issue 4 Author(s): Kristian D. Stensland, Karl Coutinho, Adele R. Hobbs, Lindsay Haines, Shemille A. Collingwood, Young Suk Kwon, Simon J. Hall, Maria Katsigeorgis, Seyed Behzad Jazayeri, David B. Samadi ObjectiveTo investigate whether tumours at threshold values for detection on magnetic resonance imaging (MRI) represent clinically significant tumours or not, and therefore the utility of MRI in active surveillance (AS) protocols.Patients and methodsA retrospective analysis of a single institution database was performed after Institutional Review Board approval. Between 2010 and 2013, 1633 patients underwent robot-assisted laparoscopic prostatectomy (RALP) at a single institution by a single surgeon. Of these, 1361 had complete clinical data and were included in analysis. Multivariate logistic regression was used to assess histopathological grade compared to tumour size whilst controlling for biopsy Gleason score, prostate-specific antigen level, body mass index, race, and age.ResultsOf 120 tumours <5mm in size, four were Gleason score 4+3. Of 276 tumours of 5–10mm, 22 (8.1%) were Gleason score 4+3 and one (0.2%) was Gleason score 8. On multivariate regression analyses, tumours of <5mm were much less likely to be high grade (Gleason score >3+4) at RALP compared to larger tumours (3.3% vs 25.1%, P<0.001), or Gleason score ⩾8 (0.0% vs 7.6%, P<0.001). Size was further shown to significantly correlate with grade on multivariate regression (P<0.001).ConclusionsProstate tumours below the detection threshold for MRI (5mm) most probably represent clinically insignificant tumours, which alone would not necessitate leaving AS in favour of more aggressive therapy. These findings point to a possible role of MRI in modern AS protocols.
Drug treatment of bothersome lower urinary tract symptoms after ureteric JJ-stent insertion: A contemporary, comparative, prospective, randomised placebo-controlled study, single-centre experience Publication date: December 2016 Source:Arab Journal of Urology, Volume 14, Issue 4 Author(s): Ihab A. Hekal ObjectiveTo provide a guide for medication to alleviate bothersome lower urinary tract symptoms (LUTS) in patients after JJ ureteric stenting.Patients and methodsBetween June 2011 and June 2015, a prospective randomised placebo-controlled study was conducted on 200 consecutive cases of ureteric stones that required JJ stents. All patients had signed informed consent and JJ-stent placement confirmed by X-ray. The patients were randomised into five groups: A, solifenacin 5mg; B, trospium chloride 20mg; C, antispasmodic; and E, α-blocker; and a placebo group (D). A standard model was created to lessen patient selection bias. Eligible patients were enrolled and assessed for side-effects and bothersome LUTS using the validated Ureteric Stent Symptoms Questionnaire. Appropriate statistical analysis was carried out.ResultsIn all, 150 male patients in the five groups were compared. LUTS were less in groups A and B (P<0.05), while dry mouth was significantly reported in Group A. Individual comparisons with the placebo group showed a non-significant difference with Group C, while Group E had significant nocturia improvement. Selective comparison of two best groups (A and B) showed less frequency in Group B, while the other LUTS were less in Group A with comparable side-effects.ConclusionsIn symptomatic patients following JJ-stent insertion, anti-muscarinic medication, namely solifenacin 5mg or trospium chloride 20mg, was the best. The advantage of trospium over solifenacin is in the control of frequency rather than the other symptoms. Addition of an α-blocker (alfuzosin 10mg) is valuable when nocturia is the predominant symptom.
Predictors of renal recovery in renal failure secondary to bilateral obstructive urolithiasis Publication date: December 2016 Source:Arab Journal of Urology, Volume 14, Issue 4 Author(s): Muthukrishna P. Rajadoss, Chandrasingh Jeyachandra Berry, Grace J. Rebekah, Vinu Moses, Shyamkumar N. Keshava, Kuruthukulangara S. Jacob, Santosh Kumar, Nitin Kekre, Antony Devasia ObjectivesTo identify factors predicting renal recovery in patients presenting with renal failure secondary to bilateral obstructing urolithiasis.Patients and methodsData from electronic records of consecutive adult patients presenting with bilateral obstructing urolithiasis between January 2007 and April 2011 were retrieved. Ultrasonography of the abdomen, and kidney, ureter, bladder (KUB study) X-ray or abdominal non-contrast computed tomography confirmed the diagnosis. Interventional radiologists placed bilateral nephrostomies. Definitive intervention was planned after reaching nadir creatinine. Renal recovery was defined as nadir creatinine of ⩽2mg/dL.ResultsIn all, 53 patients were assessed, 50 (94.3%) were male, and 18 (33.9%) were aged ⩽40years. Renal recovery was achieved in 20 patients (37.7%). A symptom duration of ⩽25days (P<0.01), absence of hypertension (P=0.018), maximum renal parenchymal thickness of >16.5mm (P=0.001), and haemoglobin >9.85g/dL (P<0.01) were significant on unadjusted analysis. Symptom duration of ⩽25days alone remained significant after adjusted analysis. Symptom duration of ⩽25days (hazard ratio (HR) 13.83, 95% confidence interval (CI) 4.52–42.26; P<0.01), parenchymal thickness of ⩾16.5mm (HR 5.91, 95% CI 1.94–17.99; P=0.002), and absence of hypertension (HR 9.99, CI 95% 1.32–75.37; P=0.026) were significantly related to time to nadir creatinine. Symptom duration of ⩽25days (HR 17.44, 95% CI 2.48–122.79; P=0.004) alone remained significant after adjusted analysis. A symptom duration of ⩽25days (P=0.007) was 22-times more likely to indicate renal recovery.ConclusionsShorter symptom duration (⩽25days) is predictive of renal recovery in renal failure secondary to bilateral obstructive urolithiasis.
Can endourology fellowship training enhance minimally invasive surgery in urology practice? Publication date: December 2016 Source:Arab Journal of Urology, Volume 14, Issue 4 Author(s): Ahmed M. Al-Kandari, Yehya Elshebiny, Hamdy Ibrahim, Ahmad AlShammari, Ahmed A. Shokeir ObjectiveTo evaluate the influence of fellowship training in endourology on different endourological procedures in a single institution.Subjects and methodsThe operative records of endourological and open surgeries were reviewed. Data analysed included numbers, types, and technical issues related to surgeries. The early study period ranged from September 1998 to September 2004, and the later period from January 2014 to June 2016. The study duration was classified into three periods according to the availability of an endourology fellowship trained member of staff (EFTS). In period A (September 1998 to September 2001) no EFTS was available, in period B (October 2001 to September 2004) an EFTS joined the urology unit, and in period C (January 2014 to June-2016) the EFTS had left the urology unit.ResultsIn periods B and C the number of rigid ureteroscopy (URS) significantly increased compared with period A. Also, flexible URS was used for the first time in period B and continued in period C. The number of percutaneous nephrolithotomies increased in period B and continued to be performed in period C. Laparoscopic urological surgery was not undertaken in period A, and only done in four cases in period C, whilst it was performed in 62 patients in period B. Holmium laser enucleation of the prostate was carried out in 36 patients during period B and not performed in periods A and C. Finally, the number of open stone surgeries decreased in periods B and C.ConclusionThe introduction of an EFTS definitely enhanced the practice of minimally invasive procedures.
A prospective randomised controlled study comparing bipolar plasma vaporisation of the prostate to monopolar transurethral resection of the prostate Publication date: December 2016 Source:Arab Journal of Urology, Volume 14, Issue 4 Author(s): Ahmed M. Elsakka, Hssan H. Eltatawy, Khaled H. Almekaty, Ahmed R. Ramadan, Tarik A. Gameel, Yasser Farahat ObjectivesTo compare the safety and efficacy of bipolar transurethral plasma vaporisation (B-TUVP) as an alternative to the ‘gold standard’ monopolar transurethral resection of the prostate (M-TURP) for the treatment of benign prostatic hyperplasia (BPH) in a prospective randomised controlled study.Patients and methodsIn all, 82 patients indicated for prostatectomy were assigned to two groups, group I (40 patients) underwent B-TUVP and group II (42 patients) underwent M-TURP. The safety of both techniques was evaluated by reporting perioperative changes in serum Na+, serum K+, haematocrit (packed cell volume), and any perioperative complications. For the efficacy assessment, patients were evaluated subjectively by comparing the improvement in International Prostate Symptom Score and objectively by measuring the maximum urinary flow rate (Qmax) and post-void residual urine volume (PVR) before and after the procedures.ResultsIn group II, there was a significant perioperative drop in serum Na+ (from 137.5 to 129.4mmol/L) and haematocrit (from 42.9% to 38.2%) (both P<0.001). Moreover, one patient in group II had TUR syndrome. The remote postoperative complication rate was (15%) in group I and comprised of stress urinary incontinence (5%), bladder outlet obstruction (5%), and residual adenoma (5%). In group II, the remote postoperative complication rate was (4.8%), as two patients developed urethral stricture. There were statistically significant improvements in micturition variables postoperatively in both arms, but the magnitude of improvement was statistically more significant in group II.ConclusionB-TUPV seems to be safer than M-TURP; however, the lack of a tissue specimen and the relatively high retreatment rate are major disadvantages of the B-TUVP technique. Moreover, M-TURP appears to be more effective than B-TUPV and its safety can be improved by careful case selection and adequate haemostasis.
Outcome of laparoscopic upper pole heminephroureterectomy in children: A two-centre experience Publication date: December 2016 Source:Arab Journal of Urology, Volume 14, Issue 4 Author(s): Ali Serdar Gözen, Haytham Badawy, Dogu Teber, Akram Assem, Jens Rassweiler ObjectiveTo report our multicentre experience and outcomes with laparoscopic transperitoneal and retroperitoneal upper pole heminephroureterectomy (HNU) in children with renal duplex systems and impaired upper pole.Patients and methodsLaparoscopic HNU was performed in 22 children (15 girls, seven boys) with a mean age of 5.9years. A retroperitoneal approach was used in 17 patients and a transperitoneal approach in the remaining five, between 2005 and 2010. Urinary tract infection was the initial presenting symptom in all children except for one with urinary retention caused by a large ureterocele. Voiding cystourethrography and renal scintigraphy revealed dual collecting systems on the right side in 11 and on the left in 11 cases. The upper pole collecting system was non-functioning in all cases. Postoperative ultrasonography was done at 1 and 3months, with renal scintigraphy at 3months, to check the remaining function of the lower moiety.ResultsOverall, the mean operation time was 152min (144min for retroperitoneal and 160min for transperitoneal). Blood loss was 10–50mL and there were no intraoperative complications. The mean (SD) hospitalisation and postoperative follow-up were 3.5 (1.25)days and 22 (9.83)months, respectively. Postoperative recovery was uneventful and at the 3-month follow-up renal scintigraphy revealed no parenchymal loss of the remaining renal moiety.ConclusionLaparoscopic HNU in children can be performed via transperitoneal or retroperitoneal approach, both with low morbidity and with the typical benefits of laparoscopic surgery.
Use of fibrin glue as a sealant at the anastomotic line in laparoscopic pyeloplasty: A randomised controlled trial Publication date: December 2016 Source:Arab Journal of Urology, Volume 14, Issue 4 Author(s): Ahmed Farouk, Ahmed Tawfick, Mohamed Kotb, Alaa Abdellmaksoud, Ahmed Safaan, Mohamed Yassin, Hassan Shaker ObjectiveTo assess the effectiveness of fibrin glue as a sealant at the anastomotic line of a stentless laparoscopic pyeloplasty (LPP) repair instead of JJ stent insertion.Patients and methodsIn all, 46 patients with pelvi-ureteric junction obstruction scheduled for LPP were randomised into two groups each containing 23 patients. Group A underwent stented repair, while group B had a stentless repair together with sealing of the anastomotic line with fibrin glue.ResultsThere was no statistically significant difference between the groups for the postoperative improvement in the renal scan and intravenous urography. However, there was a statistically significant decrease in early postoperative adverse events in group B. In group A, all the patients had irritative lower urinary tract symptoms (LUTS) and 16 (72.7%) had postoperative urinary tract infections (UTIs). In group B, no patient had a UTI or irritative LUTS. In all, 21 patients (95.4%) in group A had minimal terminal painful haematuria; while in group B, only one patient (4.3%) had minimal total painless haematuria. Also, patients in group B were spared the need for a second anaesthesia exposure for stent removal.ConclusionThe use of fibrin glue is a valid alternative to stenting in LPP with the same excellent outcome but with markedly lower short-term postoperative adverse events.
Grafted tubularised incised-plate urethroplasty: An objective assessment of outcome with lessons learnt from surgical experience with 263 cases Publication date: December 2016 Source:Arab Journal of Urology, Volume 14, Issue 4 Author(s): Vipul Gupta, Sunil Kumar Yadav, Talal Alanzi, Islam Amer, Mohmmad Salah, Mamdouh Ahmed ObjectiveSnodgrass urethroplasty remains the preferred technique in primary distal hypospadias but development of meatal stenosis often limits distal extension of the midline incision of the urethral plate (MIUP), which remains a limiting factor in reconstructing an apical neomeatus (NM). We here-in assess the cosmetic and functional outcome with distal extension of the MIUP in grafted tubularised incised-plate urethroplasty (G-TIP) repair.Patients and methodsThis prospective study included the surgical experience of 263 cases of primary hypospadias operated upon between 2012 and 2015. The G-TIP technique included standard steps of Snodgrass urethroplasty, including degloving and harvesting of glans wings, followed by MIUP that was extended distally beyond the margins of the urethral plate (UP) into the glans. The incised bed was grafted with a free preputial skin graft and fixed to the bed with polydioxanone 7-0 suture. The UP was tubularised and the suture line reinforced with a Dartos flap. The urethral catheter was removed at 7–10days after the repair and the outcome was assessed at follow-up using the Hypospadias Objective Scoring Evaluation (HOSE) system.ResultsAn apical NM was achieved in 96% of the patients with a 3.7% incidence of urethrocutaneous fistula. The presence of suture tracks and graft at the margins of the NM were seen in the initial 4% and 5% of cases, respectively. Acceptable cosmetic results, with objective HOSE scores of >14, were achieved in 96% of cases.ConclusionThe G-TIP repair is a straightforward and feasible technique facilitating reconstruction of an apical NM, with an optimum outcome based on HOSE scoring. However, multicentre data are needed for undertaking comparative analysis and to assess the universal applicability of this technique in primary hypospadias.
Surgical outcomes and complications of Tube® (Promedon) malleable penile prostheses in diabetic versus non-diabetic patients with erectile dysfunction Publication date: December 2016 Source:Arab Journal of Urology, Volume 14, Issue 4 Author(s): Elnisr Rashed Mohamed, Ahmed Rashed Hammady, Mohamed Zaki Eldahshoury, Ahmed Mamdouh Elsharkawi, Ahmed Mahmoud Riad, Hazem Mohamed Elmogazy, Mohamed Mostafa Hussien, Wael Mohamed Gamal ObjectiveTo evaluate surgical outcome, complications, and patients satisfaction with the Tube® (Promedon, Cordoba, Argentina) malleable penile prosthesis in diabetic and non-diabetic patients with refractory erectile dysfunction (ED).Patients and methodsThe records of 128 eligible patients who received Tube malleable penile prostheses at our institute between September 2008 and October 2015 were reviewed.ResultsOf the 128 patients, who received Tube penile prostheses at our institute, 53 were diabetics and 75 were non-diabetics. Both groups of patients were comparable for mean age, education level, marital status, hospital stay, time to commencing sexual intercourse, and median follow-up. Complications included: inter-corporeal septal perforation (2.3%), glanular urethral injury (1.5%), acute urinary retention (3.9%), superficial wound infection (7%), penile discomfort (9.4%), and penile prostheses infection (5.5%). Moreover, 3.9% developed atrophy of the cavernosal tissue, 5.5% experienced bad cosmesis, 6.3% experienced ejaculatory disorders, and 2.3% developed bladder calculi. In all, 13 prostheses (9.4%) were removed, seven of them due to infection, three on the patients’ demand and three due to mechanical failure. The satisfaction rates with the prostheses were 77.3% and 79.4% in the diabetic and non-diabetic patients, respectively; with an overall satisfaction rate of 78.5%. There was no significant difference in the complication rate or prostheses infection between diabetic and non-diabetic patients.ConclusionTube malleable penile prostheses are associated with low complication and high satisfaction rates. There was no significant difference in the complication rate or prostheses infection between diabetic and non-diabetic patients. A prospective comparative study with a large number of patients is recommended.
Modified one-stage dorsal-inlay buccal mucosa graft technique for ventral penile urethral and penile skin erosion: A step-by-step guide Publication date: December 2016 Source:Arab Journal of Urology, Volume 14, Issue 4 Author(s): Lennert Van Putte, Gunter De Win ObjectiveTo demonstrate the use of a modified single-stage technique for the repair of a ventral penile urethral erosion with involvement of the penile skin, as penile urethral erosion is a rare but potential complication of chronic indwelling catheterisation with a lack of available recommendations for reconstructive options.Patient and methodsA 44-year-old male with paraplegia, neurogenic bladder dysfunction and chronic sacral decubitus, presented with a large mid-penile erosion of the ventral penile shaft and urethra, which was caused by chronic transurethral indwelling catheterisation while being hospitalised in an intensive care unit. The reconstruction involved a single-stage dorsal-inlay buccal mucosa graft urethroplasty (Asopa) in addition to the second stage of a two-stage urethroplasty. The urethroplasty as well as the buccal mucosa graft harvest were performed by a single team.ResultsThe modified single-stage urethroplasty procedure had a duration of 158min with a postoperative hospitalisation of 3days. At 8-months follow-up, the lesion had fully healed and the patient was back on clean intermittent self-catheterisation with solifenacin 10mg daily. No complications occurred postoperatively.ConclusionThe modified single-stage dorsal-inlay technique is a viable method for repairing ventral penile urethral erosion with involvement of penile skin.
Oligometastatic prostate cancer: Metastases-directed therapy? Publication date: September 2016 Source:Arab Journal of Urology, Volume 14, Issue 3 Author(s): Hein Van Poppel, Gert De Meerleer, Steven Joniau Since the introduction of anatomical and functional imaging with multiparametric magnetic resonance imaging and choline or prostate-specific membrane antigen positron emission tomography–computed tomography, we are able to diagnose a previously unknown disease, the oligometastatic prostate cancer after local therapy. Reports on surgical and radiation treatment for low-volume metastatic recurrence have shown promising results, with definitive cure in few but a relevant delay of androgen-deprivation therapy with both treatment methods. Obviously, these results need to be validated with prospective randomised data.
Squamous cell carcinoma of the urinary bladder: Systematic review of clinical characteristics and therapeutic approaches Publication date: September 2016 Source:Arab Journal of Urology, Volume 14, Issue 3 Author(s): Jeremy W. Martin, Estrella M. Carballido, Ahmed Ahmed, Bilal Farhan, Rahul Dutta, Cody Smith, Ramy F. Youssef ObjectiveTo highlight the current understanding of the epidemiology, clinicopathological characteristics, and management of squamous cell carcinoma (SCC) of the bladder, as it accounts for 2–5% of bladder tumours, with a focus on non-bilharzial-associated SCC (NB-SCC). The standard treatment for bladder SCC remains radical cystectomy (RC). We present an updated clinical profile of bladder SCC and a review of NB-SCC therapeutic approaches, including RC, neoadjuvant and adjuvant treatments, radiotherapy, chemotherapy, and immunotherapy.MethodsUsing search terms relating to SCC, urinary bladder, and treatment modalities, we performed a search of the PubMed and Embase databases to identify NB-SCC treatment approaches and outcomes. Peer-reviewed English language reports from 1975 to present assessing SCC management were included. Two authors independently screened and extracted the data.ResultsOf the 806 articles screened, 10 met the pre-defined inclusion criteria. RC was performed in seven of the 10 studies. Although radiotherapy alone yielded poor outcomes, preoperative radiotherapy and RC were associated with improved survival. There is little evidence supporting the use of chemotherapy in NB-SCC, and its efficacy in relation to RC is not known.ConclusionBased on current literature, there is insufficient evidence to provide a treatment recommendation for NB-SCC. Whilst RC is the standard of care, the role of preoperative radiotherapy should be revisited and compared to RC alone. Additional studies incorporating multimodal approaches, contemporary radiation techniques, and systemic therapies are warranted. Immunotherapy as a treatment for bladder SCC has yet to be investigated.
Computed tomography virtual cystoscopy for follow-up of patients with superficial bladder tumours in comparison to conventional cystoscopy: An exploratory study Publication date: September 2016 Source:Arab Journal of Urology, Volume 14, Issue 3 Author(s): Hossam Elawady, Mahmoud A. Mahmoud, Diaaeldin M.A. Mostafa, Alaa Abdelmaksoud, Mohamed W. Safa, Remon Z. Elia ObjectiveTo evaluate and analyse the efficacy of computed tomography (CT) virtual cystoscopy in comparison to conventional cystoscopy for the follow-up of patients with non-muscle-invasive bladder cancer.Patients and methodsThe study was done over 3years, from April 2010 to June 2013, and included 30 patients who all had non-muscle-invasive transitional cell carcinoma (Ta, T1). The patients all underwent complete transurethral resection of the tumour and presented for first follow-up check cystoscopy. The examination was performed using a 16-slice multi-detector (MD) CT scanner. The results were compared for sensitivity and specificity in relation to the site, size, and shape of the tumour.ResultsIn all, 20 lesions were detected by CT virtual cystoscopy in 18 patients, whilst the remaining 12 were lesion free. Conventional cystoscopy, detected 23 lesions in 19 patients. The sensitivity of the virtual images was 87%; its specificity in identifying lesions was 100%, with a positive predictive value of 100% and negative predictive value of 78.5%.ConclusionCT virtual cystoscopy is a promising technique for detecting bladder tumours and some other bladder lesions. However, the detection rate for recurrent NMIBC does not appear to be adequate to replace conventional cystoscopy.
Comparison of ureteric stone size, on bone window versus standard soft-tissue window settings, on multi-detector non-contrast computed tomography Publication date: September 2016 Source:Arab Journal of Urology, Volume 14, Issue 3 Author(s): Hussam Uddin Soomro, M. Hammad Ather, Basit Salam ObjectiveTo compare the difference in mean stone size, as measured on bone window vs standard soft-tissue window setting using multi-detector computed tomography (MDCT) in patients with a solitary ureteric stone.Patients and methodsIn all, 60 patients presenting to the emergency and outpatient departments of a University Hospital from May 2015 to October 2015 and fulfilling the inclusion criteria were included in the study. A 64-slice MDCT was used to assess the locations and size of the ureteric stones. A consultant radiologist independently analysed the MDCT scans of all the patients. The mean difference in stone size was calculated between both window settings in axial and coronal planes.ResultsThe mean (SD) age of the patients was 37.13 (11.9)years. Males constituted ∼68% of the cohort and 32% were female. In all, 85% of the patients had left ureteric stones and 15% had right ureteric stones. The mean (SD) stone size, as measured on the soft-tissue window setting was 6.68 (2.01)mm, and on the bone window setting was 4.8 (1.9)mm. The mean (SD) difference in stone size between the two window settings was +1.85 (0.55)mm. The two means were compared using Student’s t-test, and the difference was found to be statistically significant (P<0.05).ConclusionThe stone size measured using the soft-tissue window setting on a MDCT is significantly different from the measurement on the bone window setting.
Holmium laser cystolithotripsy under local anaesthesia: Our experience Publication date: September 2016 Source:Arab Journal of Urology, Volume 14, Issue 3 Author(s): Nischith D’Souza, Ashish Verma ObjectiveTo investigate the feasibility and effectiveness of transurethral holmium laser cystolithotripsy (HLC) under local anaesthesia using a flexible cystoscope.Patients and methodsA prospective study was undertaken from January 2013 to June 2015. In all, 37 men with bladder calculi underwent HLC under local anaesthesia, preferably in a lithotomy position using a flexible cystoscope, followed by per urethral Foley catheter placement postoperatively.ResultsThe mean (SD; range) patient age was 46.6 (5.6; 32–76)years. All patients were rendered stone-free, regardless of stone size. The mean (SD; range) stone size was 2.1 (1.2; 1.4–4.1)cm and operative time was 35 (6; 26–52)min. The whole procedure was well tolerated and there were no major intraoperative complications. The mean (SD; range) hospital stay was 2.4 (1.5; 1–5)days. After a mean follow-up of 6months, no recurrent stones, urinary retention or urethral strictures had developed.ConclusionsTransurethral HLC using a flexible cystoscope under local anaesthesia is a safe and effective technique for the treatment of bladder calculi and can be used as an alternative treatment option.
Extracorporeal shockwave lithotripsy monotherapy for treating patients with bladder stones Publication date: September 2016 Source:Arab Journal of Urology, Volume 14, Issue 3 Author(s): Khaled A. Telha, Khaled Alkohlany, Ibrahim Alnono ObjectivesTo describe our experience with extracorporeal shockwave lithotripsy (ESWL) for the treatment of bladder stones of <20mm.Patients and methodsThis study was prospectively performed in two hospitals (Althawrah Modern General Hospital, and Ibn Sina Specialized Hospital) between November 2012 and November 2015. In all, 44 patients presented with urethral or bladder stones. The location and size of the stones was assessed by abdominal ultrasonography and plain abdominal radiography of the kidneys, ureters and bladder. All patients with radiopaque stones of <20mm underwent ESWL monotherapy after fixation of a Foley catheter in a supine position under intravenous analgesia.ResultsThe mean size of the stones was 15.8mm and spontaneous evacuation occurred after removal of the Foley catheter without the need for adjuvant procedures in 40 patients (90.9%). Four patients (9%) developed acute urinary retention due to urethral impaction of large stone fragments. In two of them, the urethral catheter was successfully re-inserted pushing the fragments back to the bladder and a complementary session of ESWL resulted in more fragmentation of the stones, with spontaneous passage after catheter removal. In the other two patients (4.5%), the catheter could not be re-inserted and urgent endoscopic intervention was required.ConclusionsESWL monotherapy is safe and effective method for treatment of bladder stones with no other causes of infra-vesical obstruction. Several indications can be met including patients with high anaesthetic risk, patients fearing anaesthesia or endoscopic procedures, and patients who have difficulty in positioning.
Safety and efficacy of cystoscopically guided percutaneous suprapubic cystolitholapaxy without fluoroscopic guidance Publication date: September 2016 Source:Arab Journal of Urology, Volume 14, Issue 3 Author(s): Adel H. Metwally, Mahmoud H. Sherief, Mohamed A. Elkoushy ObjectiveTo evaluate the safety and efficacy of percutaneous cystolitholapaxy (PCCL) under cystoscopic guidance and without fluoroscopy for the management of large or multiple bladder stones.Patients and methodsProspectively collected data were reviewed for patients undergoing PCCL with cystoscopic guidance and without fluoroscopy. Patients with a bladder stone burden of ⩾30mm were included. Stone fragmentation was achieved using a pneumatic lithotripter through a rigid nephroscope and the fragments were removed with peanut forceps. Patients with concomitant bladder malignancy, previous pelvic radiotherapy, previous pelvic–abdominal surgery, or benign prostate enlargement of >80mL were excluded from the study.ResultsIn all, 40 male patients were included between July 2011 and June 2014 with a mean (SD) age of 36.9 (17.6) years. A single bladder stone was detected in 22 (55%) patients, whilst 18 (45%) had multiple bladder stones, with a mean (range) stone size of 35 (32–45) mm. The stone-free rate was 100% and the procedure was well tolerated by all patients. No intraoperative bladder perforation, bleeding or major perioperative adverse events were recorded. The mean (SD) hospital stay was 2.2 (0.41) days and the catheterisation time was 1.2 (0.6) days. At 4weeks postoperatively, no significant stone fragments were found in any of the patients.ConclusionPCCL under cystoscopic control and without fluoroscopy seems to be an effective and safe technique to remove large or multiple bladder calculi. It represents an alternative treatment option, especially in situations where fluoroscopy is not available, and radiation hazards can be avoided.
Implications of different nephrolithometry scoring systems on clinical practice of endourologists: An international web-based survey Publication date: September 2016 Source:Arab Journal of Urology, Volume 14, Issue 3 Author(s): Mohamed A. Elkoushy, Adel H. Metwally, Yasser A. Noureldin ObjectivesTo assess the implications of different nephrolithometry scoring systems (NLSS) on clinical practice of endourologists to predict stone-free status (SFS) after percutaneous nephrolithotomy (PCNL).MethodsA web-based survey was sent to members of the Endourological Society. Demographic and practice pattern data were collected. Multiple-choice and open-ended questions were used to assess awareness about the NLSS and their authentic use in clinical practice. Surgeon preferences and limitations of NLSS and how to overcome them were asked.ResultsIn all, there were 162 responses, including 17 (10.5%) respondents who were not aware of NLSS. Most respondents (82.1%) denied the efficacy of NLSS in predicting SFS after PCNL. Of 145 respondents who were aware of NLSS, 85.5% did not use them in clinical practice. Endourologists aged 40–60years (P<0.001), in practice for 10–20years (P=0.003), those performing 100–200 PCNLs/year (P=0.02), and those from North America (P<0.001) seemed to use NLSS more frequently. In all, 50% of respondents preferred not to use any NLSS, while 29% chose the S.T.O.N.E followed by the Guy’s Stone Score (10.3%) and The Clinical Research Office of the Endourology Society (CROES) nomogram (8.3%). Inconsistency and variability among different NLSS were the main drawbacks reported by 82% of 89 respondents. The need for high-level evidence for NLSS through direct randomised prospective comparison was recommended by 24.8% of respondents who answered that question.ConclusionThere is a lack of compliance and acceptance of different NLSS in clinical practice among endourologists. Inconsistency and inaccuracy in predicting SFS after PCNL limits their incorporation into clinical practice. However, the results of this study might not be generalisable due to the selection bias resulting from the geographical distribution of the respondents and the heterogeneity in surgical expertise. Therefore, randomised prospective direct comparisons and validation of these systems are recommended.
The challenges in the diagnosis of detrusor underactivity in clinical practice: A mini-review Publication date: September 2016 Source:Arab Journal of Urology, Volume 14, Issue 3 Author(s): Ahmed Ahmed, Bilal Farhan, Simone Vernez, Gamal M. Ghoniem ObjectiveTo review the current definitions, terminology, epidemiology and aetiology of detrusor underactivity (DU), with specific attention to the diagnostic criteria in use. In addition, we address the relation and the overlap between DU and bladder outlet obstruction (BOO). In this mini-review, we hope to help identify DU patients and facilitate structured clinical evaluation and research.MethodsWe searched the English literature using ScienceDirect and PubMed for relevant articles. We used the following terms: ‘detrusor underactivity’, ‘underactive bladder’, ‘post voiding residual’, ‘post micturition residual’, ‘acontractile bladder’, ‘detrusor failure’, and ‘detrusor areflexia’.ResultDU is one of the most common conditions causing lower urinary tract symptoms (LUTS). Unfortunately, it is also the most poorly understood bladder dysfunction with scant research. To our knowledge there is no clear definition and no non-invasive method to characterise this important clinical condition. DU may result from the normal ageing process; however, it has multiple aetiologies including neurogenic and myogenic dysfunction. In many cases the symptoms of DU are similar to those of BOO and it usually requires invasive urodynamic study (UDS) for diagnosis to differentiate the two diagnoses. A number of diagnostic tests may be used including: UDS testing, the Schafer pressure/flow nomogram, linear passive urethral resistance relation, Watts factor, and the bladder contractility index. Of these, UDS testing is the most practical as it determines both the maximum urinary flow rate and the pressure exerted by the detrusor muscle relative to the maximal flow of urine, allowing for precise characterisation of detrusor function.ConclusionCurrently, the diagnosis of DU is based on invasive urodynamic parameters as defined by the International Continence Society in 2002. There is no consensus for the definition of DU prior to 2002. As there is significant overlap between the symptoms of DU and BOO, it is difficult to diagnose DU clinically.
Fosfomycin antimicrobial prophylaxis for transrectal ultrasound-guided biopsy of the prostate: A prospective randomised study Publication date: September 2016 Source:Arab Journal of Urology, Volume 14, Issue 3 Author(s): Ahmed M. Fahmy, Ahmed Kotb, Tamer Abo Youssif, Hussien Abdeldiam, Omer Algebaly, Ahmed Elabbady ObjectivesTo compare the incidence of infectious complications after single-dose fosfomycin vs. standard fluoroquinolone (FQ)-based prophylaxis in patients undergoing transrectal ultrasound-guided biopsy of the prostate (TRUSBx), as there is an alarming trend worldwide of increasing resistance to FQs limiting their suitability as appropriate prophylaxis for TRUSBx.Patients and methodsA prospective study was conducted in 412 consecutive patients undergoing TRUSBx between February 2012 and June 2015. Patients were randomly divided into two groups; Group 1 (202 patients) who received single-dose fosfomycin (3g, orally) 1–2h before TRUSBx and Group 2 (210 patients) who received routine empirical prophylaxis in the form of oral ciprofloxacin 500mg and metronidazole 500mg at least 1h before TRUSBx and continued this twice daily for 3days before TRUSBx. We recorded all febrile and afebrile urinary tract infections (UTIs) within the 4weeks after the procedure.ResultsThere was no difference in baseline demographics between the two groups. Total infectious complications occurred in four (1.9%) and 18 (8.5%) patients in Groups 1 and 2, respectively, which was statistically significant (P=0.001). Escherichia coli was the most common isolated pathogen from urine cultures in all patients with infectious complications (68%). The other isolated bacterium, Klebsiella pneumoniae, was detected in four patients (18%). Urine cultures revealed FQ-resistant strains (73%), all of which were extended-spectrum β-lactamase-producing E. coli and K. pneumoniae.ConclusionsSingle-dose fosfomycin before TRUSBx significantly reduces infectious complications when compared with standard therapy. Fosfomycin is an effective agent for antimicrobial prophylaxis in patients undergoing TRUSBx, particularly in populations where FQ resistance is common.
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