Adel Kurkar

Effects of opioid (tramadol) treatment on testicular functions in adult male rats: The role of nitric oxide and oxidative stress.

Nowadays, tramadol hydrochloride is frequently used as a pain reliever, and for the treatment of premature ejaculation. Decreased semen quality was noted in chronic tramadol users. The present study aimed to elucidate the effects of tramadol on the testicular functions of adult male rats. A total of 40 albino adult male rats were divided into control and tramadol groups, with 20 rats for each group. Rats of the tramadol group were subcutaneously injected with 40 mg/kg three times per week for 8 weeks. The control group received normal saline 0.9%. Blood samples from each animal were obtained. Plasma levels of different biochemical substances were determined. Nitric oxide was measured in testicular tissue samples. Those samples together with epididymal tissue samples were processed for histopathological examination. Tramadol significantly reduced plasma levels of luteinizing hormone, follicle‐stimulating hormone, testosterone and total cholesterol, but elevated prolactin and estradiol levels compared with the control group. In addition, tramadol increased the testicular levels of nitric oxide and lipid peroxidation, and decreased the anti‐oxidant enzymes activities significantly compared with the control group. The tramadol group showed decreased sperm count and motility, and numbers of primary spermatocytes, rounded spermatid and Leydig cells. Immunohistochemical examinations showed that tramadol increased the expression of endothelial nitric oxide synthase in testicular tissues. The present study showed that tramadol treatment affects the testicular function of adult male rats, and these effects might be through the overproduction of nitric oxide and oxidative stress induced by this drug.

Management of symptomatic ureteral calculi during pregnancy: Experience of 23 cases.

Purpose: To present our experience in the management of symptomatic ureteral calculi during pregnancy. Materials and Methods: Twenty-three pregnant women, aged between 19 and 28 years presented to the obstetric and urology departments with renal colic (17 cases, 73.9%) and fever and renal pain (6 cases, 26.1%); suggesting ureteric stones. The diagnosis was established by ultrasonography (abdominal and transvaginal). Outpatient follow-up consisted of clinical assessment and abdominal ultrasonography. Follow-up by X-ray of the kidneys, ureter, and bladder (KUB), or intravenous urography (IVU) was done in the postpartum period. Results: Double J (DJ) stent was inserted in six women (26%) with persistent fever followed by extracorporeal shock wave lithotripsy (ESWL) one month post-partum. Ureteroscopic procedure and pneumatic lithotripsy were performed for 17 women (distal ureteric stone in 10, middle ureter in 5, and upper ureteric stone in 2). Stone-free rate was 100%. No urologic, anesthetic, or obstetric complications were encountered. Conclusions: Ureteroscopy, pneumatic lithotripsy, and DJ insertion could be a definitive and safe option for the treatment of obstructive ureteric stones during pregnancy.

Dissolution Therapy versus Shock Wave Lithotripsy for Radiolucent Renal Stones in Children: A Prospective Study

PURPOSE We prospectively evaluated the efficacy of dissolution therapy and standard shock wave lithotripsy as a noninvasive modality for radiolucent renal stones in children. MATERIALS AND METHODS A total of 87 children with radiolucent renal calculi were included in study. Median age was 2.5 years (range 0.5 to 13). Computerized tomography was done to confirm a stone density of less than 500 HU. Median stone length was 12 mm (range 7 to 24). Patients were randomly divided into 2 groups. The medical group of 48 patients received potassium sodium hydrogen citrate at a dose of 1 mEq/kg per day for 1 to 3 months. The shock wave lithotripsy group of 39 patients were treated with a Lithotripter S (Dornier Medtech, Kennesaw, Georgia) while under general anesthesia. Complications in each group were recorded. Patients were considered stone free when imaging within 3 months showed no evidence of stones. RESULTS The stone-free rate was 72.9% for dissolution therapy vs 82.1% after a single session of shock wave lithotripsy (p = 0.314). One patient per group experienced a pyelonephritis episode during followup (p = 0.698). Three of the 13 patients in whom medical regimens failed were noncompliant and 5 ingested the medication sporadically. CONCLUSIONS Medical dissolution therapy is a well tolerated, effective treatment for radiolucent renal stones in children. It eliminates the need for shock wave lithotripsy in up to 73% of cases.

False fracture of the penis: Different pathology but similar clinical presentation and management

Introduction: Penile fracture is the most common presentation of acute penis. Rupture of the superficial dorsal penile vein (s) may mimic penile fractures with similar clinical presentation but with intact corporeal bodies. Our aim of the study is to highlight superficial dorsal penile vein (s) injury as true emergency with better prognosis. Subjects and Methods: Sixty-eight patients with suspected penile fractures presented to our hospital between June 2007 and January 2013. Out of these, 11 patients showed intact tunica albuginea on exploration with injured dorsal penile vein (s) identified. Records of such 11 cases were reviewed regarding age, etiology, symptoms, physical signs, findings of surgical exploration and post-operative erectile function. Results: All 11 patients were injured during sexual intercourse and presented with penile swelling and ecchymosis and gradual detumescence. Mild penile pain was encountered in 5 cases and the “snap” sound was noted in 2 cases. Examination revealed no localized tenderness, or tunical defect. All the patients regained penile potency without deformity after surgical ligation of the severed vessels. One patient developed penile hypoesthesia. Conclusion: Although the classic “snap” sound and immediate detumescence are usually lacking in the symptomology of dorsal penile vein rupture, its clinical presentation can be indistinguishable from true penile fracture. Surgical exploration is still required to avoid missing tunical tear with possible future complications. The long-term outcome and prognosis are excellent.

Management of calculus anuria in children: experience of 54 cases.

OBJECTIVE To evaluate the outcome of different treatment plans for calculus anuria in children. PATIENTS AND METHODS Patients were subdivided into three groups, A, B and C. Group A included patients who were critically ill, had serum creatinine> or =3.5mg/dl, blood urea> or =100mg/dl, serum potassium> or =7meq/l and/or blood pH< or =7.1; and they were treated initially by peritoneal dialysis. Patients in groups B and C were stable with serum creatinine<3.5mg/dl, blood urea<100mg/dl, serum potassium level<7meq/l and blood pH>7.1. In group B, the obstructing stone could not be localized, and they were treated either by percutaneous nephrostomy or JJ stent. In group C, stone level was confidently determined and patients were treated by open surgery. RESULTS Fifty-four patients were included. All patients regained normal serum creatinine levels within 72-120h. Overall complication rate in groups A and C was 26% and 13%, respectively. In group B, overall complication rate was 66% for percutaneous nephrostomy and 50% for internal stent. CONCLUSIONS Urinary diversion in children is associated with a high complication rate while dialysis is highly effective in children. Formal surgery in compensated children is associated with a low complication rate with good outcome and early recovery.

Laparoscopic versus open orchiopexy in the management of peeping testis: A multi-institutional prospective randomized study

OBJECTIVE Peeping testis is an inconsistently palpable/seen undescended testis that migrates back and forth at the internal inguinal ring. Both open and laparoscopic orchiopexy are effective forms of management. The present study aimed to evaluate the efficacy and safety of both approaches. PATIENTS AND METHODS Between September 2007 and January 2012, 46 peeping inguinal testes were randomly treated with either open (25 cases) or laparoscopic (21 cases) orchiopexy procedures. Spermatic vessels were preserved for all cases. Operative details, postoperative morbidity and final testicular site and size were recorded. RESULTS The median age of the children was 2.5 years (range 0.5-12.0). The follow-up period ranged from 1.0 to 5.5 years. Of these testes, 20 in the open surgery group and 19 in the laparoscopic group maintained correct intrascrotal position (P = 0.428). Re-do orchiopexy was indicated for two cases in the surgical group (P = 0.493). No cases of testicular atrophy or hernia were encountered. CONCLUSION Open and laparoscopic orchiopexy procedures for peeping testes are fairly comparable. However, laparoscopy is relatively more effective, as two re-do orchiopexies were required in the open surgical group.

A randomized, double-blind, placebo-controlled, crossover trial of "on-demand" tramadol for treatment of premature ejaculation

Objectives: The objective of this study is to assess the dose-related effects of tramadol on a group of patients with premature ejaculation (PE). Subjects and Methods: During the period of months between June 2010 and July 2012, 180 PE patients presented to outpatient clinic of our hospital. Patients were randomized in a 1:1:1 fashion to receive different sequences of the three medications: placebo, 50 mg of tramadol and 100 mg of tramadol. Every patient received 10 doses of each medication for 2 months. Intra-vaginal ejaculatory latency time (IELT) was recorded in seconds initially and for each arm. Successful treatment of PE is defined if IELT exceeded 120 s. Side-effects of medications were reported. Results: Of patients enrolled, 125 (69.4%) continued the study. Patients′ age range was 20-55 years with PE complaint of 1 to 10 years duration. Mean IELT was 72 at presentation, 82 for placebo, 150 for tramadol 50 mg, and 272 for tramadol 100 mg (P < 0.001 for all comparisons). PE was successfully treated in only 2.4% of patients with placebo, in contrast to 53.6% and 85.6% with 50 and 100 mg tramadol, respectively (P < 0.001 for all comparisons). On multivariate logistic regression analysis, baseline IELT was the only predictor of successful treatment of PE with both tramadol 50 mg (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.03-1.07, P < 0.001) and tramadol 100 mg (OR: 1.07, 95% CI: 1.04-1.11, P < 0.001). Postmicturition dribble annoyed 12.8% of those who received 50 mg tramadol and 33.6% of those who received 100 mg tramadol (P < 0.001). Weak scanty ejaculation was the main complaint in 7.2% versus 21.6% of those using 50 and 100 mg tramadol, respectively (P = 0.002). Two patients discontinued tramadol 100 mg due to side-effects. Conclusion: Tramadol hydrochloride exhibits a significant dose-related efficacy and side-effects over placebo for treatment of PE.

The management of the persistent Müllerian duct syndrome.

Abstract Objectives: To report the findings and management of patients with persistent Müllerian duct syndrome (PMDS). Patients and methods: Nineteen phenotypically male patients (aged 8 months to 27 years) presented with testicular maldescent. All of them had normal male external genitalia. Two of them had had a previous diagnosis of persistent Müllerian structures. All patients were karyotyped, and had a hormonal profile, diagnostic laparoscopy, retrograde urethrocystogram, gonadal biopsies, and surgical management according to the findings. The follow-up was based on a clinical examination, abdominal ultrasonography (US) and scrotal colour-Doppler US at 3 and 6 months after surgery, and every 6 months thereafter. Results: Diagnostic laparoscopy showed the presence of persistent Müllerian structures in all 19 patients. All patients had a normal male karyotype (46XY). Ten patients had a laparoscopic excision of their Müllerian structures while the remaining nine patients had their Müllerian structures left in place. No malignant changes were found in the excised Müllerian tissues. Of the 37 gonadal biopsies taken, 31 (84%) indicated normal testes. Conclusions The incidence and prevalence of PMDS are not well estimated. Müllerian structures should be removed whenever possible to avoid the risk of malignant transformation. The early diagnosis of PMDS makes possible the excision of Müllerian structures and a primary orchidopexy. A long-term follow-up is needed for patients with intact Müllerian structures and magnetic resonance imaging might be a better method than US for that purpose. Most of the patients had normal testicular histology, which might allow fertility.

The laparoscopic management of symptomatic renal cysts: A single-centre experience

Abstract Objectives: To present our experience of treating symptomatic renal cysts by different techniques of laparoscopic decortication, as there are many treatment options for such cysts, each of them with advantages and drawbacks. Patients and methods: Between January 2002 and December 2012, 51 patients underwent laparoscopic renal-cyst decortication; 15 of them had recurrent cysts after percutaneous aspiration. A retroperitoneal approach was adopted in 44 cases, transperitoneal in four and laparo-endoscopic single-site surgery (LESS) cyst decortication in three (two of them had bilateral renal cyst decortications in the same session). All patients were diagnosed by ultrasonography and computed tomography to determine the Bosniak classification of the cyst. Pain and cyst recurrence were assessed during the follow-up. Results: All procedures were completed successfully, with no major intraoperative complications. The mean (range) operative duration was 56 (35–125) min, affected by the site and number of cysts unroofed. All patients were symptom-free except one, who had a recurrent large cyst, anteriorly located, and who underwent open cyst decortication. Conclusions: Laparoscopic decortication of symptomatic renal cysts should be the standard of care, especially after failed percutaneous aspiration or decortication. LESS cyst decortication is a promising technique, especially with bilateral pathology. It is feasible with conventional laparoscopic instruments and gives a better cosmetic outcome.

Hyperuricemia: A Possible Cause of Hemospermia

OBJECTIVE To report our experience with hemospermia and its relation to hyperuricemia. PATIENTS AND METHODS Between July 2005 and July 2012, 143 patients with hemospermia presented to the outpatient clinic in our hospital. History, examination, workup, treatment outcomes, and long-term follow-up were reported in a prospective database. Patients were followed up monthly by semen examination till disappearance of hemospermia, then every 3 months for 1 year. We identified 43 patients, who had 4-12 hemospermia attacks for 2-10 months before presentation with no identifiable cause for hemospermia. Of them, 22 had hyperuricemia. The association between hemospermia and hyperuricemia was examined by comparing such 22 hyperuricemic hemospermic patients with the other 21 idiopathic hemospermic patients. RESULTS The commonest 5 findings identified as possible causes of hemospermia were bilharziasis (21.6%), hyperuricemia (15.4%), idiopathic (14.7%), tuberculosis (8.4%), and chronic prostatitis (8.4%). Hyperuricemic hemospermic patients were significantly of younger age (median of 31.5 vs 45 years), complaining of more painful ejaculation (68.2% vs 9.5%), and had higher serum uric acid (median, 9.3 vs 4.5 mg/dL) compared with those of idiopathic hemospermia. Hemospermia disappeared completely in all patients of the hyperuricemia group vs only 25% of the idiopathic group (P <.001) within a mean of 2 months (range, 1-4 months). CONCLUSION Hyperuricemia is a new probable cause of hemospermia. Further randomized studies are mandatory for establishment of our postulation.