Ahmad A. Elderwy

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.

Percutaneous nephrolithotomy in children: A preliminary report.

Objectives: The recurrence of pediatric nephrolithiasis, the morbidity of repeated open surgical treatment as well as our experience in percutaneous nephrolithotomy (PNL) in adult patients, all derived us to shift to PNL for managing renal stones >1.5 cm in pediatric patients. Our aim of this study is to evaluate the safety and efficacy of PNL in pediatric patients. Materials and Methods: During the period of the month between May 2011 and April 2013, 38 children (47 renal units) underwent PNL for renal stones 1.5-5 cm in length. Patient demographics, stone characteristics, and clinical outcome were prospectively studied. Data of those who underwent conventional and tubeless PNL were compared. Median follow-up period was 12 months (range: 6-24). Results: The median age at presentation was 8-year (range: 3-12). The operative time ranged from 30 to 120 min (median 90). Overall stone clearance rate was 91.5% after single PNL. The median hospital stay was 3 days. Auxiliary procedures were successful for the remaining 4 patients (nephroscopic clearance in one and shockwave lithotripsy in 3). Tubeless PNL was performed in 17 renal units with a comparable outcome to conventional ones. The perioperative complications were noted in 5/47 (10.6%) of all procedures (Clavien Grade II in 4 and Clavien Grade IIIa in 1) and were managed conservatively. Conclusions: Percutaneous nephrolithotomy for renal stones in pediatric patients is safe and feasible if performed by a well-experienced endourologist. Tubeless PNL is a better choice for children.

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.

Primary versus secondary ureteroscopy for pediatric ureteral stones

OBJECTIVE To evaluate the outcome of primary versus secondary ureteroscopy for pediatric ureteral stones. PATIENTS AND METHODS A retrospective chart review study that included 66 children aged less than 12 years, who were subdivided into two groups: Group A, which included 42 children who had undergone primary ureteroscopy without pre-stenting; and Group B, which included 24 children who had undergone ureteroscopy after ureteric stenting. Kidneys, ureters and bladder radiographs were done on the first postoperative day to assess the degree of stone clearance and stent position. RESULTS Age, gender, stone location and stone size were not significantly different between both groups. In Group A, 31 (73.8%) children required ureteric dilation, 13 (31%) had a tight ureter that failed to respond to dilation, 25 (59.5%) displayed complete stone clearance, and of these, 13 (52%) needed postoperative stenting. One child experienced ureteric injury during stone disintegration and was stented for two weeks. Children in Group B experienced a 95.8% complete stone clearance rate, with no ureteric injury reported; postoperative stenting was performed in three (12.5%) children.. CONCLUSION Secondary ureteroscopy is preferable over primary ureteroscopy in pediatric populations because of a significantly lower need for ureteric dilation, shorter procedure time and better stone clearance rate..

Long anterior urethral stricture: Reconstruction by dorsally quilted penile skin flap

Objectives: We’d like to present our experience in treating long (>5 cm) anterior urethral stricture by penile skin flap as dorsal on-lay in one-stage procedure. Patient and Methods: Between January 1998 and December 2010, 18 patients (aged from 28-65 years) presented with long urethral stricture, 5.6-13.2 cm, (penile in 6, bulbar in 2, and combined in 10 cases), those were repaired utilizing long penile skin flaps placed as dorsal on-lay flap in one-stage (Orandi flap 6 cm in 6 cases, circular flaps 7-10 cm in 8, and spiral flaps 10-15 cm in 4). Uroflowmetry and RUG were done following catheter removal and at 6 and 12 months. Results: The urethral patency was achieved in 77% of patients. The complications were fistula in 1 patient (5.5%), re-stricture occurred in 3 patients (16.6%) that required visual internal urethrotomy (VIU), and 2 patients (11%) showed curvature on erection that did not interfere with sexual intercourse. Diverticulum (penile urethra) was seen in 1 patient (5.5%) containing stones and was excised surgically. There was penile skin loss in 3 patients (16.6%). All patients completed at least one year follow-up period. Conclusion: Free penile skin flaps offer good results (functional and cosmetic) in long anterior urethral stricture. Meticulously fashioned longitudinal, circular or spiral penile skin flaps could bridge urethral defects up to 15 cm long.

Rare Radiolucent Hydroxyadenine Renal Stones in 4 Years Old Boy

Adenine phosphoribosyltransferase (APRT) deficiency is a rare under-recognized disorder of adenine metabolism. It has a familial tendency and is inherited as autosomal recessive. APRT deficiency eventually leads to increased production of 2,8-dihydroxyadenine (DHA) which has a low solubility at normal range of urine PH resulting in the formation of DHA crystals and recurrent kidney stones as the main presenting feature [1]. Deposition of Dihydroxyadenine crystals in the renal tubules can lead to permanent renal damage with significant morbidity.

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.