Ahmed A. Shokeir

GreenLight HPS 120-W Laser Vaporization Versus Transurethral Resection of the Prostate for Treatment of Benign Prostatic Hyperplasia: A Randomized Clinical Trial with Midterm Follow-up

BACKGROUND Photoselective vaporization (PVP) with the GreenLight HPS 120-W laser (GLL) was recently introduced for treatment of benign prostatic hyperplasia (BPH). OBJECTIVE To compare results of GLL PVP and transurethral resection of the prostate (TURP) for treatment of BPH. DESIGN, SETTING, AND PARTICIPANTS A total of 120 patients with BPH were randomly assigned to two equal groups: TURP or PVP. MEASUREMENTS Both groups were compared regarding all relevant preoperative, operative, and postoperative parameters. Functional results in terms of improvement of International Prostate Symptom Score (IPSS), maximum flow rate (Q(max)), and postvoid residual (PVR) urine were assessed at 1, 3, 6, 12, 24, and 36 mo. A total of 55 and 54 patients completed 36 mo of follow-up in the TURP and PVP groups, respectively. RESULTS AND LIMITATIONS Baseline characteristics were comparable. Mean operative time was significantly shorter for TURP. Compared to preoperative values, there was significant reduction in hemoglobin and serum sodium levels at the end of TURP only. A significant difference in favor of PVP was achieved regarding the duration of catheterization and hospital stay. In the PVP, no major intraoperative complications were recorded and none of the patients required blood transfusion. Among TURP patients, 12 (20%) required transfusion, 3 (5%) developed TUR syndrome, and capsule perforation was observed in 10 patients. There was dramatic improvement in Q(max), IPSS, and PVP compared with preoperative values and the degree of improvement was comparable in both groups at all time points of follow-up. Storage bladder symptoms were significantly higher in PVP. By the end of 36 mo, five patients in TURP and six in PVP were lost to follow-up. A redo procedure was required in one TURP patient and six PVP patients (p<0.05). Two TURP patients and four PVP patients developed bladder neck contracture (p>0.05) treated by bladder neck incision; none in either group experienced urethral stricture or urinary incontinence. CONCLUSIONS Compared with TURP, 120-W GLL PVP is safe and effective in treatment of BPH.

Emphysematous pyelonephritis : A 15-year experience with 20 cases

OBJECTIVES To review our experience with emphysematous pyelonephritis over the past 15 years. METHODS Twenty patients with emphysematous pyelonephritis were reviewed regarding diagnosis, treatment, and outcome. RESULTS Women outnumbered men (75% versus 25%), and 80% of patients were diabetic. The left kidney was more frequently affected than the right one (60% versus 35%) and both kidneys were involved in 5%. Obstruction of the corresponding renoureteral unit was found in all the nondiabetic and in half of the diabetic patients. Diagnosis was confirmed by gas in the parenchyma or perinephric space by plain x-ray of the abdomen or computed tomography. Escherichia coli was the most common organism; it was found in 70% of urine cultures. A prompt attempt to control diabetes was made, and intravenous antibiotics were given. Nephrectomy was immediately performed after stabilization of the general condition of the patients. A total of 80% of patients survived the procedures. CONCLUSIONS For successful management of emphysematous pyelonephritis, appropriate medical treatment should be attempted but immediate nephrectomy should not be delayed.

Squamous cell carcinoma of the bladder: pathology, diagnosis and treatment.

Squamous cell carcinoma (SCC) can occur in both nonbilharzial and bilharzial bladders; the two subtypes differ in epidemiology, pathogenesis and clinicopathological features. The nonbilharzial type occurs in Western countries and represents < 5% of all vesical tumours; it occurs most often in the seventh decade with a slight male predominance. The principal predisposing factor is prolonged indwelling urethral catheterization in patients with spinal cord injury and the main symptom is haematuria. Patients are usually diagnosed at an advanced stage and most of the tumours are of moderate and high grades. At cystoscopy tumours are predominantly ulcerative and commonly involve the trigone and lateral walls. Although distant metastasis is infrequent (8–10%) the prognosis is grave and most patients die after failure of locoregional control; radical cystectomy provides the best therapy. To avoid nonbilharzial SCC, patients with spinal cord injury should be free of catheterization if possible. The outcome can be improved by early detection with frequent cytology, cystoscopy and biopsy. Bilharzial SCC occurs commonly in the Middle East, South‐east Asia and South America where schistosomiasis is endemic. In an Egyptian series SCC represented 59% of 1026 cystectomy specimens. The tumour is diagnosed in the fifth decade, and five times more common in men than women. Bladder carcinogenesis is probably related to bacterial and viral infections, commonly associated with bilharzial infestation rather than the parasite itself. The presentation is often with irritative bladder symptoms and haematuria, and many patients present at an advanced stage, although most tumours are of low and moderate grades. At cystoscopy tumours are predominantly nodular and usually arise from the upper vesical hemisphere. Lymph‐node metastasis occurs in ≈ 19% and significantly decreases survival; radical cystectomy remains the main treatment, giving a 5‐year survival rate of 50%. Early detection improves the therapeutic yield and prevention is possible by combining snail control and mass therapy of the infested rural population by oral antibilharzial drugs.

Renal colic in pregnant women: role of renal resistive index

OBJECTIVES To investigate the value of the renal resistive index (RI) in the identification of acute renal obstruction in pregnant women. METHODS The study included 22 pregnant women with acute unilateral ureteral obstruction due to a stone disease (group A), 71 normotensive pregnant patients without loin pain (group B), and 20 nonpregnant women of child-bearing age with both kidneys normal (group C). All patients underwent Doppler ultrasound (DUS) with determination of the RI and the difference between the RI of the corresponding and contralateral kidney (DeltaRI). The RI and DeltaRI was considered positive for obstruction with a value of 0.70 or greater and 0.04 or greater, respectively. Ureteral obstruction was confirmed by several clinical, radiologic, and endoscopic findings. The sensitivity, specificity, and overall accuracy of RI and DeltaRI for the diagnosis of acute unilateral ureteral obstruction were calculated. RESULTS In group A, kidneys with ureteral obstruction (n = 22) had a mean RI of 0.69 +/- 0.03; the contralateral normal kidneys (n = 22) had a mean RI of 0.63 +/- 0.03, a significant difference (P <0.0001). The mean RI of all kidneys in group B (n = 142) and all kidneys in group C (n = 40) was 0.64 +/- 0.05 and 0.62 +/- 0.04, respectively; the difference was not statistically significant. A comparison between the mean RI of the normal kidneys of group A and all the kidneys of groups B and C revealed no significant difference. The mean RI of the obstructed kidneys in group A was significantly higher than the mean RI of all the kidneys in groups B and C. Similarly, the mean DeltaRI of group A was significantly higher than the mean DeltaRI of groups B and C (0.06 +/- 0.01 versus 0.006 +/- 0.003 versus 0.006 +/- 0.004, respectively). The RI was sensitive in 45%, specific in 91%, and accurate in 87%. The corresponding values for DeltaRI were 95%, 100%, and 99%. CONCLUSIONS The DeltaRI is a sensitive and specific test that can replace intravenous urography in the diagnosis of acute unilateral ureteral obstruction in pregnant women.

Varicocelectomy for Male Infertility: A Comparative Study of Open, Laparoscopic and Microsurgical Approaches

PURPOSE We compared the outcomes of 3 techniques of varicocelectomy in infertile patients with varicocele. MATERIALS AND METHODS The study included 298 infertile patients (446 varicoceles) who were randomized to varicocelectomy by an open inguinal technique in 92, laparoscopy in 94 and subinguinal microsurgery in 112. The 3 techniques were compared regarding intraoperative, and early and late postoperative parameters, changes in semen parameters and the pregnancy rate. Patients were followed a +/- mean +/- SD of 21 +/- 9 months (range 4 to 35). RESULTS Operative time was significantly longer in the microscopic group. Early postoperative complications were comparable in the 3 groups. At followup none of the patients in the microsurgical group had hydrocele, while it was observed in 4 of 143 (2.8%) in the open group and in 8 of 148 (5.4%) in the laparoscopy group, representing a significance difference in favor of microsurgery. The incidence of recurrent varicocele was significantly lower in the microsurgical group than in the open and laparoscopy groups (4 of 155 patients or 2.6% vs 16 of 143 or 11% and 25 of 148 or 17%, respectively). Compared to preoperative values in the 3 groups postoperative semen parameters showed significant improvement in sperm concentration, motility and morphology. The incidence of patients with improved sperm count and motility was significantly higher in the microsurgical group. The pregnancy rate at 1 year was not significantly different among the 3 groups. CONCLUSIONS Compared with open and laparoscopic varicocele treatment microsurgical varicocelectomy has the advantages of no hydrocele formation, a lower incidence of recurrent varicocele, and better improvement in sperm count and motility.

Does the Extent of Lymphadenectomy in Radical Cystectomy for Bladder Cancer Influence Disease-Free Survival? A Prospective Single-Center Study

BACKGROUND Controversy exists regarding the optimal extent of lymphadenectomy and the number of lymph nodes to be retrieved at radical cystectomy (RC). OBJECTIVE To compare the disease-free survival of patients with standard lymphadenectomy (endopelvic region composed of the internal, external iliac, and obturator groups of lymph nodes) versus extended lymphadenectomy (up to the level of origin of the inferior mesenteric artery) at RC in a prospective cohort of patients at a single, high-volume center. DESIGN, SETTING, AND PARTICIPANTS Prospective data were collected from 400 consecutive patients treated with RC for bladder cancer by two high-volume surgeons at Mansoura Urology and Nephrology Center. Of the 400 patients, 200 (50%) received extended lymphadenectomy and the other 200 (50%) underwent standard lymphadenectomy at RC. The patients did not receive any neoadjuvant or adjuvant therapy. MEASUREMENTS Patient characteristics and outcomes are evaluated. RESULTS AND LIMITATIONS Median patient age for the entire group was 53.0 yr. Ninety-six patients (24.0%) had lymph node metastases. Median follow-up was 50.2 mo. Estimates of 5-yr disease-free survival in the extended lymphadenectomy group were 66.6% compared with 54.7% for patients with standard lymphadenectomy (p = 0.043). Extended lymphadenectomy was associated with better disease-free survival after adjusting for the effects of standard pathologic features (p = 0.02). When restricting the analyses to lymph node-positive patients, patients with extended lymphadenectomy had much better 5-yr disease-free survival compared with patients with standard lymphadenectomy (48.0% vs 28.2%; p = 0.029). The study was nonrandomized. CONCLUSIONS Extended lymphadenectomy is associated with better disease-free survival for bladder cancer patients with endopelvic lymph node involvement and should be considered in these patients.

Late malignancy in bowel segments exposed to urine without fecal stream

OBJECTIVES This study was constructed so as to screen malignant transformation after uroenteric reconstructions using bowel segments exposed to urine without fecal stream for more than 10 years. METHODS Follow-up data were available for 186 patients who underwent various uroenteric reconstructions using bowel segments exposed to urine without fecal stream for more than 10 years. There were 68 eligible patients with isolated rectosigmoid bladder, 23 with bladder augmentations (15 ileocystoplasty and 8 colocystoplasty), 57 with ileal ureter, and 38 with ileal loop conduit. Besides routine laboratory and radiologic investigations, urine for cytology was obtained from all patients. Moreover, endoscopy and random biopsy of the part of bowel exposed to urine were carried out in all patients. RESULTS Uroenteric malignancy was diagnosed in 4 patients (2%): 2 adenocarcinoma in an isolated rectosigmoid bladder, 1 transitional cell carcinoma following augmentation colocystoplasty, and 1 squamous cell carcinoma after ileal ureter. None of the patients developed tumors in ileal loop conduits. CONCLUSIONS Malignant changes do not only occur after ureterosigmoidostomy but are also observed after different uroenteric reconstructions not exposed to fecal stream. Hematuria, ureteral obstruction, and abnormal urine cytology are warning signs of malignancy. Routine cytology is recommended at least yearly beginning 10 years after surgery.

Renal Colic: Pathophysiology, Diagnosis and Treatment

Acute renal colic is one of the most anguishing forms of pain in humans that needs quick diagnosis and treatment. The magnitude of the problem is large worldwide; the lifetime risk of developing an acute attack of renal colic is estimated at 1–10% [1]. It is caused by acute partial or complete ureteric obstruction due to a calculus in the vast majority of cases. In approximately 5% of the patients, renal colic may be caused by abnormalities of the urinary tract unrelated to a stone disease such as pyelonephritis and pelviureteric junction (PUJ) obstruction [2]. A proportion of up to 10% of patients with renal colic may have extrinsic ureteral obstruction by a variety of other conditions including intestinal, gynecological, retroperitoneal and vascular lesions [2]. The aim of the present review is to provide new insights into renal colic caused by a stone disease with special emphasis on the most recent advances in this field. The review is divided into sections discussing pathophysiology, diagnosis and treatment.

Treatment of varicocele : A comparative study of conventional open surgery, percutaneous retrograde sclerotherapy, and laparoscopy

OBJECTIVES To present our experience with the results of three different methods of treatment of idiopathic varicoceles. METHODS A total of 301 patients with 417 varicoceles were retrospectively assigned into three groups according to the method of treatment. Group 1 included 94 patients with 131 varicoceles treated by open surgery. Group 2 consisted of 120 patients with 163 varicoceles treated by percutaneous retrograde sclerotherapy, and in group 3, 87 patients with 123 varicoceles were treated by laparoscopic varicocelectomy. Of all patients, 222 (73.8%) were closely followed up with clinical and Doppler ultrasound examinations 6 and 12 months after the treatment. Seminal analysis was carried out before treatment and repeated in 172 patients with subfertility or infertility 4 to 6 months after treatment. RESULTS Patients in the three treatment groups were balanced regarding the different variables. The mean operative time was significantly shorter among patients with open surgery. The cost of sclerotherapy is one fourth to one fifth that of surgery and the cost of laparoscopy is double. Sclerotherapy was successful in 96 (82.8%) of 116 left varicoceles and in only 24 (51%) of 47 right varicoceles. The recurrence rate at follow-up was not significantly different among the three groups. The recurrence rate increased progressively with the increase of varicocele size from grade I to grade III in all groups. The overall incidence of postoperative complications was significantly higher among patients with open surgery. Postoperative spermiogram showed a significant increase in the density and motility and a significant reduction in the percentage of abnormal forms in all groups. The pregnancy rate was approximately similar in all groups. CONCLUSIONS First, sclerotherapy is best used for isolated left-sided varicoceles. Second, laparoscopy is the treatment of choice for bilateral varicoceles. Finally, open surgery still has a role in isolated right-sided varicoceles and in left-sided cases with failed sclerotherapy.

Efficacy of tamsulosin in the management of lower ureteral stones: a randomized double-blind placebo-controlled study of 100 patients.

OBJECTIVE To study the impact of tamsulosin on the rate of spontaneous passage of distal ureteral stones. METHODS A total of 100 patients with stones sized 10 mm or smaller, located in the distal part of the ureter were included. Patients were randomly assigned to 2 equal groups. Group 1 received 0.4 mg tamsulosin once daily and group 2 received placebo. The investigators and the patients were masked to the type of treatment. Patients were followed-up until passage of the stone, or for a maximum of 4 weeks. The number of pain episodes, need for analgesia, stone expulsion rate and time, and possible side effects of medications were observed in both groups. RESULTS Apart from 4 patients in the placebo group who were lost to follow-up, all patients complied with the prescribed medications and continued the study. Stone expulsion occurred in 41 of 50 patients (82%) in group 1 and in 28 of 46 patients (61%) in group 2 (P = .02). The chance of stone expulsion was 3 times higher in the tamsulosin group (relative risk [RR] = 2.93; 95% CI, 1.152-7.45). In group 1, patients with stones sized < or = 5 mm showed a significantly higher expulsion rate compared to those with larger stones (> 5 mm). Age, gender, and stone laterality had no significant impact on the expulsion rate. The expulsion time was significantly shorter in the tamsulosin group (6.4 +/- 2.77 days vs 9.87 +/- 5.4 days for groups 1 and 2, respectively). Moreover, the frequency of pain episodes, the need for diclofenac, and its total dosage were significantly lower in the tamsulosin group. Side effects observed in both groups were comparable and mild, and no patient withdrew because of them. CONCLUSIONS Tamsulosin is a safe and effective drug that enhances spontaneous passage of distal ureteral stones sized 10 mm or smaller.