Ahmed Al-Sayyad

Laparoscopic transperitoneal ureterolithotomy for large ureteric stones

Objectives: To evaluate the efficacy and safety of laparoscopic transperitoneal ureterolithotomy for management of large proximal ureteric stones. Materials and Methods: Medical records of patients who underwent laparoscopic transperitoneal ureterolithotomy for proximal ureteral stones ≥2 cm were reviewed retrospectively. Patients’ characteristics, stone characteristics, perioperative and follow-up data were studied. Patients with stones <2 cm in size, previous transperitoneal surgical procedure, or follow-up duration <6 months were excluded from the study. Results: Twelve patients (mean age = 52.9 ± 12 years) with large upper ureteric stones (mean stone largest diameter = 39 ± 13 mm) were included. Nine patients had single stone, 2 patients had two stones, and 1 patient had large impacted stone with 2 small stones floating above. Mean operative time was 107 ± 49.5 min with mean blood loss of 60.5 ± 19.2 cc. Mean total pain score was 38.4 ± 5.5 (100 point scale) and mean time till resuming oral intake was 3.6 ± 0.5 h. Mean duration of hospital stay was 2.6 ± 1.4 days and mean duration of stenting was 7.3 ± 2 weeks. Throughout a mean duration of follow-up of 14.8 ± 7.6 months, 100% stone clearance rate was achieved with no recurrence. One patient developed a ureteric stricture treated by laser endoureterotomy and stenting for 6 weeks and responded without re-stricture formation. Conclusion: Laparoscopic transperitoneal ureterolithotomy is a safe and effective approach for selected patients with large proximal ureteric stones with reduced postoperative pain and short hospital stay, and should be considered as a treatment option for such stones.

Bilateral complete duplication of the ureters, with calculi simultaneously obstructing the four ureters.

Bilateral complete duplication of the ureters is a rare condition. We report a case of an adult male patient with bilateral complete duplication of the ureters, with a single stone simultaneously obstructing each of the four ureteral limbs. Multiple bilateral renal stones were awlso demonstrated in the imaging studies. The ureteral stones ranged from 7 to 23 mm in length and 5–11 mm in width. Ureteroscopy and holmium laser lithotripsy for the ureteral stones were done sequentially in the four ureteral limbs, in a single session. Four double-J stents were inserted after removal of all ureteric stones, one in each ureter. The patient passed uneventful postoperative course. The patient has received extracorporeal shock wave lithotripsy sessions for the bilateral renal stones. The double-J stents were removed under local anesthesia after clearance of all stones. To the best of our knowledge, there are no data in the literature representing an identical case.

The Effect of Body Mass Index on Stone-Free Rate and Operative Complication Rate of Percutaneous Nephrolithotomy

Objective: To study the effect of body mass index (BMI) on percutaneous nephrolithotomy (PCNL) stone-free rate and operative complication rate. Materials and Methods: Retrospective cohort study included patients who underwent PCNL from January 2005 till December 2007. All were stratified according to world health organization BMI classification (normal, overweight, obese, morbidly obese) into the effect of BMI on PCNL stone-free rate and operative complications including bleeding, transfusion, septicemia, intensive care unit admission and urinary leak. Results: Totally 70 patients were included in our study with mean age of 42 years, male to female ratio 5:1, and 68.2% of them had no comorbid factors while 11.6% with diabetic, 9.3% with hypertensive, and 4.7% having both and 15.5% having the history of previous pyelolithotomy. Most of the patients (94.3%) had performed intravenous pyelogram preoperatively, in which 7% showed anomalous kidney (horseshoe, malrotated), 44% staghorn and 42% pelvic stones > 2 cm in size. The indications for PCNL in our study group were staghorn stone in 41.4%, failed extracorporeal shock wave lithotripsy in 14.3%, large stones > 2 cm in 44.3%. The operative success rate was 87.1%. When we stratified our patients according to the world health organization BMI, 28.6% were normal BMI, 37.1% overweight and 34.3% obese. Multiple regression analysis revealed that increasing BMI do influence the operative risk of bleeding, transfusion, leak, intensive care unit admission, sepsis with significant p = 0.026 (CI 8.7–0.59) and inversely influence the stone-free rate with p = 0.017 (CI 0.012–0.64). Conclusion: Obese patients have higher operative complication risk and low stone-free rate on PCNL.

Sonic Hedgehog Expression is Associated with Lymph Node Invasion in Urothelial Bladder Cancer

Bladder cancer (BC) is a deadly disease characterized by high recurrence rates and frequent progression to an aggressive phenotype. Dysregulation of various signaling pathways have been implicated in BC tumorigenesis, however, the clinical relevance of sonic hedgehog pathway (Shh) remains under investigated. The aim of the current study was to analyze the prognostic value of Shh expression in patients with bladder carcinoma. Immunohistochemical expression of Shh was performed using tissue microarray with 128 specimens from bladder cancer patients. Kaplan-meier survival was analysed and correlation between Shh protein expression and patients’ clinicopathological parameters wasexamined using Fisher’s exact test. The immuno-staining results revealed that Shh protein exhibits cytoplasmic localization and is expressed in 49% of the analyzed bladder cancer cohort. Our data indicated that high Shh expression significantly correlated with increased lymph node metastasis (p = 0.02), however no association was reported between Shh expression and other clinicopatholigical parameters. High expression of sonic hedgehog was associated with lymph node invasion which may indicate that Shh might play an important role in progression and metastasis of bladder cancer.

Novel augmentation ileocystoplasty technique to manage non- compliant bladders in the presence of obstructed megaureters: The "fez procedure"

To show the efficacy and safety of a novel modification of Studers neobladder, herein defined as the “fez procedure.”

Laparoscopic Pyelolithotomy for Partial Staghorn Stones

Objective: To confirm the feasibility and safety of laparoscopic pyelolithotomy in partial staghorn stones. Patients and Methods: Seventeen patients who underwent laparoscopic pyelolithotomy for partial staghorn stone were included in the prospective study at King Abdulaziz University Hospital in the period between May 2007 and Feb 2009. Preoperatively all patients had blood work, urine culture, ultrasonography and CT renal stone study. Inclusion criteria included stones with largest diameter of more than 25 mm (measured by CT), branching into one or more group of calices, and no contraindication for laparoscopic surgery. All patients underwent cystoscopy, double J stent insertion prior to the procedure, while prophylactic antibiotics were provided for all the patients with or without positive urine culture. Results: All patients were completed laparoscopically where none required conversion to open surgery or developed intraoperative complications. The largest diameter of the stones varied between 29 and 48 mm with mean diameter of 41 mm, and the number of stones removed was 1–4 with mean of 1.3. The mean operative time was 175 minutes (range 125–240 minutes) and the estimated blood loss was 20–150 ml with mean of 49 ml. All patients cleared from their stones except 2 patients had small residual stones of 5 and 7 mm which were managed later by extracorporeal shock wave lithotripsy. One patient developed ileus postoperatively. Conclusion: Laparoscopic removal of partial staghorn stones is safe and feasible and has an equal outcome to open surgery.