Ahmed El-Assmy

Bladder tumour staging: comparison of diffusion- and T2-weighted MR imaging

The aim of this work was to evaluate the clinical feasibility of diffusion-weighted (DW) MRI in detection and staging of urinary bladder tumour and to compare DW MRI with the T2-weighted technique. One hundred and six patients with bladder tumour were prospectively included in our study. All patients were evaluated with MR imaging. We started with axial T2-weighted high resolution MR of the urinary bladder, then DW MRI. Two radiologists independently interpreted the MR images, and discrepancies were resolved by consensus. The accuracy of DW MRI in staging of bladder tumour was evaluated using the final histopathological findings. In DW imaging (DWI) staging accuracy was 63.6% and 69.6% in differentiating superficial from invasive tumours and organ-confined from non-organ-confined tumours, respectively. On a stage by a stage basis, DWI accuracy was 63.6% (21/33), 75.7% (25/33), 93.7% (30/32) and 87.5% (7/8) for stages T1, T2, T3 and T4, respectively. In the T2-weighted technique, the overall staging accuracy was only 39.6% and accuracy for differentiating superficial from invasive tumours and organ-confined from non-organ-confined tumours was 6.1% and 15.1%, respectively. DW is superior to T2-weighted MRI in staging of organ-confined tumours (≤T2) and both techniques are comparable in the evaluation of higher-stage tumours.

Bladder Cancer : Diagnosis with Diffusion-weighted MR Imaging in Patients with Gross Hematuria

PURPOSE To prospectively evaluate the usefulness of diffusion-weighted (DW) magnetic resonance (MR) imaging for the detection of bladder neoplasms in patients with gross hematuria of lower urinary tract origin. MATERIALS AND METHODS The study protocol received institutional ethical committee approval, and informed consent was obtained. Between April 2007 and March 2008, 130 consecutive patients with gross hematuria whose upper urinary tract had a normal appearance at ultrasonographic examination were prospectively enrolled. Mean age was 59.4 years (range, 45-75 years). All patients were evaluated by using T2-weighted high-spatial-resolution MR imaging of the urinary bladder, followed by DW MR imaging. Two radiologists independently interpreted the T2-weighted and DW images, and discrepancies were resolved by consensus. Agreement was evaluated by using the kappa statistic. All patients underwent conventional cystoscopy. With cystoscopy and the final histopathologic findings as the reference standards, a comparison with imaging findings was performed by using the McNemar test. RESULTS The consensus diagnostic performance of DW MR imaging for identification of bladder tumors was: sensitivity, 98.1% (104 of 106); specificity, 92.3% (24 of 26); PPV, 100% (104 of 104); negative predictive value, 92.3% (24 of 26); and accuracy, 97.0% (128 of 132). Two cases were falsely negative on T2-weighted MR images but were correctly diagnosed by using DW MR images. The agreement between DW MR imaging results and cystoscopic findings was excellent (kappa = 0.94) for identification of bladder neoplasm. DW MR imaging had a sensitivity and PPV of 98.5% (128 of 130) and 100% (128 of 128), respectively, for determining the cause of hematuria. CONCLUSION DW MR imaging is a highly reliable imaging approach for identification of bladder tumors in patients with gross hematuria.

Semirigid Ureteroscopy for Ureteral Stones: A Multivariate Analysis of Unfavorable Results

PURPOSE We determined the factors predicting unfavorable results of semirigid ureteroscopy for ureteral calculi. MATERIALS AND METHODS We reviewed the computerized files of 841 patients who underwent a total of 908 ureteroscopic procedures for ureteral stones from January 2003 through December 2006. A semirigid 6/7.5Fr ureteroscope was used in pediatric patients and an 8/10Fr or 8.5/11.5Fr ureteroscope was used in adults. Patients with favorable results were those who became stone-free after a single ureteroscopic procedure without any complications. They were compared with patients who had unfavorable results using univariate (chi-square and t tests) and multivariate (logistic regression) statistical tests to identify risk factors for unfavorable results. RESULTS The study included 567 males and 274 females with a mean age of 48.5 years (range 2 to 81). The complication rate was 6.7% (61 procedures). The stone-free rate after a single ureteroscopic intervention was 87% (791 procedures). Favorable results were documented in 751 procedures (82.7%). Significant factors for unfavorable results were proximal ureteral stones, ureteroscopy done by surgeons other than experienced endourologists, stone impaction and stone width (relative risk 4, 2.5, 1.8 and 1.2, respectively). CONCLUSIONS Semirigid ureteroscopy is a safe and highly effective treatment modality for ureteral stones.

Recoverability of Erectile Function in Post–Radical Cystectomy Patients: Subjective and Objective Evaluations

BACKGROUND Literature regarding both subjective and objective evaluations of erectile function following radical cystectomy is deficient. OBJECTIVE To study the recoverability of erectile function in post-radical cystectomy patients on subjective and objective bases. DESIGN, SETTING, AND PARTICIPANTS Between March 2003 and March 2005, 45 male patients with organ-confined invasive bladder cancer were prospectively enrolled in this study. INTERVENTION Radical cystectomy and urinary diversion were offered to all patients (21 patients underwent a nerve-sparing [NS] surgical technique, and 24 patients underwent a non-nerve-sparing [NNS] surgical technique). MEASUREMENTS Patients were evaluated preoperatively using the International Index of Erectile Function (IIEF) questionnaire and using penile Doppler ultrasound (PDU). Patients were followed up regularly at 2 mo, 6 mo, and 12 mo using the same parameters. RESULTS AND LIMITATIONS Among patients in the NS group, 17 patients (78.8%) were potent postoperatively: 12 patients (57.8%) with spontaneous complete tumescence and 5 patients (21%) with partial tumescence using phosphodiesterase type 5 inhibitor (PDE5-I) as erectogenic aid; 4 patients needed intracorporeal prostaglandin E1 injections. In contrast, no patients in the NNS group showed spontaneous erection, and they did not improve with sildenafil; all of them needed prostaglandins as an erectogenic aid. The comparison between preoperative and postoperative IIEF domains showed that postoperatively the erectile function and overall satisfaction domains deteriorated initially, but in the NS group they gradually improved with time (p<0.0001). Corresponding PDU findings were comparable in peak systolic velocity during the course of follow-up in both groups. Although the end diastolic velocity was significantly more deteriorated postoperatively than preoperatively in both groups, gradual improvement in patients in the NS group was more evident 12 mo after surgery. CONCLUSION The return of erectile function was better in the NS group on subjective and objective bases. The most significant change was in veno-occlusive function, which improved rapidly and progressively in the NS group during 1 yr of follow-up.

Diffusion-Weighted MR Imaging in Diagnosis of Superficial and Invasive Urinary Bladder Carcinoma: A Preliminary Prospective Study

We conducted a prospective study to demonstrate the feasibility of using diffusionweighted (DW) magnetic resonance imaging (MRI) for the detection of urinary bladder carcinomas. Between January to June 2007, 43 patients with single bladder tumor were included in our study. Before taking a biopsy, DW MRI was obtained in the axial plane under free breathing scanning with a multisection, spin-echo type, single-shot echo planar sequence with a body coil. Moreover, the apparent diffusion coefficient (ADC) value was measured in a circular region of interest within the carcinoma, urine, normal bladder wall, prostate, and seminal vesicle. All carcinomas in the 43 patients were clearly shown as high signal intensity relative to the surrounding structure. The sensitivity and positive predictive values of DW MRI were 100% in terms of correctly detecting the carcinomas. The ADC value in the carcinoma (1.40 ± 0.51) was significantly lower compared with that of urine (3.50 ± 0.43) (p < 0.001), normal bladder wall (2.29 ± 0.78) (p < 0.001), peripheral zone of prostate (1.77 ± 0.44) (p < 0.05), transition zone of prostate (1.88 ± 0.54) (p < 0.05), and the seminal vesicle (2.12 ± 0.43) (p < 0.001). There was no statistical difference in ADC values between different histological subtypes. There was no overlap between the ADC values of the tumors and the urine, but there was no clear cutoff between the tumor and bladder wall, prostate, or seminal vesicles. Bladder carcinomas have significantly lower ADC when compared to surroundings. Clinical experience with this method is still preliminary and further studies are required.

Penile fracture: long-term outcome of immediate surgical intervention.

OBJECTIVES To assess the etiology and the late effects of penile fractures treated by immediate surgical intervention. METHODS Between 1986 and 2008, a total of 155 patients with penile fracture were treated surgically in our center. The interval from injury to presentation was between 1 and 96 hours. Those patients were contacted by mail or phone and were re-evaluated. All patients were re-evaluated by questionnaire and local examination. Patients with erectile dysfunction were evaluated by color Doppler ultrasonography. RESULTS The most common cause of fracture of penis is sexual intercourse (51.5%). Unilateral and bilateral corporeal ruptures were present in 139 (89.7%) and 3 (1.9%) cases, respectively, whereas no tunical tear was found in 13 (8.4%) cases. Concomitant urethral injury was present in 14 (9%) cases. Long-term follow-up (>12 months) was available for 141 patients; among whom there was no complications in 108 (77%), painful erection in 2 (1.3%), penile deviation in 5 (3.2%), both in 1 (0.7%), erectile dysfunction in 11 (7.8%), and palpable scarring in 14 (10%). Scar formation was highly associated using nonabsorbable sutures (P <.001). CONCLUSIONS Vigorous sexual intercourse was found to be the most common cause of penile fracture. Immediate surgical intervention has low morbidity, short hospital stay, rapid functional recovery, and no serious long-term sequelae. Nonabsorbable sutures should be avoided as it has a higher incidence of scar formation.

Factors Affecting Stone-free Rate and Complications of Percutaneous Nephrolithotomy for Treatment of Staghorn Stone

OBJECTIVE To determine factors affecting the stone-free rate and complications of percutaneous nephrolithotomy (PNL) for treatment of staghorn stones. METHODS The computerized database of patients who underwent PNL for treatment of staghorn stones between January 2003 and January 2011 was reviewed. All perioperative complications were recorded and classified according to modified Clavien classification system. The stone-free rate was evaluated with low-dose noncontrast computed tomography (CT). Univariate and multivariate statistical analyses were performed to determine factors affecting stone-free and complication rates. RESULTS The study included 241 patients (125 male and 116 female) with a mean age of 48.7 ±14.3 years. All patients underwent 251 PNL (10 patients had bilateral stones). The stone-free rate of PNL monotherapy was 56% (142 procedures). At 3 months, the stone-free rate increased to 73% (183 kidneys) after shock wave lithotripsy. Independent risk factors for residual stones were complete staghorn stone and presence of secondary calyceal stones (relative risks were 2.2 and 3.1, respectively). The complication rate was 27% (68 PNL). Independent risk factors for development of complications were performance of the procedure by urologists other than experienced endourologist and positive preoperative urine culture (relative risks were 2.2 and 2.1, respectively). CONCLUSION Factors affecting the incidence of residual stones after PNL are complete staghorn stones and the presence of secondary calyceal stones. Complications are significantly high if PNL is not performed by an experienced endourologist or if preoperative urine culture is positive.

Critical evaluation of the factors influencing erectile function after renal transplantation

A total of 400 male renal transplant recipients (RTR) were investigated. Data on medical, sexual history, clinical examination and laboratory variables were collected. The severity of erectile dysfunction (ED) was assessed using the International Index of Erectile Function questionnaire. Univariate and multivariate logistic regression analyses were used to determine prognostic variables, which have independent impact on erectile function. ED was detected in 35.8% of the whole group. Current erectile function as compared to pretransplant status was improved, deteriorated or remained static in 44, 12.5 and 43.5% of the evaluated transplant recipients, respectively. After logistic regression analysis, age, hemoglobin level and presence of DM and/or peripheral neuropathy had significant and independent negative impact on erectile function. We concluded that renal transplantation has varying effects on erectile function. ED is highly prevalent among RTR and its pathogenesis is multifactorial.

Shock Wave Lithotripsy Versus Semirigid Ureteroscopy for Proximal Ureteral Calculi (<20 mm): A Comparative Matched-pair Study

OBJECTIVES To use a matched-pair analysis design to compare the safety and efficacy of shock wave lithotripsy (SWL) and ureteroscopy (URS). Controversy still exists regarding whether SWL or URS is the best management of upper ureteral calculi. METHODS We reviewed the records of patients with a single radiopaque upper ureteral stone treated by URS or SWL from January 2003 to December 2005. SWL was performed as an outpatient procedure using the electromagnetic lithotripter (Dornier Lithotripter S). URS was performed using an 8F or 8.5F semirigid ureteroscope. Intracorporeal lithotripsy with pneumatic or holmium laser energy was used when needed. A matched-pair analysis was performed using 3 parameters (sex, stone size, and degree of hydronephrosis). The success rates, retreatment rates, auxiliary procedures, and complications were compared in each group. RESULTS A total of 427 patients were treated for upper ureteral stones. Forty-three matched pairs were identified and compared. The success rate was 83.7% for SWL vs 88.4% for URS (P = .8). The retreatment rate was significantly greater in the SWL group than in the URS group (65% vs 2.3%, respectively; P < .001). The need for auxiliary procedures was equal in both groups (16.3%). The complication rate was 14% in the URS group and 4.7% in the SWL group (P = .1). CONCLUSIONS SWL and semirigid URS are highly effective in the treatment of proximal ureteral stones <20 mm. The results of our study showed that SWL was safer and less invasive, but that URS was more effective and resulted in a lower retreatment rate.

Long-Term Effects of Extracorporeal Shock Wave Lithotripsy on Renal Function: Our Experience With 156 Patients With Solitary Kidney

PURPOSE We studied the long-term impact of shock wave lithotripsy on renal function, stone recurrence and hypertension in patients with a solitary kidney. Patients with a solitary kidney provide a unique opportunity to evaluate any clinically significant change in renal function. MATERIALS AND METHODS We retrospectively reviewed the records of 156 patients with stones in a solitary kidney treated with shock wave lithotripsy monotherapy. Treatment outcome was evaluated after 3 months. Long-term followup (more than 12 months) was available for 108 patients. Serum creatinine, systolic and diastolic blood pressure, new onset hypertension, calculated glomerular filtration rate, and kidney morphology were determined before and after treatment, and compared by chi-square, paired and unpaired t tests. RESULTS After 3 months the overall stone-free rate was 80.8% (126 of 156). Renal obstruction caused by steinstrasse after shock wave lithotripsy occurred in 14 (8.9%) patients. Secondary procedures were required in 20 (12.8%) patients. Followup ranged from 1 to 16 years with a mean of 3.8 (SD +/- 3.5). After long-term followup the stone-free rate was 76.8% and real stone recurrence developed in 18.5% of patients. There was no significant difference in any evaluated pretreatment or posttreatment parameters. CONCLUSIONS The demonstrated effectiveness, small number of complications at short-term followup, insignificant effect on renal function, blood pressure and relatively small number of recurrences at the long-term followup confirm that shock wave lithotripsy is not only effective but is also safe in the long run.