Ahmed Fahmy

Tamsulosin for the management of distal ureteral stones in children: A prospective randomized study

PURPOSE Based on efficacy demonstrated in the adult population, tamsulosin was evaluated with regard to facilitating ureteral stone expulsion in children presenting with distal ureteric calculi. PATIENTS AND METHODS A prospective randomized controlled study involving 61 children with distal ureteric calculi <12 mm was performed. The children were randomly divided into two groups. Group I (study group, n = 33) received tamsulosin and standard analgesia, and Group II (placebo group, n = 28) received standard analgesia and placebo. Patients were offered a closely monitored trial for spontaneous stone passage in the 4-week period prior to definitive therapy. The stone expulsion rate, number and duration of pain episodes, need for analgesia and possible side effects of medications were observed. RESULTS All patients completed the study and none were excluded due to side effects. No significant differences were found between the groups for age, gender and stone size. Mean patient age was 8.1 ± 6.8 years. There were 25 females and 36 males. The stone-free rate was 87.8% in Group I (29/33), compared with 64.2% (18/28) in Group II. A mean stone expulsion time of 8.2 and 14.5 days was recorded for Group I and II respectively, and this difference was statistically significant (P < 0.001). CONCLUSIONS Medical expulsion therapy for lower ureteric stones is a successful procedure in children. Tamsulosin demonstrated no clinically significant adverse effect, while proving to be a safe and effective treatment option.

Optimizing prophylactic antibiotic regimen in patients admitted for transrectal ultrasound-guided prostate biopsies: A prospective randomized study

Background Transrectal ultrasound-guided prostate biopsies (TRUSBx), in spite of being one of the most frequently performed urological office procedures, are associated with a spectrum of complications, most significantly including infection. The aim of the study is to evaluate the prevalence of fluoroquinolone-resistant bacteria in rectal swabs from our local population prior to TRUSBx and to identify risk factors among a patient population harboring fluoroquinolone-resistant organisms. Methods We prospectively included 541 men who were submitted for TRUSBx in our center from March 2011 to June 2015. The indications for TRUSBx were an elevated prostate-specific antigen level and/or abnormal digital rectal exam. All patients were randomly divided into two groups: Group 1 (n = 279 cases) who received standard empirical prophylactic antibiotics and Group 2 who received targeted prophylaxis based on a rectal swab culture and susceptibility result. Differences in risk factors between quinolone-resistant and nonresistant patients were compared. Univariate and multivariate analyses were performed to identify independent potential risk factors associated with fluoroquinolone-resistant rectal flora. Results Sixteen out of 271 men developed infectious complications after TRUSBx in the group receiving standard empirical prophylaxis (5.7%). No men in the group who received targeted prophylactic antibiotic guided by rectal swab developed infectious complications. Among the 262 patients who underwent prebiopsy rectal swab cultures, 76 men (29%) displayed fluoroquinolone-resistant rectal flora (29%). In the multivariate analysis, a history of antibiotic exposure before prostate biopsy was the only independent factor associated with an increased risk of fluoroquinolone resistance. Conclusion Determining the prevalence of fluoroquinolone resistance in rectal flora has important implications in the selection of targeted prophylactic antibiotic regimens. Antimicrobial profiles guided by rectal swabs may prove useful to optimize prophylaxis prior to TRUSBx; this strategy is effective at reducing the rates of infectious complications, including sepsis, especially in men at higher risk of infectious complications.

Complexing ability of some γ-lactone derivatives. Thermal, magnetic and spectral studies on cobalt(II), nickel(II) and copper(II) complexes and their base adducts

Abstract The complexes of some γ-lactone derivatives with cobalt(II), nickel(II) and copper(II) have been synthesized and formulated as [ML 2 ]· n H 2 O, M = Co 2+ , Ni 2+ or Cu 2+ , n = 2 or 3 and L = anion of the corresponding ligand. Their structures have been suggested on the basis of analysis, spectral (UV-Vis, IR) and magnetic susceptibility data. The thermal analysis revealed the non-coordinated water among these complexes. The infrared spectra show the existence of water molecules involved in a hydrogen-bonding with the coordinated ligands and the γ-lactones are mono-basic bidentate coordinated to the metal ion via the benzoyl carbonyl and the deprotonated hydroxylic oxygen atoms. The bulkiness and the electronic properties of the lactones on the structure of the complexes are rationalized from the electronic spectral data. The interaction of the complexes with different Lewis basis is studied spectrophotometrically. The ligand field parameters are calculated and related to the bulkiness effect of the ligand molecules. These parameters indicate the axial ligation of the base molecules and that the equatorial plane is occupied by the MO 4 , M = Co 2+ , Ni 2+ or Cu 2+ , chromophore. The interelectronic repulsion parameter indicates the ionic nature of these complexes. The extent of distortion from the idealized structure is also discussed.

Factors that predict the spontaneous passage of ureteric stones in children

Abstract Objective:To study the natural history of stone passage in children with ureterolithiasis and to define factors predictive of spontaneous passage. Patients and methods: In all, 72 children with ureteric stones were evaluated; patients with ureteric calculi of >10 mm were excluded, as were those with absolute indications for surgical stone removal. Stone size, location, side, presence of hydronephrosis, perinephric stranding and degree of the tissue-rim sign were estimated by unenhanced helical computed tomography (UHCT). All patients were sent home with no administration of an α-blocker. The stone status was evaluated by a plain abdominal film or CT at ≈6 weeks after the initial diagnostic evaluation. The time from the initial complaint to the passage of the stone was recorded for each patient. Results: In all, 54 (75%) children with ureteric stones of ⩽6 mm eventually passed their stones spontaneously. However, stones of <4 mm and those in the distal ureter had a significantly higher spontaneous passage rate and shorter time to stone passage (P < 0.05). The UHCT findings of a higher degree of the tissue-rim sign, hydronephrosis and perinephric fat stranding were associated with a lower likelihood of stone passage. Conclusions: The rate of spontaneous passage of ureteric stones in children varies with stone location, and perinephric stranding on UHCT seems to be useful for predicting the possibility of spontaneous passage. In cases with unfavourable signs an early intervention might have better outcomes than conservative therapy.

Single- vs. multi-stage repair of proximal hypospadias: The dilemma continues.

Abstract Introduction: The surgical reconstruction of distal penile hypospadias in a single stage is the standard practice for managing anterior hypospadias. Unfortunately, it is not simple to extrapolate the same principle to proximal hypospadias. There is no consensus among hypospadiologists about whether a single- or multi-stage operation is the optimal treatment for proximal hypospadias. In this review, we assess the currently reported outcomes and complications of both techniques in proximal hypospadias repair. Methods: We searched Medline, Pubmed, Scopus and Ovid for publications in the last 10 years (2002–2012) for relevant articles, using the terms ‘proximal hypospadias’, ‘posterior hypospadias’ ‘single stage’, ‘multiple stage’, and ‘complications’. Articles retrieved were analysed according to the technique of repair, follow-up, complications, success rate, number of included children, and re-operative rate. Results and conclusions: The reported complications in both techniques were similar, including mostly minor complications in the form of fistula, meatal stenosis, partial glans dehiscence, and urethral diverticulum, with their easy surgical repair. The outcomes of single- and multistage repairs of proximal hypospadias are comparable; no technique can be considered better than any other. Thus, it is more judicious for a hypospadiologist to master a few of these procedures to achieve the best results, regardless of the technique used.

Ureteroscopy in infants and preschool age children: technique and preliminary results.

Introduction We present our experience with the use of semirigid ureteroscopy for the treatment of ureteric stones in children less than or equal to 6 years of age. Material and methods The records of 21 children (12 female, 9 male) with an average age of 4.7 years (range 8 months to 6 years) treated with semirigid ureteroscopy between June 2006 and July 2010 were reviewed. In 13 ureteral units 7Fr semirigid ureteroscopy was carried out in a retrograde manner to treat stone disease, while an adult ureteroscope (9.5 fr) was used in the remaining patients. Stones were located in the upper ureter in 2 cases, middle ureter in 2 cases, and lower ureter in 17 cases. Ureteral dilation was not required in all patients. Results Stone size varied from 4 to 13 mm (mean 6 mm). The management of stones in 18 (90.7%) children was straightforward and a single ureteroscopy was required to clear the ureters. In 2 (6.2%) children, repeat ureteroscopy was undertaken to render the ureters stone free, and in 1 child (3.1%) it was not possible to remove the stone. Stones were fragmented with pneumatic lithotripsy in 12 cases and stones were removed mechanically without fragmentation in the remaining 9 cases. Intraoperative complications occurred in 2 (9.3%) children and included extravasation (1 patient), which was managed with ureteral stenting and stone upward migration (1 patient). Early postoperative complications included pyelonephritis (1 patient). Mean follow-up was 6.4 (3-36) months. Incidence of stricture at the site of stone impaction was not detected in any patients. None of the patients managed without a post-operative stent required subsequent intervention. Conclusions In the hands of an experienced surgeon, ureteroscopy in young children can be a safe and efficient treatment for ureteral stones that can be performed without ureteral dilation. Routine ureteral stenting is not a requirement when the procedure is relatively atraumatic. Further studies and longer follow-up are necessary to determine the success of this technique.

MP90-18 SILODOSIN FOR MEDICAL EXPULSIVE THERAPY IN CHILDREN WITH DISTAL URETERAL STONE: A PROSPECTIVE RANDOMIZED, PLACEBO-CONTROLLED, SINGLE BLIND STUDY STUDY

management of stone patients, substantial differences exist in the recommendations. We sought to characterize the care of stone patients within a cohort of primary care providers to better understand practice patterns and determine factors influencing urologic referral. METHODS: We surveyed primary care providers attending a regional internal medicine conference in March 2016. Participants were questioned regarding their practice with stone patients in respect to acute symptoms, routine surveillance and metabolic evaluation / prevention. Responses were compared using appropriate statistical measures. RESULTS: Of 147 (43%) respondents, the mean age was 52 years (range 27-86). 79% of the cohort were physicians. 87% of providers noted routine treatment of stone patients while 68% expressed comfort with their care delivery. For acute colic, imaging was obtained by 87%. 41% routinely used alpha blockers for medical expulsive therapy which was most associated with physicians and older providers (p<0.007). For recurrent stones, surveillance imaging was ordered in 21%. When available, stone analysis was performed by 39% and most associated with older providers (p<0.002). 24 hour urine studies were ordered by only 12%. Thiazides, alkali citrate and allopurinol were routinely prescribed for preventive measures at equal frequencies by 38% of respondents and more commonly by those with increased comfort treating stone patients (p1⁄40.003). Of providers using preventive medications, therapy was empiric in 79%. However, use of thiazides and allopurinol was associated with those ordering urine studies (p<0.004). Routine urologic referral was cited by 52% for acute symptoms, 31% for routine surveillance and 22% for metabolic prevention. Patient factors most associated with prompting referral included stone size (84%), pain symptoms (74%) and urinary symptoms (68%). CONCLUSIONS: Kidney stone disease is a common complaint in the primary care setting. In our cohort, there was variable use of routine measures including imaging, stone analyses, urine studies and preventive medications. This highlights the importance of improved collaboration for developing uniform stone guidelines. Future studies are needed to confirm differences in patient care based on specialty and may assist in establishing baseline shared treatment pathways and detailed indications for urologic referral.

Can percutaneous nephrolithotomy be performed as an outpatient procedure

Abstract Objectives: To examine the safety and effectiveness of percutaneous nephrolithotomy (PCNL) as an outpatient procedure, as in most centres PCNL is performed as an inpatient procedure that necessitates postoperative hospital admission. Patients and methods: Our study included 186 patients undergoing PCNL for renal calculi. Only those who met strict inclusion criteria were discharged home on the same day. Preoperative eligibility criteria for outpatient management included no complex medical problem, normal renal function, and easy access to an emergency room. Patients were divided into two groups. The outpatient group (Group 1) included those patients discharged on the same day as the PCNL and the hospitalised group (Group 2) included those who were considered appropriate for outpatient management but needed to be hospitalised. Results: In all, 162 patients (87%) fulfilled the inclusion criteria for outpatient management and 146 of these patients (90.1%) planned for outpatient management were discharged on the same operative day (Group 1). The mean time to discharge home was 8.97 h. In all, 16 patients who opted for the outpatient approach subsequently required hospitalisation (Group 2). In the hospitalised group the mean operative time was longer, which was probably related to its higher stone burden. Conclusion: PCNL can be safely performed with excellent outcomes as an outpatient procedure. Outpatient PCNL offers several advantages including a more rapid patient convalescence, reduced healthcare expenditure, decreased postoperative nosocomial infections with no additional morbidity for the patient, and with no compromising of the stone-free rate.

Pattern of prostate cancer presentation among the Egyptian population: A study in a single tertiary care center.

Introduction Prostate cancer is a common health problem that in the majority of cases starts to develop at the age of 50 years, reaching its peak at 60–70 years of age. A variation in its incidence and prevalence exists between western, Asian and Arabic populations. The aim of our work was to report the pattern of prostate cancer presentation in Alexandria University that as a tertiary referral center provides care for uro–oncology cases. Material and methods Data collection for all patients diagnosed with prostate cancer at Alexandria University in Egypt through the year 2012 was done. Results The mean age of the patients was 67. Mean serum total PSA, prostate volume and PSAd were 149 ng/ml, 63 grams and 3.1 ng/ml/gm respectively. 25% of patients were asymptomatic diagnosed accidentally during screening for prostate cancer. The remaining group was presenting with LUTS, including 23 patients who presented initially with back pain. Conclusions Egyptian men with prostate cancer have a markedly high PSA density and Gleason grade at diagnosis.

MP68-07 1-BILATERAL SIMULTANEOUS RETROGRADE INTRARENAL SURGERY IN CHILDREN: IS IT SAFE AND FEASIBLE?

was based on the location and the stone burden of cases (considering encrusted stents and associated stones) and of course renal function. BetweenJune2010and June2015, all patients referredwith retainedand encrusted ureteral stents to our hospital were submitted to a combined endourological approach with a Galdakao-modified Valdivia positioning supine removal of the stents without need of bolster below the patient. RESULTS: Fifty patients were evaluated. Two groups were created additionaly to the grading system proposed by Acosta-Miranda et al: calcified and broken stent (stage VI 9 cases) and isolated ureteral calcification (stage VII 5 cases). Percutaneous nephrolithotripsy was common for stages III to VI and rare or not performed in stage I, II and VII, as these encrustations were usually minor and not located in the kidney and therefore did not hinder stent extraction (p1⁄40.004). Ureterolithotripsy was commonly used for ureteral stent encrustation, especially in groups with lower stone burden (stages I and II) and stage VII (ureteral only). Length of operation was higher for groups with severe stone burden (stages III and IV 158.1 64.8 min) when compared to moderate stone burden (stage III 110.0 64min) and low stone burden (stages I, II, VI and VII 78.6 29.8 min) p value 0,0012. Number of procedures, length of stay, blood transfusion, complications and stone analysis were similar between groups. Stone-free was worse in stages III to V, as expected, due to higher stone burden, even though not statistically significant. All stents were successfully removed in all cases (100%) by our combined endourological approach, which was the primary objective of our study. CONCLUSIONS: Galdakao-modified Valdivia positioning supine removal of retained and encrusted stents is a safe and feasible technique, with all catheters removed in a single procedure. A modified classification of the encrusted stones might help urologists to advise their patients on expected surgical outcomes.