Ahmed Hammady

Solo Ultrasonography-Guided Percutanous Nephrolithotomy for Single Stone Pelvis

PURPOSE To evaluate the success and outcomes of solo ultrasonography (US)-guided percutaneous nephrolithotomy (PCNL) for management of a single stone pelvis. PATIENTS AND METHODS From April 2008 to April 2010, the procedure was applied to 34 patients (22 men and 12 women) whose ages ranged from 25 to 55 years (mean 29.5 y) with unilateral single stone pelvis in a moderately to markedly dilated pelvicaliceal system (PCS). The stone size ranged from 20 to 30 mm (mean 24 mm). Middle caliceal puncture and dilation were performed in all cases by an experienced urologist under US guidance with a needle-guided system attached to the side wall of the US probe. The evaluation of the procedure included the success of accessing the stones, the occurrence of intraoperative or postoperative complications, the stone-free rate, and the need for auxiliary maneuver. RESULTS The access was successful in all cases. Minor intraoperative complications occurred in two cases where PCS perforation was detected and was managed conservatively by Double-J stent insertion for 4 weeks. The only reported postoperative complication was fever in five cases that responded to antibiotic treatment. Thirty-two (94%) patients were stone free on postoperative day 2; significant residual stones (8 and 10 mm) were detected in two patients who underwent shockwave lithotripsy, and they became stone free within 10 days. CONCLUSION Solo US-guided PCNL can be performed safely as an alternative to the fluoroscopy-guided PCNL for single stone pelvis in a moderately to markedly dilated PCS by an experienced urologist.

Evaluation of Ureteral Stent Placement After Retroperitoneal Laparoscopic Ureterolithotomy for Upper Ureteral Stone: Randomized Controlled Study

PURPOSE To determine the necessity of ureteral stent placement after retroperitoneal laparoscopic ureterolithotomy (RLU) for upper ureteral stones more than 1 cm. PATIENTS AND METHODS Between May 2006 and May 2009, 104 RLUs were performed as primary management of large upper ureteral stones. The patients were randomly divided into two groups: In group 1 (52 patients), RLU was performed without stent placement afterward, and in group 2 (52 patients), the stent was placed after RLU. The mean stone size was 16.8 cm in group 1 and 18.2 cm in group 2. The stent in group 2 was placed cystoscopically. RESULTS All procedures were performed successfully. The mean operative time was 48 minutes in group 1 vs. 65 minutes in group 2. The mean drainage time was 4.1 days in group 1 vs. 2.3 days in group 2. All the patients were followed up for a period of 6 months with no recorded cases of residual stone or ureteral stricture. CONCLUSION RLU for large upper ureteral stones could be considered as a primary line for treatment as regards the economic status in developing countries. Laparoscopic ureterolithotomy (LU) without stent placement for upper ureteral stones is safe, cost effective, has less operative time, and needs no auxiliary procedures when compared with the use of stent placement after LU, which adds costs and discomfort for the patient.

Modified N-shaped ileal neobladder after radical cystectomy

OBJECTIVE We report on the feasibility and outcomes of the N-shaped pouch with an afferent tubular isoperistaltic segment as a new technique for creating a capacious, low pressure bladder substitute following radical cystectomy. METHODS Between April 2000 and April 2006, 42 patients (36 male, 6 female) with invasive bladder cancer were considered good candidates for orthotopic urinary diversion. All had radical cystectomy with bilateral pelvic lymphadenectomy and orthotopic bladder substitution by an ileal low pressure reservoir (N-shaped) with an afferent isoperistaltic tubular segment. Of the 42 patients, 36 (86%) had squamous cell carcinoma; 6 had transitional cell carcinoma. None of the patients had positive lymph nodes after pathologic examination of the specimen. The patients were available for a median follow-up period of 24.8 months. Follow-up included clinical and radiographic studies to determine functional and oncological outcomes. RESULTS Eleven patients (26.2%) had early complications during the period ≤ 3 months following surgery. Seven of these patients had complications such as wound infection, prolonged ileus, persistent urinary leakage, and deep venous thrombosis that were treated conservatively. One female patient developed a pouch-vaginal fistula that required repair. The remaining 3 patients had oncologic failures, 1 of which was isolated urethral recurrence. Late complications occurred in 15 patients (35.7%). These included pouch stones, outflow obstruction, mucus retention, and adhesive bowel obstruction. Daytime and night-time continence was achieved in 92% and 80% of the patients, respectively, and ureteroileal stricture was observed in 5%. The upper tracts remained unchanged or improved in nearly 95% of the patients. CONCLUSIONS Ileal orthotopic bladder substitution (N-shaped) with an afferent ileal tubular segment offers good functional results with good preservation of the renal units. It is considered a safe and technically feasible surgical procedure.

Supine pediatric percutaneous nephrolithotomy (PCNL).

INTRODUCTION/BACKGROUND Many authors reported their experience with supine PCNL in adult population comparing the outcome with prone PCNL and they found that the stone free rate and the operative time were in favor of prone PCNL with a lower patient morbidity among patients with supine PCNL. This encouraged us to perform supine PCNL in pediatric population. AN OBJECTIVE In this study we evaluated the safety and efficacy of supine PCNL in pediatric population. STUDY DESIGN (SUBJECTS/PATIENTS/MATERIALS/METHODS) Between April 2011 and February 2014 a total of 27 children (6 girls and 21 boys) presented with renal calculi. The stones were single pelvic stone in 14 cases, pelvic stone with lower calyceal stones in 7 cases and pelvic stone with upper calyceal stones in 6 cases. The mean stone size was 32 mm (range 20-47 mm). All patients were managed with supine PCNL performed by a single surgeon. Marking the posterior axillary line in standing position before the operation is a mandatory initial step. The patients were placed in supine position with elevation of the ipsilateral shoulder and hip by means of two bags one underneath the shoulder and the other underneath the hip to widen the operative field. The technique was performed using a sheathless 19 fr. Richard wolf rigid nephroscope after acute tract dilation by amplatz dilators. Complications (intraoperative and postoperative) and stone free rate rates were reported. RESULTS A single lower calyceal access was used in all cases through which we could successfully remove even the upper calyceal stones. Kinking of the guide wire during tract dilatation were encountered in 4 cases and the guide wire was successfully exchanged using a small Teflon dilator in 2 cases while ultrasonographic guided lower calyceal repuncture was done in 2 cases. The average operative time (from the beginning of the puncture trial to nephrostomy tube insertion) was (41 ± 15) min. The operation was successfully completed as planned in all cases with two cases of intraoperative complications (one case of pelvicalyceal system perforation and another case of intraoperative bleeding and blood transfusion). The initial stone free rate was (92.5%). Postoperative complications was reported in the form of 2 cases of fever that respond to medical treatment for 72 h. DISCUSSION The main advantages of supine pediatric PCNL is that it is comfortable for the surgeon, the anesthetist and the child. The main disadvantages of supine pediatric PCNL is that it is not familiar for most urologists and small field of operation. The short outcome of our study is the small number of cases and the lack of comparative study with prone pediatric PCNL. CONCLUSIONS Pediatric supine PCNL is a safe and effective method for management of pediatric renal stones. It carries the advantages of easily upper calyx access through the lower calyceal tract, low incidence of fluid absorption or hypothermia and easy anesthesia monitoring. However a larger number of cases are needed to be evaluated.

Upper urinary tract retroperitoneoscopic surgery under epidural anesthesia: Shifting towards outpatient treatment

Abstract Objective. Laparoscopy for urological surgery is usually carried out under general anesthesia. However, laparoscopy under epidural anesthesia has been reported to be successful for laparoscopic cholecystectomy, hernia repair, gynecological procedures, renal biopsy and renal cyst unroofing. Materials and methods. From August 2011 to July 2013, 46 patients (26 male, 20 female) with a mean age of 35 years underwent retroperitoneoscopic surgery (15 nephrectomy, 21 ureterolithotomy, 10 renal cyst excision) under epidural anesthesia, performed by the same surgeon. Inclusion criteria were patients with benign upper urinary tract pathology, no history of flank operation, American Society of Anesthesiologists score I–II and body mass index less than 25. Pulse oximetry, electrocardiography, non-invasive arterial blood pressure and respiratory rate were monitored intraoperatively. The partial pressure of carbon dioxide in arterial blood and pain assessment via a visual analogue scale were assessed every 30 min. The serum cortisol level was measured to evaluate the surgical stress under epidural anesthesia. Results. All operations were completed laparoscopically with no conversion to open surgery. Hypotension was observed in six patients (13%) and 16 (34.7%) experienced shoulder pain. The mean operative time was 90 min. No postoperative analgesia was given. All patients could ambulate 4 h after the operation and were discharged on the same day; the mean hospital stay was 6.5 h. Conclusions. Retroperitoneoscopy for benign upper tract pathology combined with epidural anesthesia is a feasible and an attractive method for both surgeon and patient. No postoperative pain and early recovery are the most beneficial results of this technique. Further studies, applying this technique in patients with cardiopulmonary problems, should be conducted.

Reduced expression of erythropoietin-producing hepatocyte B6 receptor tyrosine kinase in prostate cancer

Loss of erythropoietin-producing hepatocyte (Eph) B6 gene expression is associated with poor prognosis in neuroblastoma, melanoma and other tumors. The present study evaluated the expression of EphB6 receptor tyrosine kinase in normal and prostate cancer tissue using immunohistochemistry. The association between EphB6 expression, clinicopathological findings, proliferating-cell nuclear antigen (PCNA; another prognostic marker) and progression of prostate cancer was analyzed. Tissue microarray samples of normal prostatic tissue and prostate cancer tissue from 46 patients treated with radical prostatectomy for prostate cancer were included in this study. Polyclonal anti-EphB6 and monoclonal anti-PCNA antibodies were used to assess EphB6 and PCNA expression by immunohistochemistry. EphB6 was expressed in normal and prostate cancer tissue; however, its expression was significantly reduced in prostate cancer tissue compared with normal prostatic tissue (P<0.0001), in high volume (≥4 cm3) cancer compared with low volume (<4 cm3; P=0.015), and in pT3 stage compared with pT2 stage of the disease (P=0.0007). No correlation was observed between the expression of EphB6 and PCNA. Short biochemical progression-free survival was associated with low EphB6 protein expression (P=0.157). This study revealed that EphB6 may have a tumor suppressor effect in prostate cancer, at least during early stages of this disease. This provides new insight into the potential utility of EphB6 receptor as a diagnostic/prognostic marker for prostate cancer.

Laparoscopic repyeloplasty after failed open repair of ureteropelvic junction obstruction: a case-matched multi-institutional study

Abstract Objective: The aim of this study was to retrospectively review the experience and midterm results of laparoscopic pyeloplasty (LP) in patients with previous failed open pyeloplasty in comparison to primary LP. Materials and methods: Thirty-two patients who had undergone previous failed open surgery for management of ureteropelvic junction obstruction (UPJO) were reviewed. The patients underwent transperitoneal dismembered LP. All operations were performed by the same laparoscopist from March 2009 to June 2013. Surgical results were compared to 72 patients who underwent primary LP carried out by the same surgeon during the same period. Results: The laparoscopic repyeloplasty group consisted of 14 men and 18 women. The mean age was 29 ± 6 years. The mean operative period was 133 ± 42 and 110 ± 57 min; the mean length of stay in hospital was 2.7 ± 2.3 and 1.3 ± 2.1 days; and the mean follow-up period was 32.4 ± 14 and 29.3 ± 11.2 months in the secondary and primary LP groups, respectively. The success rate was 90.6% for secondary LP and 94.4% for primary LP. There was no conversion in either group. The percentage of intraoperative and postoperative complications in secondary LP was 9.4% and 12.5%, respectively, compared with 0% and 5.6% in the primary LP group. Conclusions: Laparoscopic repyeloplasty is a safe and viable treatment option for secondary UPJO, with a success rate similar to that of primary repair but with longer operative time. Considerable experience in laparoscopic reconstructive procedures is a prerequisite for optimal results.

Surgical outcomes and complications of Tube® (Promedon) malleable penile prostheses in diabetic versus non-diabetic patients with erectile dysfunction.

Abstract Objective To evaluate surgical outcome, complications, and patients satisfaction with the Tube® (Promedon, Cordoba, Argentina) malleable penile prosthesis in diabetic and non-diabetic patients with refractory erectile dysfunction (ED). Patients and methods The records of 128 eligible patients who received Tube malleable penile prostheses at our institute between September 2008 and October 2015 were reviewed. Results Of the 128 patients, who received Tube penile prostheses at our institute, 53 were diabetics and 75 were non-diabetics. Both groups of patients were comparable for mean age, education level, marital status, hospital stay, time to commencing sexual intercourse, and median follow-up. Complications included: inter-corporeal septal perforation (2.3%), glanular urethral injury (1.5%), acute urinary retention (3.9%), superficial wound infection (7%), penile discomfort (9.4%), and penile prostheses infection (5.5%). Moreover, 3.9% developed atrophy of the cavernosal tissue, 5.5% experienced bad cosmesis, 6.3% experienced ejaculatory disorders, and 2.3% developed bladder calculi. In all, 13 prostheses (9.4%) were removed, seven of them due to infection, three on the patients’ demand and three due to mechanical failure. The satisfaction rates with the prostheses were 77.3% and 79.4% in the diabetic and non-diabetic patients, respectively; with an overall satisfaction rate of 78.5%. There was no significant difference in the complication rate or prostheses infection between diabetic and non-diabetic patients. Conclusion Tube malleable penile prostheses are associated with low complication and high satisfaction rates. There was no significant difference in the complication rate or prostheses infection between diabetic and non-diabetic patients. A prospective comparative study with a large number of patients is recommended.

Adjustable vs. ordinary transobturator tape for female stress incontinence. Is there a difference

Abstract Objectives: To determine whether there are any significant differences in complications and success rate between adjustable transobturator tape (TOA) and ordinary transobturator tape (TOT) in the treatment of female stress urinary incontinence (fSUI), as the TOA was recently introduced for the treatment of female SUI, its advantage being the ability to adjust the tape after surgery to address over- or under-correction. Patients and methods: In all, 96 women with SUI (mean age 53 years, SD 10) were included in the study. Patients were randomised into two equal groups (group 1, TOA, vs. group 2, TOT). The operative duration, blood loss, intra- and post-operative complications, and the success rate, were compared between the groups. Results: There was no statistically significant difference between the groups in cure rates (83% vs. 80%, groups 1 and 2, respectively) or in postoperative stay. The mean operative duration in group 2 was significantly shorter than in group 1. No intraoperative bleeding requiring a blood transfusion was recorded, and there were no bladder injuries. Postoperative adjustment of the tape was only required in three patients in group 1. Conclusions: The TOA is a safe and accurate method for treating fSUI, but with experienced surgeons there was no difference in the cure rate and postoperative outcome between TOA and TOT.