Ahmed Harraz

Adipose derived stem cells ameliorate hyperlipidemia associated detrusor overactivity in a rat model.

PURPOSE Adipose tissue derived stem cells can differentiate into muscle and neuron-like cells in vitro. We investigate the usefulness of adipose tissue derived stem cells for overactive bladder in obese hyperlipidemic rats. MATERIALS AND METHODS Hyperlipidemia was induced in healthy rats by a high fat diet. The resulting obese hyperlipidemic rats were treated with bladder injection of saline, adipose tissue derived stem cells or tail vein injection of adipose tissue derived stem cells. Bladder function was assessed by 24-hour voiding behavior study and conscious cystometry. Bladder histology was assessed using immunostaining and trichrome staining, followed by image analysis. RESULTS Serum total cholesterol and low density lipoprotein were significantly higher in obese hyperlipidemic rats than in normal rats (p <0.01). The micturition interval was shorter in saline treated obese hyperlipidemic rats than in normal rats, obese hyperlipidemic rats that received adipose tissue derived stem cells via the tail vein and obese hyperlipidemic rats that received adipose tissue derived stem cells by bladder injection (mean +/- SEM 143 +/- 28.7 vs 407 +/- 77.9, 281 +/- 43.9 and 368 +/- 66.7 seconds, respectively, p = 0.0084). Bladder wall smooth muscle content was significantly lower in obese hyperlipidemic rats than in normal animals (p = 0.0061) while there was no significant difference between obese hyperlipidemic groups. Nerve content and blood vessel density were lower in controls than in obese hyperlipidemic rats treated with adipose tissue derived stem cells. CONCLUSIONS Hyperlipidemia is associated with increased urinary frequency, and decreased bladder blood vessel and nerve density in rats. Adipose tissue derived stem cell treatment ameliorates these adverse effects and holds promise as a potential new therapy for overactive bladder.

Evaluation and management of priapism: 2009 update.

Priapism is defined as a persistent penile erection (typically 4 h or longer) that is unrelated to sexual stimulation. Priapism can be classified as either ischemic or nonischemic. Ischemic priapism, the most common subtype, is typically accompanied by pain and is associated with a substantial risk of subsequent erectile dysfunction. Prompt medical attention is indicated in cases of ischemic priapism. The initial management of choice is corporal aspiration with injection of sympathomimetic agents. If medical management fails, a cavernosal shunt procedure is indicated. Stuttering (recurrent) ischemic priapism is a challenging and poorly understood condition; new management strategies currently under investigation may improve our ability to care for men with this condition. Nonischemic priapism occurs more rarely than ischemic priapism, and is most often the result of trauma. This subtype of priapism, which is generally not painful, is usually initially managed with conservative treatment.

Cavernous nerve repair with allogenic adipose matrix and autologous adipose-derived stem cells

OBJECTIVES To investigate whether adipose-derived matrix seeded with adipose-derived stem cells (ADSC) can facilitate the repair of injured cavernous nerves (CNs). METHODS Human and rat adipose tissues were decellularized and fabricated into various forms, including adipose tissue-derived acellular matrix thread (ADMT). ADMT seeded with ADSC were transplanted into subcutaneous space and examined for signs of inflammation. ADSC-seeded ADMTs were then used to repair CN injury in rats, followed by assessment of histology and erectile function. RESULTS Adipose tissue can be fabricated into acellular matrices of various shapes and sizes, including threads and sheets. Seeding of ADMT occurred rapidly: within 24 hours, 55% of the surface was covered with ADSC and within 1 week, 90% was covered. Transplantation of the seeded ADMT into the subcutaneous space of an allogenic host showed no signs of inflammatory reaction. At 3 months after grafting into CN injury rats, approximately twice as many cells were found on seeded ADMT as on unseeded ADMT. The seeded ADMT also had various degrees of S100 and neuronal nitric oxide synthase expression, suggesting CN axonal ingrowth. Rats grafted with seeded ADMT overall had the best erectile function recovery when compared with those grafted with unseeded ADMT and those ungrafted. However, as a result of large variations, the differences did not reach statistic significance (P = .07). CONCLUSIONS Grafting of ADSC-seeded matrix resulted in a substantial recovery of erectile function and improvement of histology. However, further refinement of the matrix architecture is needed to improve the success rate.

Can Renal Ultrasonography Predict Early Success after Pyeloplasty in Children? A Prospective Study

Objective: To study the predictive value of 6 ultrasonographic (USG) parameters for early detection of children at risk of recurrent obstruction. Patients and Methods: A prospective nonrandomized study included all patients who underwent pyeloplasty between 2010 and 2012. All of the patients had completed at least 6 months of follow-up and preoperative and postoperative USG imaging data were available. The primary outcome was the correlation between USG and diuretic scintigraphic parameters. The secondary outcome was the predictive ability of the pelvicalyceal system parameters, measured by USG, of parenchymal growth after surgery. Results: Sixty-eight patients were evaluated. The mean age was 3.6 years (range 0.1-12). The mean (± standard deviation) differential renal function improved from 37.4 ± 11 ml/min to 37.7 ± 14 ml/min, which was a difference of no statistical significance. On the other hand, the mean (± SD) half-time (T1/2) significantly improved. After constructing a linear regression model of the 4 USG parameters and the parenchymal growth, the model explained 57.2% of the variance in parenchymal growth after pyeloplasty. The calyx-to-parenchyma ratio change was the largest unique contribution for explaining the variance in parenchymal growth, followed by anteroposterior diameter and calyceal dilatation. Conclusion: We proved that calyx-to-parenchyma ratio, anteroposterior diameter and calyceal dilatation are independent predictors of early success after pyeloplasty.

1115 Low-intensity extracorporeal shock wave therapy for severe erectile dysfunction in poor responders to phosphodiesterase type-5 inhibitors: A short-term prospective study

MATERIAL & METHODS: An open label, prospective study was conducted and included 53 consecutive patients with severe vasculogenic ED who are PR-PDE5I (International index of erectile function–erectile function domain <10 and erection hardness score ≤2). All patients received 12 sessions of penile LI-SWT(2 sessions/week for 3 weeks, then 3 weeks free of treatment, then 2 sessions/week for another 3 weeks). The shock waves were delivered to the distal, mid and proximal penile shaft, and the left and right crura using a specialized focused shock wave probe(Dornier MedTech System, GmbH, Wessling, Germany). The 300 shocks at an energy density of 0.09 mJ/mm2 and a frequency of 120 shocks per minute were delivered at each of the 5 treatment points with frequency of 4 Hz. Each treatment session was 15 minutes and no local or systemic analgesia was needed. Patients were followed-up after the 1st month of treatment(FU1), 3 months(FU2) and 6 months (FU3) intervals. Effectiveness was assessed by International index of erectile function questionnaire (IIEF) and erection hardness score(EHS). Success was defined as patients who achieved erection hard enough for vaginal penetration (IIEF-EF domain ≥26 and EHS ≥3). During the active treatment and till FU1, all patients stopped any regular or on demand intake of PDE5I. After FU1 patients were classified into complete responders to LI-SWT and were followed up at 3 and 6 months, and poor responders(IIEF-EF domain <26 and EHS ≤2) who received 50 mg daily dose of sildenafil citrate for 2 months, and then reevaluated at 3 months for further subdivision into: responders (PDE5I converter) and non PDE5I converters who will be offered penile prosthesis.

Re: Repair of pan-urethral stricture: Proximal ventral and distal dorsal onlay technique of buccal mucosal graft urethroplasty. By Subbarao Chodisetti, Yogesh Boddepalli, Malakondareddy Kota

https://doi.org/10.1016/j.aju.2018.04.001 2090-598X 2018 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). The authors have described their technique for managing panurethral strictures by applying buccal mucosal graft (BMG) dorsally and ventrally in the distal and proximal portions of the stricture, respectively. The merit of this approach, from our perspective, is that it could handle extremely proximal strictures, as these strictures are deeply seated in the pelvis and the ventral approach is more technically feasible in this situation. Nevertheless, two main points should be considered. First, the authors have used two separate incisions to approach the entire anterior urethra, and this could have been avoided by using the penile invagination technique described by Kulkarni et al. [1], and hence, minimising patient morbidity. Second, the use of a single dorsal incision is technically feasible even in proximal urethral strictures and has proven effectiveness [2]. To summarise, although the described approach is potentially feasible, the single dorsal incision with penile invagination should be considered as well.

MP91-03 ROLE OF LOW-INTENSITY SHOCK WAVE THERAPY IN PENILE REHABILITATION POST NERVE SPARING RADICAL CYSTO-PROSTATECTOMY: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL

INTRODUCTION AND OBJECTIVES: To evaluate role of lowintensity shock wave therapy (LI-SWT) in penile rehabilitation (PR) post nerve sparing radical cysto-prostatectomy (NS-RCP). METHODS: Eighty seven sexually active men with muscle invasive bladder cancer were enrolled in this prospective study. After bilateral NS-RCP with orthotopic diversion (W-Pouch) by a single expert surgeon between January 2015 & October 2016, patients were randomized into 3 groups (29 patients/group). SWL Group received 12 sessions of penile LI-SWT (2/week for 3 weeks, then 3 weeks free of treatment, then 2/week for another 3 weeks). Phosphodiesterase type-5 inhibitors (PDE5i) Group received oral PDE5i of 50 mg /day for 6 months. Control Group was followed up only without any therapy. Patients were assessed before surgery and at 1 (FU1), 3 (FU2), 6 (FU3) and 9-month (FU4) post operatively. Effectiveness was assessed by IIEF-15 questionnaire and erection hardness score (EHS). RESULTS: Mean age was 54.1 5.9 years with mean followup period 15.9 4.2 months. There were no statistically significant differences regarding preoperative patients demographic data & tumor criteria. At FU1; All patients have insufficient erection for vaginal penetration. EHS < 2; with decrease of preoperative IIEF-EF mean score from 28 to 6.6. In SWL group; At FU2; 17/29 patients regained potency which is maintained in 15 only at FU3&4. However; 6 of remaining 12 patients regained & maintained potency at FU3&4. Statistical evaluation showed significant increase in IIEF-EF score from 6.6 at FU1 to 23 at FU2, 24 at FU3 and 24.5 at FU4 ( P <0.001). In PDE5i group; At FU2; 16/29 patients regained & maintained potency at FU3&4. However; 7 of remaining 13 patients regained & maintained potency at FU3&4. Statistical evaluation showed significant increase in IIEF-EF score from 6.6 at FU1 to 22.8 at FU2, 24 at FU3 and 24.7 at FU4 (P <0.001). In Control group; At FU2; 12/29 patients regained & maintained potency at FU3&4. However; 6 of remaining 17 patients regained & maintained potency at FU3&4. Statistical evaluation showed no significant difference in potency recovery rates at FU2 & FU3,4 among the groups ( P 1⁄4 0.14 & P 1⁄4 0.24 respectively). Potency recovery rates at FU2 were 58.6% vs 55.2% vs 41.4% in SWL, PDE5i and Control group, respectively. While potency recovery rates at FU3,4 were 72.4% vs 79.3% vs 62.1% in SWL, PDE5i and Control group, respectively. CONCLUSIONS: LI-SWT is safe and as effective as oral PDE5i in PR post NS-RCP. A large-scale study is required to determine the value of this treatment modality in ED post NS-RCP.

MP74-20 NECESSITY OF PRE-TRANSPLANT BLADDER CYCLING FOR PATIENTS WITH DEFUNCTIONALIZED BLADDER : A PROSPECTIVE RANDOMIZED TRIAL

INTRODUCTION AND OBJECTIVES: Renal transplantation in patients with lower urinary tract (LUT) dysfunction is a unique challenge, as they are at higher risk of urinary tract infection, sepsis, surgical complications, allograft dysfunction and graft loss. We opt to identify the impact of pre-transplant bladder cycling on the urological complications, graft function and lower urinary tract function. METHODS: The study included patients maintained on hemodialysis for more than 12 months with oliguria or anuria, reduced bladder capacity by ascending cystogram, poor compliance by cystometry, no history of lower urinary tract dysfunction and have no evidence of urological cause of renal failure. Patients were randomly allocated into two groups, group I received direct renal transplantation without bladder recycling. Group II received renal transplant after programmed bladder recycling throughbladder instillation of sterilewater in amount equal to the estimated bladder capacity to be gradually increased till patient can withstand filling the bladder with 200 cc for 2 hours. Standard renal transplantation was carried out with stented Leich Gregoir ureteroneocystostomy. Urological complications and graft functions were recorded at 3 months. Patients were assessed by IPSS, Cystogram as well as cystometry. To achieve a difference in mean cystometric capacity of 50 cc in favor of bladder training patients, 16 patients in each group are required to achieve a power of 80% and an a error of 0.05. RESULTS: A total of 22 patients were randomized so far including 11 patients in each group. All the cases underwent right iliac renal allotransplantation. Urinary leakage occurred in 2 cases (18%) in group I that was managed conservatively and subsided with prolongation of the internal stent and one case required percutaneous tube drainage. In group II urinary leakage occurred in one case (9%) that was managed by surgical exploration and redo ureterovesical reimplantation (p1⁄4 0.07 ). At 3 months, mean serum creatinine was 0.9 mg/dl and 1 mg/dl in both groups respectively (p1⁄4 0.4 ). Symptom score was 9 and 11 in both groups respectively (p 1⁄40.09 ). Mean cystometric capacity three months after transplant was 382 cc and 397 cc in both groups respectively (p1⁄4 0.1). CONCLUSIONS: Pretransplant programmed bladder recycling for patients with defunctionalized bladder provide no clinical advantage as regard postoperative urological complications, graft function, lower urinary tract symptoms and cystometric capacity.

MP38-18 URETHRAL RECURRENCE AFTER RADICAL CYSTECTOMY: REVISITING THE INCIDENCE AND PREDICTORS IN A LARGE CONTEMPORARY SERIES

INTRODUCTION AND OBJECTIVES: There is paucity of data about the incidence and predictors of urethral recurrence after radical cystectomy. We opt to identify risk factors of urethral recurrence stratified by gender in a large contemporary series. In addition, sub-analysis for male patients underwent orthotopic bladder substitution (OBS) was performed to determine the risk of urethral recurrence and potential urinary conversion. METHODS: The electronic records of 3208 patients underwent radical cystectomy between 1988 and 2010 were reviewed. Patients0 demographics and pathological results were retrieved and were evaluated for the potentiality of urethral recurrence stratified by gender. Univariate and multivariate time-to-event analyses were performed to identify potential predictors. RESULTS: A total of 686 patients were excluded because of perioperative mortality, missed follow up or incomplete records. Of the study cohort, 2050 males were available for analysis. Urethral recurrence occurred in 59 (2.9%) patients over a median (IQR) follow up of 24 (34) months. On multivariate analysis, prostatic stromal invasion (Hazards ratio [HR]: 6.4; 95%Confidence interval [CI]: 3.412; p<0.001), tumors at the trigone (HR: 2.1; 95%CI: 14.3; p1⁄40.02), and multicentricity (HR: 2.4; 95%CI: 1.3-4.3; p1⁄40.002) were independent predictors. A total 472 females were available for analysis of whom 8 (1.7%) developed urethral recurrence over a median (IQR) follow up of 40 (64) months. None of the patients0 demographics or histopathological criteria was significantly associated with urethral recurrence. Subanalysis of 1098 male patients underwent OBS revealed that only multicentricity was independent predictor for urethral recurrence (HR: 4.2; 95%: 1.6-10.9; p1⁄40.003). CONCLUSIONS: Urethral recurrence in males and females after radical cystectomy is relatively rare and occurs in 2.9% and 1.7%, respectively. In addition to prostatic stromal invasion, tumors at the trigone and multicentricity were independent predictors of urethral recurrence in males. Only multicentricity was independent predictor for males undergoing OBS. This information is crucial in preoperative counselling and planning of follow up.

Modulation of renal ischemia/reperfusion in rats by a combination of ischemic preconditioning and adipose-derived mesenchymal stem cells (ADMSCs)

The present study investigated the effects of combination of ischemic preconditioning (Ipre) and adipose-derived mesenchymal stem cells (ADMSCs) on renal ischemia-reperfusion (I-R) injury in rats. 90 male Sprague Dawley rats were divided into 5 equal groups; sham operated, control (45 min left renal ischemia), Ipre group as control group with 3 cycles of Ipre just before renal ischemia, ADMSCs-treated group (as control with ADMSCs 10(6) cells in 0.1 mL via penile vein 60 min before ischemia time), and Ipre + ADMSCs group as ADMCs group with 3 cycles of Ipre. Ipre and ADMSCs groups showed significant decrease in serum creatinine and blood urea nitrogen (BUN) and caspase-3 and CD45 expression in kidney and significant increase in HIF-1α, SDF-1α, CD31, and Ki67 expressions in kidney compared with the control group (p < 0.05). Moreover, the Ipre + ADMSCs group showed significant decrease in serum BUN and caspase-3 and CD45 expression in kidney with significant increase in HIF-1α, SDF-1α, CD31, and Ki67 expression in kidney compared with the Ipre and ADMCs groups (p < 0.05). We concluded that Ipre potentiates the renoprotective effect of ADMSCs against renal I/R injury probably by upregulation of HIF-1α, SDF-1α, CD31, and Ki67 and downregulation of caspase-3 and CD45.