Ahmed M. Shoma

Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion

To develop a technique of nerve‐sparing robot‐assisted radical cystoprostatectomy (RRCP) for patients with bladder cancer.

Percutaneous nephrolithotomy in the supine position: technical aspects and functional outcome compared with the prone technique

OBJECTIVES To compare the results of percutaneous nephrolithotomy in the supine and prone positions. METHODS A total of 130 patients who underwent percutaneous nephrolithotomy for renal or upper ureteral stones were evaluated in a prospective and nonrandomized manner. The procedure was carried out in the supine or prone position in 53 and 77 patients, respectively. The results in both positions were compared regarding the technical aspects, success rate, and morbidity. RESULTS Regardless of the position, the pelvicaliceal system could be successfully approached in all patients, and the posterior calices were the most common site of entry. Punctures through the anterior calices were more frequently reported with the supine position. A higher incidence of anteromedial displacement of the kidney during tract dilation was reported with the supine approach. The overall success rate was 89% and 84% in the supine and prone positions, respectively. The complication rates were similar in both groups, and none of the patients experienced injury of adjacent organs. CONCLUSIONS The approach to the pelvicaliceal system is feasible in the supine position. The success and complication rates are comparable to the prone approach.

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.

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.

Pretransplant native nephrectomy in patients with end-stage renal failure: assessment of the role of laparoscopy

OBJECTIVES To evaluate the outcome and morbidity of laparoscopic nephrectomy in patients with end-stage renal disease. METHODS Between August 1991 and September 2001, 64 laparoscopic nephrectomies were carried out for the native kidneys of 62 patients with end-stage renal failure. The procedures were performed in preparation for renal transplantation. The indications were vesicoureteral reflux with persistent or recurrent urinary tract infection in 26 renal units, uncontrolled hypertension in 15, chronic pyelonephritis or hydronephrosis with urinary tract infection in 8, renal calculi in 13, heavy proteinuria in 1, and small renal tumor in 1. The left side was removed in 52 procedures and the right side was removed in 12. Forty-eight and 16 renal units were removed through the retroperitoneal and transperitoneal approach, respectively. RESULTS Sixty procedures were successfully performed (94%). Four patients required open exploration (6%). Four major complications were recorded: pneumothorax in 1, large hematoma in 1, colonic injury in 1, and bleeding in 1. No mortality related to the procedures or their complications occurred. The patients received allograft transplantation shortly after the procedure, with a mean of 26 days. Both transperitoneal and retroperitoneal approaches were effectively used with satisfactory outcome. CONCLUSIONS Laparoscopy should be considered as the procedure of choice for pretransplant nephrectomy. The high success rate, low morbidity, early recovery, and short duration between nephrectomy and transplantation all are considered as real advantages for this patient population.

GreenLight™ Laser (XPS) Photoselective Vapo-Enucleation versus Holmium Laser Enucleation of the Prostate for the Treatment of Symptomatic Benign Prostatic Hyperplasia: A Randomized Controlled Study

PURPOSE After the advent of the GreenLight XPS™ (180 W) 532 nm laser, photoselective vapo-enucleation of the prostate could compete with holmium laser enucleation of the prostate as a size independent procedure. We assessed whether photoselective vapo-enucleation of the prostate-XPS is not less effective than holmium laser enucleation of prostate for improvement of lower urinary tract symptoms secondary to benign prostatic hyperplasia. MATERIALS AND METHODS A randomized controlled noninferiority trial comparing holmium laser enucleation of the prostate to photoselective vapo-enucleation of the prostate-XPS 180 W was conducted. I-PSS, flow rate, residual urine, prostate specific antigen and prostate volume changes as well as perioperative and late adverse events were compared. Noninferiority of I-PSS at 1 year was evaluated using a 1-sided test at 5% level of significance. The statistical significance of other comparators was assessed at the (2-sided) 5% level. RESULTS Overall 50 and 53 patients were included in the holmium laser enucleation and photoselective vapo-enucleation of the prostate groups, respectively. Operative time, hospital stay and time to catheter removal were comparable between the groups. There was significant, comparable improvement in I-PSS and post-void residual urine volume at 1, 4 and 12 months. After 4 months prostate size reduction was significantly higher in the holmium laser enucleation of prostate group (74.3% vs 43.1%, p=0.001). At 12 months maximum urine flow rate was significantly higher in the holmium laser enucleation of prostate group (26.4 ±11.5 vs 18.4 ±7.5 ml per second, p=0.03). Re-intervention was needed in 2 and 3 cases in the holmium laser enucleation and photoselective vapo-enucleation of the prostate groups, respectively (p=1.0). Mean estimated cost per holmium laser enucleation of prostate procedure was significantly lower than per photoselective vapo-enucleation of the prostate procedure. CONCLUSIONS Compared to holmium laser enucleation of prostate, GreenLight XPS laser photoselective vapo-enucleation of the prostate is safe, noninferior and effective in treatment of benign prostatic hyperplasia.

Prospective, Randomized Comparison of Ureteroscopic Endopyelotomy Using Holmium:YAG Laser and Balloon Catheter

PURPOSE We compared the safety and efficacy of the 2 retrograde endopyelotomy techniques. MATERIALS AND METHODS A prospective study was done from January 2001 to October 2003. Preoperative radiological evaluation included excretory urography, multiphasic helical computerized tomography and diuretic renography. Exclusion criteria were marked hydronephrosis, ipsilateral renal function less than 25% and renal stones or a significant crossing vessel at the ureteropelvic junction. Eligible patients were randomized to ureteroscopic laser endopyelotomy and retrograde Acucise endopyelotomy (20 per group). UPJ obstruction was primary in 14 patients and secondary in 26. The ureteropelvic junction was incised in the lateral direction and an endopyelotomy Double-J stent (Medical Engineering Corp., New York, New York) was left for 6 weeks. Subjective and objective outcomes were evaluated 3 and 6 months after stent removal, and every 6 months thereafter. RESULTS Mean operative time +/- SD was comparable in the laser and Acucise groups (64.7 +/- 22.4 and 58.7 +/- 20.2, respectively). The overall complication rate in the Acucise group was more than in the laser group (25% vs 10%). At a mean followup of 29.9 +/- 10.8 months (range 6 to 48) the laser group showed a higher success rate than the Acucise group (85% vs 65%) but the difference in the complication and success rates was not statistically significant. CONCLUSIONS Despite the advanced endourological skills required for ureteroscopic laser endopyelotomy its safety and efficacy seem to be better than those of Acucise endopyelotomy. However, a larger number of patients is needed to confirm these findings.

SAFETY AND EFFICACY OF SUPRACOSTAL PERCUTANEOUS NEPHROLITHOTOMY IN PEDIATRIC PATIENTS

PURPOSE This study was conducted to evaluate the safety and efficacy of the supracostal approach for percutaneous nephrolithotomy in pediatric patients. MATERIALS AND METHODS We retrospectively reviewed 60 percutaneous nephrolithotomy procedures done in 50 children (32 boys and 18 girls) between 2000 and 2007. Mean patient age was 7 +/- 4 years (range 9 months to 14 years). Noncontrast computerized tomography was the primary radiological investigation for most of the cases. The subcostal approach was used in 40 procedures, and the supracostal approach (above the 12th rib) was required in 20. We compared both approaches regarding preoperative characteristics, stone-free and complication rates, and the need for auxiliary procedures. RESULTS The preoperative characteristics of the patients, urinary tracts and stones were comparable for both treatment groups. There were no major complications. Significant bleeding requiring blood transfusion was observed in 3 patients (5%), transient fever in 3 (5%) and urinary leakage through the nephrostomy site in 3 (5%). The distribution of complications among subcostal and supracostal approaches was comparable. Of the 60 renal units 46 (77%) were stone-free after percutaneous nephrolithotomy at discharge from the hospital. Of the remaining 14 units 9 (15%) were stone-free after shock wave lithotripsy and 5 (8%) had insignificant residual stones. Therefore, the overall stone-free rate at 3 months was 92.5%. Comparing the subcostal and supracostal approaches, there were no significant differences between hospital stays, complication rates, unplanned auxiliary procedures, and stone-free rates at discharge home and at 3-month followup. CONCLUSIONS Percutaneous nephrolithotomy for treating renal stones in children provides a high degree of safety and efficacy whether a supracostal or subcostal approach is used.

Long-term results of percutaneous nephrolithotomy for treatment of staghorn stones.

Study Type – Therapy (case series)

Nephrostomy Tube Placement After Percutaneous Nephrolithotomy: Critical Evaluation Through a Prospective Randomized Study

OBJECTIVE To evaluate the hemostatic and drainage functions of the nephrostomy tube after percutaneous nephrolithotomy through a prospective randomized study. Additionally, the effect of nephrostomy tube placement on postoperative pain, hospital stay, and the success and complication rates was assessed. METHODS The present study was designed to include 100 patients with upper urinary tract calculi who were prospectively randomized to tubeless (group 1) and standard (group 2) PCNL using closed envelopes. The hemoglobin and hematocrit deficits, development of hematuria and hematoma, and blood transfusion rate were compared to assess the hemostatic effect. The drainage effect was evaluated by comparing the incidence of postoperative urinary leakage, urinoma, and/or hydrothorax development. RESULTS A total of 123 patients were assessed for eligibility, and 100 fulfilled the study requirements. The hemoglobin and hematocrit deficits were comparable. Significant hematuria and/or hematoma were recorded in 5 and 4 patients in groups 1 and 2, respectively. Blood transfusion was required in 5 and 6 patients in groups 1 and 2, respectively. One patient with chronic kidney disease in the tubeless group required abdominal exploration because of respiratory embarrassment and a large hematoma. Transient urinary leakage was recorded in 2 and 31 patients in groups 1 and 2, respectively (P < .05). No urinoma developed. Hemothorax developed in 1 patient in the tubeless group with supracostal puncture. Postoperative pain was significantly less in the tubeless group. No statistically significant difference was found in the success rate, morbidity, or hospital stay between the 2 groups. CONCLUSION The hemostatic and drainage functions of the nephrostomy tube were modest. However, the tubeless approach might be not suitable for the patients with chronic kidney disease or a supracostal approach.