Ahmed Sakr

Efficacy of laparoscopically assisted high ligation of patent processus vaginalis in children

INTRODUCTION Laparoscopic hernia repairs have been proven to be efficient and safe for children, despite the slightly higher recurrence rate compared with the classic surgical repair. They have the advantage of easy and precise identification of the type of defect and its correction, both in ipsilateral and contralateral sides. OBJECTIVES The objectives of this study were to evaluate the efficacy, safety and outcome of the laparoscopically assisted piecemeal high ligation of a patent processus vaginalis (PPV) in children. METHODS A total of 40 children were enrolled into this prospective study; they were aged ≥ 6 months and had an inguinal hernia. The peritoneal cavity, including the contralateral side, was inspected for the possibility of bilateral hernias using a 3-mm 30° telescope. Another 3-mm port was introduced through the same infra-umbilical incision. The hernia was manually reduced or with the aid of a working infra-umbilical grasper. A prolene or vicryl 2/0 or 3/0 suture on a curved semicircle round-bodied taper-ended 25-30 mm needle was introduced through a very small inguinal skin-crease incision. It was passed through the abdominal wall layers to the peritoneum and was manipulated by the laparoscopic grasper to pick up the peritoneum in piecemeal all around the internal ring. The needle was then pushed to the outside near to the entrance site, thus forming a semicircle around the internal ring. The suture was then tied and the knot was subcutaneously buried. The primary outcome of the procedure was the incidence of intraoperative diagnosis and surgical repair of contralateral hernias in pre-operatively diagnosed unilateral cases. The secondary outcomes were defined as the incidence of complications and hernia recurrence. RESULTS DISCUSSION The exploratory laparoscopy found contralateral patent processus vaginalis (CPPV) with a detection rate of 28.1%. Chan et al., Esposito et al., Toufique et al. and Niyogi et al. reported similar figures for laparoscopic contralateral hernia detection rates of 28%, 39%, 39.7% and 29.2%, respectively. The limitations of this study were the small sample size, plus the risk factors and clinical significance for CPPV. CONCLUSION Laparascopically assisted piecemeal closure of the internal inguinal ring in children is a safe and effective procedure. It helps in detecting a contralateral hernia without prolonging the operative time.

Silodosin vs tamsulosin in the management of distal ureteric stones: A prospective randomised study.

Abstract Objectives: To compare the efficacy of silodosin (8 mg) vs tamsulosin (0.4 mg), as a medical expulsive therapy, in the management of distal ureteric stones (DUS) in terms of stone clearance rate and stone expulsion time. Patients and methods: A prospective randomised study was conducted on 115 patients, aged 21–55 years, who had unilateral DUS of ⩽10 mm. Patients were divided into two groups. Group 1 received silodosin (8 mg) and Group 2 received tamsulosin (0.4 mg) daily for 1 month. The patients were followed-up by ultrasonography, plain abdominal radiograph of the kidneys, ureters and bladder, and computed tomography (in some cases). Results: There was a significantly higher stone clearance rate of 83% in Group 1 vs 57% in Group 2 (P = 0.007). Group 1 also showed a significant advantage for stone expulsion time and analgesic use. Four patients, two in each group, discontinued the treatment in first few days due to side-effects (orthostatic hypotension). No severe complications were recorded during the treatment period. Retrograde ejaculation was recorded in nine and three patients in Groups 1 and 2, respectively. Conclusion: Our data show that silodosin is more effective than tamsulosin in the management of DUS for stone clearance rates and stone expulsion times. A multicentre study on larger scale is needed to confirm the efficacy and safety of silodosin.

Definitive ureteroscopy and intracorporeal lithotripsy in treatment of ureteral calculi during pregnancy

Abstract Objective: To evaluate the outcome of using semi-rigid ureteroscopy with or without intracorporeal pneumatic lithotripsy vs. temporary ureteric JJ stenting in the management of obstructing ureteric calculi in pregnant women. Patients and methods: This prospective comparative study comprised 43 pregnant women with obstructing ureteric calculi. The diagnosis was based on the acute flank pain as the main symptom, microscopic haematuria, and unilateral hydronephrosis on abdominal ultrasonography (US). The patients were randomly divided into two groups; those in group 1 (22 patients) were treated by temporary ureteric JJ stenting until after delivery, and those in group 2 (21) were treated definitively by ureteroscopic stone extraction with intracorporeal pneumatic lithotripsy. Postoperative complications and the degree of patient satisfaction were reported. Results: An obstructing ureteric stone was identified by US in 68% and 76% of groups 1 and 2, respectively. In group 1, nine patients had mid-ureteric stones and 13 had stones in the lower ureter. In group 2, seven patients had mid-ureteric stones, whilst the stones were in the distal ureter in 14. No perioperative foetal complications were detected in any group and all patients completed the full term of pregnancy. In group 1, four patients had a postoperative urinary tract infection (UTI), and the JJ stent was exchanged in seven. Two patients in group 2 had a postoperative UTI. Conclusions: Definitive ureteroscopy, even with intracorporeal pneumatic lithotripsy, is an effective and safe treatment for pregnant women with obstructing ureteric calculi. It has a better outcome and is more satisfactory for the patients than a temporary JJ stent.

Immediate versus delayed shockwave lithotripsy for inaccessible stones after uncomplicated percutaneous nephrolithotomy

Abstract Objective: To evaluate the efficacy and safety of immediate versus delayed shockwave lithotripsy (SWL) for inaccessible stones after uncomplicated percutaneous nephrolithotomy (PCNL). Patients and methods: Between December 2011 and June 2014, patients with residual inaccessible stones after uncomplicated PCNL were prospectively randomised into two treatment groups; Group I, immediate SWL and Group II, delayed SWL at 1 week after PCNL. Patients with residual stones of ⩾1.5 cm, a stone density of >1000 Hounsfield units and body mass index of >40 kg/m2 were excluded from the study. The following data were reported: patients’ demographics, stone characteristics after PCNL, hospital stay, perioperative complications, stent duration, and stone-free rate (SFR). Results: In all, 84 patients (51 males and 33 females) with mean (SD) age of 39 (8.5) years were included in the study. Group I included 44 patients, whilst Group II included 40 patients. There was no statistically significant difference amongst the groups for patients’ demographics, stone characteristics, and perioperative complications. The hospital stay was significantly shorter in Group I, at a mean (SD) of 34 (3.7) vs 45 (2.9) h (P < 0.001). The duration of ureteric stenting was significantly lower in Group I as compared to Group II, at a mean (SD) of 12 (4.2) vs 25 (3.5) days (P < 0.001). The SFR was 93.2% and 95% in Groups I and II, respectively (P = 0.9). Conclusions: Immediate SWL after PCNL is as effective and safe as delayed SWL with a lesser hospital stay and duration of ureteric stenting.

Sildenafil citrate in combination with tamsulosin versus tamsulosin monotherapy for management of male lower urinary tract symptoms due to benign prostatic hyperplasia: A randomised, double-blind, placebo-controlled trial

Abstract Objective: To assess the additive effect of sildenafil citrate to tamsulosin in the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) in men with or without erectile dysfunction (ED). Patients and methods: In all, 150 men with untreated LUTS/BPH with or without ED were randomised to receive sildenafil 25 mg once daily (OD) or placebo OD (night time) combined with tamsulosin 0.4 mg OD (day time) for 6 months. Changes from pre-treatment scores in International Prostate Symptom Score (IPSS), IPSS-quality of life (QoL) score, maximum urinary flow rate (Qmax), and the five-item version of the International Index of Erectile Function questionnaire (IIEF-5) were assessed at 3 and 6 months. Safety profiles were assessed by physical examination and monitoring clinical adverse events. Results: Group A comprised of men who received tamsulosin and sildenafil (75 men), whilst those in Group B received tamsulosin and placebo (75). The IPSS was significantly improved in Group A compared to Group B, at −29.3% vs −13.7% (P = 0.039) at 3 months and −37% vs −19.6% (P = 0.043) at 6 months after treatment. Qmax significantly improved in both groups compared with before treatment (P < 0.001). The IIEF-5 scores improved more in Group A than in Group B, at 58.7% vs 11.7% at 3 months and 62.4% vs 12.4% at 6 months after treatment (both P < 0.001). Conclusion: Sildenafil citrate combined with tamsulosin improved LUTS, erectile function, and patient QoL more than tamsulosin monotherapy with the merit of a comparable safety profile in patients with LUTS/BPH.

The prognostic significance of p53, p63 and her2 expression in non-muscle-invasive bladder cancer in relation to treatment with bacille Calmette–Guerin

Abstract Objective: To investigate whether the immunohistochemical expression of p53, p63 and her2/neu is correlated with the prognosis of tumour recurrence and progression in patients with non-muscle invasive (NMI) bladder cancer. Patients and methods: In all, 88 patients diagnosed with NMI transitional cell carcinoma of the bladder in a Urology Department from May 2009 to April 2014 were included in the study. Paraffin-embedded specimens were obtained by transurethral resection of the bladder tumours. Sections on haematoxylin and eosin-stained slides were examined histologically and tumour grade was classified according to the World Health Organisation system (2004) Mostofi classification. The sections were evaluated using p63, p53 and her2/neu immunohistochemical staining before and after immunotherapy with bacille Calmette–Guerin (BCG), and patients were followed up for 36 months in the Urology Department. Results: For tumour grade there was a significant relationship with the overexpression of p53 (P = 0.010), her2 (P = 0.025) and negativity of p63 (P = 0.025). There was no significant relationship between p53 or her2/neu overexpression and tumour stage. However, there was a significant correlation (P = 0.005) between p63 negativity and tumour stage. There was a significant relationship between p53 (P = 0.01), her2/neu (P = 0.025) overexpression and p63 negativity (P = 0.005) and tumour recurrence and progression. Conclusion: Patients with transitional cell carcinoma who are selected for BCG treatment should preferably be positively immunoreactive for p63, but negative for both p53 and her2/neu. These patients were less susceptible to recurrence and/or progression after BCG adjuvant therapy. Further studies are needed to investigate the relationship between these three markers and treatment with anti-her2/neu therapies.

The role of neural precursor cell-expressed developmentally down-regulated protein 9 in predicting bacillus Calmette-Guerin response in nonmuscle invasive bladder cancer

OBJECTIVE To report the sensitivity and specificity of neural precursor cell-expressed developmentally down-regulated protein 9 (NEDD9) protein high expression in predicting BCG response and its effect on recurrence or progression free survivals. PATIENTS AND METHODS Between May 2014 and April 2017, a prospective cohort study was conducted on 105 patients with intermediate or high-risk nonmuscle invasive bladder cancer. Immunohistochemical staining with mouse monoclonal anti-NEDD9 antibody was done. Examination of the slides was done to detect NEDD9 cytoplasmic expression. Intravesical induction bacillus Calmette-Guerin (BCG) instillation therapy was started for all patients 2 to 4 weeks after endoscopy with once weekly instillation for 6 weeks. Intravesical maintenance BCG instillation was then continued every 3 months for at least 1 year. Follow up with cystoscopy every 3 months for 2 years and every 6 months after that. RESULTS The mean age ± SD of the patients was 57 ± 4.5 years. The median follow-up period was 25 (12-36) months. NEDD9 protein was highly expressed in 61 (58.1%) patients, whereas low expression was in 44 (41.9%) patients. Sensitivity and specificity of NEDD9 high expression in predicting recurrence were 83.6% and 64.2%, respectively. Its sensitivity and specificity in predicting progression to muscle invasion or distant metastases were 91.3% and 51.2%, respectively. Its sensitivity and specificity in predicting complete response to BCG therapy were 84.1% and 80.9%. Kaplan-Meier test showed highly significant difference (P<0.0001) in survival without recurrence or progression between patients showing high expression and those showing low expression. CONCLUSION NEDD9 protein tissue marker could be used as a predictive marker for BCG response in nonmuscle invasive bladder cancer with reasonable sensitivity and specificity.

Lingual mucosal graft two-stage Bracka technique for redo hypospadias repair

Abstract Objectives: To report our initial experience in redo hypospadias repair with a lingual mucosal graft (LMG) using a two-stage Bracka technique. Patients and methods: This study was prospectively conducted and included 26 patients with hypospadias with failed previous repairs. All the patients had a LMG using a two-stage Bracka technique. In the first stage, the harvested LMG, from the ventro-lateral surface of the tongue, was implanted in a well-prepared vascularised bed in the ventral aspect of the penis. After 6 months, tubularisation of the well-taken graft was completed. Tunica vaginalis or a dartos flap was used as second-layer coverage of the neourethra. Success was defined as acceptable aesthetic and functional outcomes without any additional surgical interventions. Results: The mean (SD) patient age was 5.15 (1.6) years. The mean (SD) LMG length was 3.82 (0.9) cm and the width was 1.5 (0.5) cm. The mean (SD) number of previous repairs was 2.76 (1.1). The mean (SD) follow-up was 12 (2) months. Donor-site complications included: pain in all patients, with a pain score of >3 on the visual analogue pain scale (0–10) in 10 (38%); and speech problems in 19 (73%). First-stage complications were graft loss (n = 2) and contracture (n = 1). The second stage was completed in 23 patients resulting in the following significant complications: meatal stenosis plus fistula (n = 2), breakdown (n = 1). Successful hypospadias repair was achieved in 77% (20/26) of the patients. Conclusion: Lingual mucosa is a reliable and versatile graft material in the armamentarium of two-stage Bracka hypospadias repair with the merits of easy harvesting and minor donor-site complications.