Akram Assem

Calculating the Number of Shock Waves, Expulsion Time, and Optimum Stone Parameters Based on Noncontrast Computerized Tomography Characteristics

OBJECTIVE To define the parameters that accompanied a successful extracorporeal shock wave lithotripsy (ESWL), namely the number of shock waves (SWs), expulsion time (ET), mean stone density (MSD), and the skin-to-stone distance (SSD). METHODS A total of 368 patients diagnosed with renal calculi using noncontrast computerized tomography had their MSD, diameter, and SSD recorded. All patients were treated using a Siemens lithotripter. ESWL success meant a stone-free status or presence of residual fragments <3 mm, ET was the time in days for the successful clearance of stone fragments. Correlation was performed between the stone characteristics, number of SWs, and ET. Two multiple regression analysis models defined the number of SWs and ET. Two receiver operating characteristic curves plotted the best MSD cutoff value and optimum SSD for a successful ESWL. RESULTS Three hundred one patients were ESWL successes. A significant positive correlation was elicited between number of SWs and stone diameter, density and SSD; between ET and stone diameter and density. Multiple regressions concluded 2 equations: Number of SWs = 265.108 + 5.103 x1 + 22.39 x2 + 10.931 x3 ET (days) = -10.85 + 0.031 x1 + 2.11 x2 x1 = stone density (Hounsfield unit [HUs]), x2 = stone diameter (mm), and x3 = SSD (mm). Receiver operating characteristic curves demonstrated a cutoff value of ≤ 934 HUs with 94.4% sensitivity and 66.7% specificity and P = .0211. The SSD curve showed that a distance ≤ 99 mm was 85.7% sensitive, 87.5% specific, P <.0001. CONCLUSION Stone disintegration is not recommended if MSD is >934 HUs and SSD >99 mm. The required number of SWs and the expected ET can be anticipated.

Retroperitonoscopic pyelopexy for pelviureteral junction obstruction with crossing vessel in adolescents: Hellstrom principle revisited.

OBJECTIVE To present our new approach using a minimally invasive technique for the management of pelviureteral junction (PUJ) obstruction with a crossing vessel. MATERIALS AND METHODS In December 2009 to December 2011, out of 23 cases of retroperitoneoscopic laparoscopic pyeloplasty, four adolescents presenting with PUJ obstruction due to an aberrant crossing vessel, with intermittent attacks of renal colic and mild dilatation of the renal pelvis and calyces, were operated by retroperitoneoscopic pyelopexy. A retroperitoneoscopic approach was used in all patients using three trocars. After dissection of the PUJ from the anterior crossing vessel, and ensuring good funneling of the PUJ that proved to show mild dilatation, an interrupted 3/0 polyglycolic suture was used to fix the renal pelvis to the psoas muscle away from the crossing vessel (pyelopexy). A retrograde DJ stent was placed at the end of the procedure. RESULTS The four patients had a mean age of 18.25 years (16-20): 2 males and 2 females, two right sided and two left sided. Average operative time was 46 min (40-55). All patients were discharged on the same day. No intraoperative complications were encountered. The DJ stent was removed 6 weeks postoperatively. After a mean follow up of 2.125 years (6 months-3 years) no recurrences were observed. CONCLUSION Retroperitoneoscopic pyelopexy is shown to be a reliable, effective, safe and minimally invasive technique for the management of PUJ obstruction with a crossing vessel in selected cases. Long-term follow up is needed to assess any recurrence or development of complications.

Bipolar vs monopolar resection of bladder tumours of >3 cm in patients maintained on low-dose aspirin: A randomised clinical trial

Abstract Objective: To compare the safety and efficacy of bipolar vs monopolar transurethral resection of bladder tumour (TURBT) in patients maintained on low-dose aspirin with tumours >3 cm. Patients and methods: A prospective randomised single-centre study was performed including 200 patients with bladder tumours of >3 cm, as measured by ultrasonography. All patients were using low-dose aspirin (81 mg/day), which was not stopped in the perioperative period. Patients were randomised into two groups: Group A, monopolar TURBT (M-TURBT); Group B, bipolar TURBT (B-TURBT). The primary endpoint of the study was the decrease in postoperative haemoglobin (Hb) concentration measured using an automated cell counter. The secondary endpoints of the study were intraoperative blood transfusion or the occurrence of urethral trauma during cystoscopy and the need for re-coagulation. Results: The postoperative reduction in Hb concentration, was significantly lower in the B-TURBT group [mean (SD) 0.55 (0.26) g/dL] compared with the M-TURBT group [mean (SD) 1.24 (0.61) g/dL] (P < 0.001). There was also a significant difference (in favour of B-TURBT) between the groups in the mean postoperative reduction in haematocrit and the mean postoperative hospital stay. There was no significant difference between the groups for the occurrence of obturator jerk, bladder perforation, and the need for blood transfusion. Conclusion: B-TURBT in patients maintained on low-dose aspirin is better than M-TURBT for minimising postoperative drop in Hb concentration.

Retroperitonoscopic Nephrectomy and Nephrouretrectomy in Children and Adolescents: Analysis of a Single-Center Experience

INTRODUCTION AND OBJECTIVES Retroperitonoscopic nephrectomy in children was considered by some authors to be the final gold standard in children. Hence, we reviewed our data focusing on the safety and efficacy of the procedure. MATERIALS AND METHODS In the period from November 2005 till February 2010, 35 patients were operated by a single surgeon (the first author); patients comprised 18 boys and 17 girls, with a mean age of 7.5 years (range: 1-19 years). In all patients, the retroperitonoscopic approach was used with the use of only three trocars, one 10-mm optic trocar and two 5-mm trocars. The retroperitoneal space was established either by direct insufflation into the Gerota fascia, which is grasped and opened under vision, or using a balloon dilator to widen the space and then incising the Gerota fascia under control of the optic trocar, then control of the pedicle is performed, and the specimen is extracted from the same optic trocar. RESULTS The mean operative time is 75 minutes (range: 45-120 minutes). Nineteen nephrectomies and 16 nephrouretrectomies were performed. Blood loss was minimal, blood transfusion was not given, and conversion to open surgery was not needed. There were no intraoperative complications, and only one postoperative hematoma resolved spontaneously. The mean hospital stay was 2 days (1-3 days). CONCLUSION Retroperitonoscopic nephrectomy in children is safe and feasible. Blood loss is minimal, hospital stay is very short, and complications are minimal. It has excellent cosmetic outcome.

Outcome of laparoscopic upper pole heminephroureterectomy in children: A two-centre experience

Abstract Objective To report our multicentre experience and outcomes with laparoscopic transperitoneal and retroperitoneal upper pole heminephroureterectomy (HNU) in children with renal duplex systems and impaired upper pole. Patients and methods Laparoscopic HNU was performed in 22 children (15 girls, seven boys) with a mean age of 5.9 years. A retroperitoneal approach was used in 17 patients and a transperitoneal approach in the remaining five, between 2005 and 2010. Urinary tract infection was the initial presenting symptom in all children except for one with urinary retention caused by a large ureterocele. Voiding cystourethrography and renal scintigraphy revealed dual collecting systems on the right side in 11 and on the left in 11 cases. The upper pole collecting system was non-functioning in all cases. Postoperative ultrasonography was done at 1 and 3 months, with renal scintigraphy at 3 months, to check the remaining function of the lower moiety. Results Overall, the mean operation time was 152 min (144 min for retroperitoneal and 160 min for transperitoneal). Blood loss was 10–50 mL and there were no intraoperative complications. The mean (SD) hospitalisation and postoperative follow-up were 3.5 (1.25) days and 22 (9.83) months, respectively. Postoperative recovery was uneventful and at the 3-month follow-up renal scintigraphy revealed no parenchymal loss of the remaining renal moiety. Conclusion Laparoscopic HNU in children can be performed via transperitoneal or retroperitoneal approach, both with low morbidity and with the typical benefits of laparoscopic surgery.