Faruquz Zaman

Simultaneous Anterograde and Retrograde Endourologic Access: “The Barts Technique”

We present our technique for achieving simultaneous anterograde and retrograde endourologic access to manage complex and demanding cases.

Drugs for pain management in shock wave lithotripsy.

Objective. With this review, we provide a comprehensive overview of the main aspects and currently used drugs for analgesia in shockwave lithotripsy. Evidence Acquisition. We reviewed current literature, concentrating on newer articles and high-quality reviews in international journals. Results. No standardized protocols for pain control in SWL exist, although it is crucial for treatment outcome. General and spinal anaesthesia show excellent pain control but are only recommended for selected cases. The newer opioids and nonsteroidal anti-inflammatory drugs are able to deliver good analgesia. Interest in inhalation anaesthesia with nitrous oxide, local anaesthesia with deep infiltration of the tissue, and dermal anaesthesia with EMLA or DMSO has recently rekindled, showing good results in terms of pain control and a favourable side effect profile. Tamsulosin and paracetamol are further well-known drugs being currently investigated. Conclusion. Apart from classically used drugs like opioids and NSARs, medicaments like nitrous oxide, paracetamol, DMSA, or refined administration techniques for infiltration anaesthesia show a good effectiveness in pain control for SWL.

Radical prostatectomy--too soon to abandon the perineal approach?

Perineal radical prostatectomy (PRP) is one of the oldest surgical procedures for prostate cancer, but its use has declined over the past 30 years. New studies show that PRP is not only minimally invasive but beneficial from an economic perspective and should not yet be abandoned in the treatment of early prostate cancer.

Laparoscopic cranial plication in pelviureteral junction obstruction by aberrant lower pole artery.

BACKGROUND AND PURPOSE The standard management for pelviureteral junction (PUJ) obstruction is a laparoscopic dismembered pyeloplasty. We present the initial results of our experience of laparoscopic cranial transposition of lower-pole crossing vessels in the management of adult PUJ obstruction where crossing vessels were identified. PATIENTS AND METHODS All patients during the last 2 years who presented with PUJ obstruction caused by crossing lower-pole vessels underwent a laparoscopic transposition of the artery to a more cranial position and, in fact, plicated within the renal pelvis well above the PUJ to reduce the size of the baggy renal pelvis. Patients were followed up postoperatively with mercaptoacetyl triglycine renography as well as clinical symptom review at 3 months, 6 months, and then yearly. RESULTS Seven patients have undergone this procedure so far. The mean follow-up period at present is 14 months (range 8-22 months). All patients had a nonobstructive renogram curve at 3 months and 6 months. One patient has had renography at 22 months, which still shows a nonobstructive drainage pattern. All patients have had a resolution of their pain and urinary tract infections. The mean operative time, including the retrograde study and Double-J stent insertion was 121 minutes (range 110-131 min) with a mean blood loss of 30 mL. The mean hospital stay was 2 days. There were no complications. CONCLUSIONS Although currently the number of patients is small and follow-up is short, this procedure appears to be effective in relieving both symptoms and obstruction in patients with lower-pole crossing vessels. Other benefits include shorter operative time, less blood loss, as well as no risk of anastomotic stricture and urine leak when compared with a dismembered pyeloplasty. The Double-J stent can be removed within a few days (typically 5 in our hands) or even shorter where logistically feasible. This reduces stent-related complications.

A technique to flush out renal stone fragments during percutaneous nephrolithotomy.

There are a number of graspers and baskets to snare and remove stones during percutaneous nephrolithotomy (PCNL). These instrumental techniques can, however, cause inadvertent trauma to the renal mucosa and can be time consuming. Increasingly, these graspers and baskets are disposable, which also has financial implications. We use a simple technique to flush out fragments from the kidney during PCNL. Once fragments have been identified as a size that can pass through the Amplatz sheath, a cut nasogastric tube is inserted through the sheath--if possible next to or behind the fragments. It is repeatedly moved forward and backward in a jerking motion while saline is instilled under some pressure to create some turbulence. This results in the mechanical flushing out of stone fragments. We have found this to be a safe, effective, and reliable technique of stone extraction during PCNL.

New developments in the use of prostatic stents

Bladder outflow obstruction is a very common age-related clinical entity due to a variety of benign and malignant diseases of the prostate. Surgical treatment under general or regional anesthesia is not suitable for high-risk elderly patients who seek minimally invasive management. Unfortunately, for patients who are not fit for transurethral and/or laser prostatectomy, few treatment options remain, other than long-term catheterization and insertion (under local anesthesia) of a prostatic stent. In this review, we present developments in the use of prostatic stents.

Inguinal lymph node metastases from a testicular seminoma: a case report and a review of the literature.

IntroductionWe report the case of a true hermaphrodite with testicular seminoma with resulting metastases to the inguinal lymph nodes eight months after radical orchidectomy. This is an unusual presentation of testicular cancer and, to the best of our knowledge, the first report of this kind in the literature.Case presentationA 45-year-old Caucasian true hermaphrodite, raised as a male, developed a testicular seminoma. He had undergone a left orchidopexy at the age of 10 for undescended testes. Metastases from testicular tumors to inguinal lymph nodes are a rare occurrence. It has been suggested that previous inguinal or scrotal surgery may alter the pattern of nodal metastasis of testicular cancer. We review the literature to evaluate the incidence of inguinal lymph node involvement in early stage testicular cancer and discuss possible routes of metastases to this unusual site. We also discuss the management of the inguinal lymph nodes in patients with testicular tumors and a previous history of inguinal or scrotal surgery, as this remains controversial.ConclusionInguinal lymph node metastases from testicular cancer are rare. A history of inguinal or scrotal surgery may predispose involvement of the inguinal nodes. During radical inguinal orchidectomy, the surgeon should be careful to minimize the handling of the testis and ensure high ligation of the spermatic cord up to the internal inguinal ring to reduce the risk of inguinal lymph node metastasis.

Should urologists in the UK undertake their own nephrostomies and renal access for endourological procedures: what does the future hold?

© 2 0 0 9 T H E A U T H O R S J O U R N A L C O M P I L A T I O N

Endourological management of ureteric strictures after kidney transplantation: Stenting the stent.

Abstract The incidence of ureteric obstruction after kidney transplantation is 3–12.4%, and the most common cause is ureteric stenosis. The standard treatment remains open surgical revision, but this is associated with significant morbidity and potential complications. By contrast, endourological approaches such as balloon dilatation of the ureter, ureterotomy or long-term ureteric stenting are minimally invasive treatment alternatives. Here we discuss the available minimally invasive treatment options to treat transplant ureteric strictures, with an emphasis on long-term stenting. Using an example patient, we describe the use of a long-term new-generation ureteric metal stent to treat a transplant ureter where a mesh wire stent had been placed 5 years previously. The mesh wire stent was heavily encrusted throughout, overgrown by urothelium and impossible to remove. Because the patient had several previous surgeries, we first considered endourological solutions. After re-canalising the ureter and mesh wire stent by a minimally invasive procedure, we inserted a Memokath® (PNN Medical, Kvistgaard, Denmark) through the embedded mesh wire stent. This illustrates a novel method for resolving the currently rare but existing problem of ureteric mesh wire stents becoming dysfunctional over time, and for treating complex transplant ureteric strictures.

The Floppy Iris Syndrome – What Urologists and Ophthalmologists Need to Know

Introduction: Benign prostatic hyperplasia (BPH) and cataract formation are common in older people. Medical management of symptomatic BPH is often preferred to surgical treatment as surgery increases the risk of morbidities, whereas, surgery is the main form of treatment to restore sight in patient with cataract. The clinical treatment of BPH is either alpha-1 adrenergic antagonist alone or combination of alpha reductase inhibitor and alpha adrenergic receptor (AR) antagonist. There are four alpha-AR antagonists currently available to treat BPH. The uroselective alpha-blocker tamsulosin is the most commonly used drug among all. Studies showed that the majority of the patients who develop intraoperative floppy iris syndrome (IFIS) were on tamsulosin. Women are more likely to develop cataract than men and some recent studies showed that tamsulosin is effective in treating female lower urinary tract symptoms and thereby can cause IFIS during cataract surgery. Evidence Acquisition: We performed a critical review of the published articles and abstracts on association of IFIS with alpha-blockers and other medications as well as other medical conditions. Evidence Synthesis: Tamsulosin is the most common cause of formation of IFIS. However, not all patients given tamsulosin develop IFIS and cases have been reported without any tamsulosin treatment. Conclusion: Tamsulosin is a recognized cause to impede mydriasis and lead to IFIS during cataract surgery. Urologist should collaborate with their ophthalmology colleagues and general practitioner during prescribing tamsulosin in patients with history of cataract or waiting for planned cataract surgery. The increasing life expectancy and growth of older people will increase the number of men and women who suffer from lower urinary tract symptoms as well as cataract. Therefore, further research and studies are required to properly understand the relation of alpha blockers and IFIS.