Hamdy M. Ibrahim

Flexible ureterorenoscopy versus extracorporeal shock wave lithotripsy for treatment of lower pole stones of 10–20 mm

Study Type – Therapy (case series)

Role of Ureteral Stenting After Uncomplicated Ureteroscopy for Distal Ureteral Stones: A Randomized, Controlled Trial

PURPOSE We determined the differences in outcome between ureteral stenting and nonstenting following uncomplicated ureteroscopy for distal ureteral stones. MATERIALS AND METHODS A total of 220 patients treated with successful ureteroscopy for distal ureteral stones were randomized to 2 equal groups according to postoperative placement of a ureteral stent (Cook Ireland, National Technological Park, Ireland), including group 1--without a stent and group 2--with a stent. Outcome measures were flank pain and dysuria at 48 hours and 1 week, early postoperative complications, analgesia need, rehospitalization, return to normal physical activity, stone-free rate, stone recurrence and late postoperative complications. Patients were followed a mean +/- SD of 25 +/- 9 months (range 12 to 49). RESULTS Early postoperative complications, including low grade fever, hematuria and urinary tract infection, were observed in 22 patients (20%) in group 1 and 19 (19%) in group 2, a difference of no significant value. Mean initial hospitalization and time to return to normal physical activity were not different between the 2 groups. At 48 hours and 1 week there was no significant difference in flank pain between the 2 groups, while dysuria was significantly less in the nonstented group. The amount of analgesics required in the recovery room was not different but after discharge from the hospital stented patients used a larger amount of analgesia while the stent was still in the ureter. The stone-free rate at 4 weeks was 100% in each group. Late postoperative sequelae, including stone recurrence and ureteral narrowing, were reported in 6 patients (5.5%) in group 1 and 4 (3.6%) in group 2, a difference of no significant value. CONCLUSIONS Uncomplicated ureteroscopy for treatment of distal ureteral stones is safe without stent placement. Patients without stents have significantly fewer irritative bladder symptoms and are not at risk of increased complications.

Single Versus Double Ureteral Stent Placement After Laser Endoureterotomy for the Management of Benign Ureteral Strictures: A Randomized Clinical Trial

BACKGROUND AND PURPOSE Endoureterotomy is a viable option for treating patients with benign ureteral stricture. We compared the efficacy and safety of double versus single ureteral stent placement after laser endoureterotomy. PATIENTS AND METHODS This study included 55 patients with benign ureteral strictures; all patients underwent retrograde laser endoureterotomy. Patients were randomized either to single or double ureteral stents. Single stents were placed in 27 ureters while double stents were placed in 28 ureters. The stent diameter used was 7 F, and stents were indwelling for 8 weeks. Imaging was performed 1 month after stent removal and repeated regularly every 3 months. Clinical characteristics, operative results, and functional outcomes were compared for strictures managed in both groups. Success was evaluated both subjectively and objectively. RESULTS Fifty-five patients with a mean age of 46 (16-75) years had benign ureteral strictures; the mean stricture length was 1.92 (1-3) cm. The mean follow-up was 25.7 (9-42) months. The overall success rate was 67.3% (37 patients) with no radiologic evidence of obstruction, 6 (10.9%) patients showed symptomatic improvement while 12 (21.8%) patients underwent surgical reconstruction. Success was significantly higher for ureteral strictures (>1.5 cm) managed with double stent placement (82.4%), compared with single stent placement (38.9%) with a P value of 0.009. CONCLUSIONS Double stent placement of the ureter after laser endoureterotomy achieved a higher success rate compared with single stent placement in cases of benign ureteral strictures. Although ureteral strictures (≤1.5 cm) achieved better outcome after laser endoureterotomy, strictures (>1.5 cm) favored better with double stent versus single stent placement.

Post-Transurethral Resection of the Prostate Inflation of Pressure-Controlled Endorectal Balloon-Impact on Postoperative Bleeding: A Preliminary Experimental Pilot Study.

OBJECTIVE To evaluate the impact of rectal balloon (RB) inflation on post-transurethral resection of the prostate (TURP) bleeding in patients with symptomatic benign prostatic hyperplasia. METHODS After institutional review board approval, patients who were eligible for TURP were randomized into two equal groups, depending on whether they received postoperative endorectal balloon (RB) (GII) or not (GI). The tip of three-way Foley catheter was fixed to a balloon by a blaster strip to prepare air-tight RB. Postoperatively, the RB was inflated for 15 minutes by a pressure-controlled sphygmomanometer. Perioperative data were compared between both groups, including hemoglobin (Hb) deficit 24-hour postoperatively and at time of discharge. Functional outcomes, anorectal complaints, and adverse events were assessed perioperatively and after 1 and 3 months. RESULTS Fifty patients were enrolled, including 13 (26%) patients who presented with indwelling urethral catheters. Baseline data and mean resected tissue weight were comparable between both groups, including preoperative Hb (p = 0.17). Immediate postoperative Hb deficit was, comparable between GI and GII patients (0.58 ± 0.18 vs 0.60 ± 0.2, p = 0.56) before RB inflation, respectively. However, compared to GI patients, mean Hb deficit significantly decreased in GII patients 24-hour postoperatively (0.2 ± 0.2 vs 0.7 ± 0.3 g, p = 0.002) and at time of discharge (0.8 ± 0.2 vs 1.3 ± 0.4 g, p = 0.003). GII patients needed significantly less postoperative irrigation (2.1 ± 1.6 vs 8.3 ± 1.8 L, p < 0.001), shorter catheterization time (2.3 ± 0.8 vs 3.8 ± 1.3 days, p < 0.001), and shorter hospital stay (2.6 ± 0.5 vs 4.3 ± 1.0 days, p < 0.001). Both groups were comparable in all functional outcomes at the most recent follow-up. Blood transfusion was needed in only one patient (4%) in GI. No patient needed recystoscopy for hematuria or clot retention in either group, while there were no anorectal complaints reported by GII patients. CONCLUSIONS Post-TURP endorectal balloon inflation seems to be simple, safe, and an efficient procedure to reduce postoperative bleeding and irrigation volume. It is significantly associated with shorter catheterization time and hospital stay.

Can endourology fellowship training enhance minimally invasive surgery in urology practice

Abstract Objective To evaluate the influence of fellowship training in endourology on different endourological procedures in a single institution. Subjects and methods The operative records of endourological and open surgeries were reviewed. Data analysed included numbers, types, and technical issues related to surgeries. The early study period ranged from September 1998 to September 2004, and the later period from January 2014 to June 2016. The study duration was classified into three periods according to the availability of an endourology fellowship trained member of staff (EFTS). In period A (September 1998 to September 2001) no EFTS was available, in period B (October 2001 to September 2004) an EFTS joined the urology unit, and in period C (January 2014 to June-2016) the EFTS had left the urology unit. Results In periods B and C the number of rigid ureteroscopy (URS) significantly increased compared with period A. Also, flexible URS was used for the first time in period B and continued in period C. The number of percutaneous nephrolithotomies increased in period B and continued to be performed in period C. Laparoscopic urological surgery was not undertaken in period A, and only done in four cases in period C, whilst it was performed in 62 patients in period B. Holmium laser enucleation of the prostate was carried out in 36 patients during period B and not performed in periods A and C. Finally, the number of open stone surgeries decreased in periods B and C. Conclusion The introduction of an EFTS definitely enhanced the practice of minimally invasive procedures.

Difficulties in Laparoscopic Access

Laparoscopic surgery has developed rapidly over the last few years, and many surgical procedures formerly carried out through large abdominal incisions are now performed laparoscopically. Reduction of the trauma of access by avoidance of large wounds has been the driving force for such development.1 However, the insertion of needles and trocars necessary for the pneumoperitoneum and the performance of the procedure are not without risk.2 The technical modifications imposed by surgical laparoscopy are obvious (e.g., number and size of trocars, location of insertion sites, specimen retrieval), and therefore morbidity may be substantially modified. Complications such as retroperitoneal vascular injury, intestinal perforation, wound herniation, wound infection, abdominal wall hematoma, and trocar site mestastasis have been reported.3

Bilateral Single-session Vs Staged Mini-percutaneous Nephrolithotomy for Renal Stones: A Comparative Study

OBJECTIVE To compare safety and efficacy of bilateral single-session mini-percutaneous nephrolithotomy (BSS-Mini-PNL) vs staged-Mini-PNL. PATIENTS AND METHODS Adult patients with bilateral renal stones indicated for PNL were managed with BSS-Mini-PNL (45 patients and 90 renal units) and prospectively compared vs staged-Mini-PNL (55 patients and 110 renal units) between July 2014 and December 2017. Mini-PNL was done through 18-Fr tract in prone position under regional anesthesia and fluoroscopy using pneumatic lithotripsy. A semirigid ureteroscope (8.5/11.5 Fr) was used. Mann-Whitney, Student t, chi-square, or Fishers exact tests were used as appropriate. RESULTS Both groups were comparable in characteristics of stones and patients. Stone burden was 3.36 ± 1.61 vs 3.38 ± 1.18 cm2 in BSS-Mini-PNL vs staged-Mini-PNL, respectively. Staghorn stones were present in 13.3% vs 8.2% in BSS-Mini-PNL vs staged-Mini-PNL, respectively. There was no significant difference in the number of required tracts (1.34 ± 0.6 vs 1.25 ± 0.51 tract/renal unit) as well as the rate of tubeless Mini-PNL (81.1% vs 85.5%) or stone-free rate (90% vs 92.7%) in BSS-Mini-PNL vs staged-Mini-PNL, respectively. BSS-Mini-PNL had significantly shorter operative time (126.22 ± 37.2 vs 169.63 ± 61.28 minutes), shorter hospital stay (2 [1-8] vs 4 [2-16] days) and higher hemoglobin loss (1.1 [0.1-2.8] vs 0.5 [0.1-2.17] gm/d) than staged-Mini-PNL. The complications profile (17.8% vs 13.6%) and rate of blood transfusion (4.4% vs 3.6%) were comparable in BSS-Mini-PNL vs staged-Mini-PNL, respectively, without significant difference. CONCLUSION BSS-Mini-PNL is comparable to staged-PNL as regard stone-free rate and complications according to the selection criteria of the present study. However, BSS-Mini-PNL is associated with significant reduction in the cumulative operative time and hospital stay, which are reflected on the overall cost.

Intermittent Testicular Torsion in Adults: An Overlooked Clinical Condition

Objectives: The aim of this study was to describe the management protocol for intermittent testicular torsion (ITT) in adults and report the outcome of this clinical condition, which is commonly overlooked in adults. Subjects and Methods: Sixty-three patients were included in the study. The inclusion criterion was the presence of sudden intermittent testicular pain over a duration of 3 months. All the patients underwent clinical examination, urine analysis, culture, and scrotal ultrasound with Doppler. The testicle was in an abnormal or in transverse lie and/or could easily be twisted. Scrotal support and analgesia were given for 1 month, then patients were offered orchidopexy or conservative treatment. Nineteen patients chose orchidopexy while 44 chose conservative treatment. Follow-up ranged from 3 months to 2 years. The improvement was assessed using a visual analog pain score. The outcome of the treatment was compared between the surgical and conservative groups using a χ2 test. Results: The median age of the patients was 28 years (range: 17-50). Of the 19 patients who underwent orchidopexy, the pain resolved or visual analog pain scores improved (median 1/10) in 18 (94.7%) cases. On the other hand, 21 of the 44 (47.7%) cases that chose the conservative approach claimed their pain resolved or improved (visual analog pain scores: median 3/10) with a median of 13 months of follow-up. Conclusion: In this study, scrotal orchidopexy proved to be superior to conservative measures in cases of ITT in adults.

Endourologic Management of Nonmalignant Bilharzial Urinary Complications

Urinary schistosomiasis is a chronic parasitic infection of the circulatory system caused by S. haematobium which affects the bladder and subsequently the urinary tract system of man. The effect of S. haematobium infection is due to deposition of eggs in the bladder and ureter which elicits chronic granulomatous injury. This granulomatous inflammation causes nodules, polypoid lesions, and ulcerations of the lumen of the ureter and bladder, which results clinically in urinary frequency, dysuria, and terminal hematuria. The disease may progress and terminate in renal failure or carcinoma of the bladder. The clinical picture and disease outcomes in persons infected with S. haematobium vary dramatically, ranging from mild symptoms to severe damage of the urinary tract including the kidney and bladder.

Ureteroscopy During Pregnancy

Pregnancy is a physiological state with complex hemodynamic changes. Pain (renal colic) is the most common presentation of urolithiasis, as well as the most common nonobstetric cause of hospitalization during pregnancy. Symptomatic urolithiasis, an uncommon event in pregnancy, is nevertheless of clinical concern because it may adversely affect birth outcome with an increased risk of preterm delivery. In the 9-month duration of pregnancy, the incidence of symptomatic stones appears not to differ from the incidence during a similar interval in women of childbearing age despite increased urinary calcium excretion in pregnancy.