Ibrahim Mokhless

Tamsulosin for the management of distal ureteral stones in children: A prospective randomized study

PURPOSE Based on efficacy demonstrated in the adult population, tamsulosin was evaluated with regard to facilitating ureteral stone expulsion in children presenting with distal ureteric calculi. PATIENTS AND METHODS A prospective randomized controlled study involving 61 children with distal ureteric calculi <12 mm was performed. The children were randomly divided into two groups. Group I (study group, n = 33) received tamsulosin and standard analgesia, and Group II (placebo group, n = 28) received standard analgesia and placebo. Patients were offered a closely monitored trial for spontaneous stone passage in the 4-week period prior to definitive therapy. The stone expulsion rate, number and duration of pain episodes, need for analgesia and possible side effects of medications were observed. RESULTS All patients completed the study and none were excluded due to side effects. No significant differences were found between the groups for age, gender and stone size. Mean patient age was 8.1 ± 6.8 years. There were 25 females and 36 males. The stone-free rate was 87.8% in Group I (29/33), compared with 64.2% (18/28) in Group II. A mean stone expulsion time of 8.2 and 14.5 days was recorded for Group I and II respectively, and this difference was statistically significant (P < 0.001). CONCLUSIONS Medical expulsion therapy for lower ureteric stones is a successful procedure in children. Tamsulosin demonstrated no clinically significant adverse effect, while proving to be a safe and effective treatment option.

Retrograde Intrarenal Surgery Monotherapy Versus Shock Wave Lithotripsy for Stones 10 to 20 mm in Preschool Children: A Prospective, Randomized Study

PURPOSE We compared the outcome of retrograde intrarenal surgery monotherapy vs shock wave lithotripsy for stones 10 to 20 mm in preschool children. MATERIALS AND METHODS This prospective study included 60 children with a mean ± SD age of 2.4 ± 1.3 years. Patients were randomly divided into 2 groups. Group 1 underwent shock wave lithotripsy and group 2 underwent retrograde intrarenal surgery as monotherapy. Retrograde intrarenal surgery was started using a 7.5Fr semirigid ureteroscope (Storz®) and the holmium laser, and completed by the Flex X™2 flexible ureterorenoscope. A ureteral access sheath was not used and only hydrodilatation was performed. Patients were evaluated preoperatively by ultrasound and plain abdominopelvic x-ray. Followup was 3 months. RESULTS The stone-free rate after a single session treatment was 70% and 86.6% in groups 1 and 2, respectively. Mean operative time was 27.9 ± 3.5 and 40 ± 7.8 minutes, mean fluoroscopy exposure time was 60 ± 42 and 50 ± 35 seconds, and mean hospital stay was 6 ± 2 and 12 ± 8 hours, respectively. No major complication occurred in either group and no child in either group received blood transfusion. Nine group 1 patients needed a second shock wave lithotripsy session, of whom 2 required a third session. At 3 months the overall stone-free rate was 93.3% and 96.6% in groups 1 and 2, respectively. CONCLUSIONS Retrograde intrarenal surgery is an option for treating medium sized renal stones in preschool children with results comparable to those of shock wave lithotripsy and a safe short-term outcome.

Augmentation ureterocystoplasty in boys with valve bladder syndrome

OBJECTIVE Children with valve bladder syndrome represent the worst end of the posterior urethral valve spectrum. When conservative measures fail to control recurrent infections, prevent deterioration of the upper tract (in the form of increasing hydronephrosis and or worsening of kidney function) and improve incontinence, augmentation cystoplasty is considered. In most of these boys, renal insufficiency precludes the use of intestine for augmenting the bladder. Our aim was to evaluate the efficacy and safety of ureterocystoplasty in managing children with valve bladder syndrome. PATIENTS AND METHODS Eight boys (mean age 5 years) with valve bladder syndrome were included in this study. All boys had successful valve ablation at the time of presentation. When conservative treatment failed, ureterocystoplasty was scheduled. The entire ureter was folded and used in four boys after nephrectomy for a non-functioning kidney. The lower dilated ureter was used to augment the bladder, and transureteroureterostomy in two and re-implantation of the remaining ureter in two were performed. Radiological and urodynamic investigation was performed preoperatively and postoperatively at 3, 6 and 12 months. Improvement of hydroureteronephrosis was judged by ultrasound. RESULTS Bladder capacity (as measured during cystometry at 30 cmH(2)O) and compliance were significantly improved in all children following the procedure (P<0.001), and reached or exceeded the normal calculated capacity for age-matched boys. Hydroureteronephrosis improved in six boys (75%). The procedure avoids almost all the complications of enterocystoplasty. Clean intermittent self-catheterization was performed in all cases routinely after surgery, weaning off as judged by the voiding pattern of the child. CONCLUSION Ureterocystoplasty is an ideal option for augmenting the hypocompliant bladder in boys with valve bladder syndrome. The entire ureter or the dilated lower part can be used. This is a solution for boys with impaired renal function when enterocystoplasty cannot be performed.

Early Valve Ablation Can Decrease the Incidence of Bladder Dysfunction in Boys With Posterior Urethral Valves

PURPOSE Valve bladder syndrome represents the worst end of the posterior urethral valve spectrum. Recent data suggest that early valve ablation can provide the chance for the bladder to heal and improve dynamics. We tested the hypothesis that early valve ablation can decrease the incidence of bladder dysfunction in these boys. MATERIALS AND METHODS A total of 16 full-term males with prenatally diagnosed hydronephrosis and a full bladder proved postnatally to have posterior urethral valve were studied. Valve ablation was performed during the neonatal period (group 1). The records of 16 boys with posterior urethral valves who underwent valve ablation after age 1 year were obtained (group 2). Ultrasound was performed every month and urodynamics were performed every 6 months. At age 3 years voiding diary and toilet training results were obtained. The incidence of bladder dysfunction in the 2 groups was recorded according to clinical, ultrasound, voiding cystourethrogram and urodynamic parameters. RESULTS Mean followup was 3 years. Post-void residual urine, measured as more than 30% of expected bladder capacity for age, improved in 14 patients (87.5%) in group 1 and in 10 (62.5%) in group 2. Excluding cases of vesicoureteral reflux-renal dysplasia syndrome, vesicoureteral reflux was present in 20 renal units initially in group 1 and showed resolution or improvement in 16. In group 2 vesicoureteral reflux was present in 26 units and improved in 14. At last followup mean cystometric bladder capacity, measured at 30 cc H(2)O, in group 1 was 145 +/- 22 ml which was comparable to age matched normal bladder capacity. In group 2 mean +/- SD cystometric bladder capacity was 130 +/- 30 ml, which was significantly lower than age matched normal bladder capacity. Hypocompliance and instability were significantly lower in group 1. Toilet training was easier and yielded better results for dryness in group 1. Overall bladder dysfunction was present in 2 boys (12.5%) in group 1 and in 8 (50%) in group 2. CONCLUSIONS Neonatal valve ablation would protect the bladder and allow normal cycling, which helps in bladder healing. This underscores the importance of routine prenatal screening and early intervention at a specialized center.

Radiolucent Renal Stones in Children: Combined Use of Shock Wave Lithotripsy and Dissolution Therapy

OBJECTIVES To provide a noninvasive efficient modality for the treatment of radiolucent renal stones in children. Uric acid calculi comprise a significant proportion of urinary stones. METHODS This study included 24 children (10 girls and 14 boys) with radiolucent renal stones. Of the 24 patients, 5 presented with bilateral renal stones, 8 with multiple stones, 4 with staghorn stones, and 7 with a solitary renal stone. Their age range was 2-12 years (mean 6.3 +/- 2.8). The stone size range was 12-65 mm in the largest diameter. All patients were treated with combined extracorporeal shock wave lithotripsy (ESWL) and medical therapy in the form of urinary alkalization using potassium sodium hydrogen citrate and allopurinol for the treatment of hyperuricosuria. Before ESWL, 3 patients had a percutaneous nephrostomy tube inserted and 2 patients had a ureteral stent placed to relieve obstruction. ESWL was performed with a Siemens Lithostar using either general anesthesia or intravenous sedation. The follow-up period after stone clearance was 12-36 months (mean 26 +/- 7.2). RESULTS The stone-free rate of 100% was achieved in all 24 patients after 3 months of combined use of extracorporeal shock wave lithotripsy and dissolution therapy. CONCLUSIONS Combined ESWL and dissolution therapy accelerated stone clearance and delayed stone recurrence. The use of ESWL and medical therapy as a combined modality is a safe and effective treatment of radiolucent renal stones in children.

Z-plasty for sculpturing of the bifid scrotum in severe hypospadias associated with penoscrotal transposition

PURPOSE Bifid scrotum is usually associated with scrotal and perineal hypospadias. Conventional surgical repair involves rotation of two scrotal flaps, joining them in the midline, and vertical skin closure. Dimpling of skin can occur, resulting in suboptimal aesthetic results. We describe a technique whereby the bifid scrotum is rebuilt and contoured using single or multiple Z-plasties. METHODS We repaired 43 children with scrotal, penoscrotal or perineal hypospadias and varying degrees of bifid scrotum. Age range was 5 months-18 years. Patients were divided into three groups: I) 26 children with primary perineoscrotal hypospadias who underwent two-stage hypospadias repair and had a Z-scrotoplasty during either the first or second stage repair; II) 11 children who had previous hypospadias surgery with vertical closure of scrotum, and who underwent secondary Z-scrotoplasty; III) 6 children with primary posterior hypospadias who had their scrotum repaired with midline vertical closure, serving as control. RESULTS 24 children in Group I and all patients in Group II achieved excellent aesthetic results, with rounded scrotum, no midline dimpling and no major complications. Midline dimple was encountered in 4 patients in Group III. CONCLUSIONS In repairing bifid scrotum associated with hypospadias, the principle of Z-plasty can be incorporated in scrotal contouring. This elongates, relaxes and interrupts the longitudinal tension of the midline closure. Multiple Z-plasties avoid contracture and scar formation, which are apt to result in recurrence of bifid scrotum.

Penile advancement and lengthening for the management of post-circumcision traumatic short penis in adolescents.

OBJECTIVES To report on the safety of combing suprapubic fat liposuction, penile suspensory ligament severing, and Z-plasty of penoscrotal webbing for penile lengthening in cases of post-circumcision traumatic short penis in adolescents. METHODS This prospective study was conducted in 9 male patients with a mean age of 15.6 ± 1.4 years. All patients had a short penis because of traumatic amputation of the glans in 7 patients and both glanular and partial distal corporal loss in 2 patients during circumcision. All were initially treated in childhood by penile skin advancement for phallic coverage. Penile length and circumference were measured pre- and post-operatively, both in the flaccid state at maximal stretch and in the erect state. Operative technique included Z-plasty of penoscrotal web, release of suspensory ligament, and suprapubic fat liposuction. RESULTS Average functional penile length measured 3 months post-operatively had significantly increased by 18-30 mm (mean: 23 ± 4 mm) in the provoked, erect state. All patients had normally developed penile corpora cavernosa and wide circumference (mean: 11.7 ± 0.2 cm). No post-operative complications occurred in any of the patients. No patients had sexual partners or were sexually active. CONCLUSIONS The described technique of penile advancement and lengthening can be safely applied to patients with post-circumcision traumatic short penis.

Percutaneous nephrolithotomy for the management of stones in anomalous kidneys in children

PURPOSE We report percutaneous nephrolithotomy for the management of stones in anomalous kidneys in children. MATERIALS & METHODS We performed PCNL on 6 children (one with bilateral stones), 3 boys and 3 girls with anomalous kidneys. Three had horseshoe kidneys, 2 malrotated kidneys, and one crossed fused ectopic kidney. Their age ranged from 5 to 12 years with a mean of 7.3 ± 3 years. Two patients had previous failed ESWL, 4 underwent PCNL for large stone burden. Mean stone burden was 324.9 ± 191.8 mm(2). Under fluoroscopic guidance we performed serial dilatation using Alken metal dilators. In 4 patients 17 Fr rigid nephroscope was used, in 2 patients 26 Fr nephroscope was utilized. Pneumatic lithotripsy was used for stone disintegration and forceps for stone extraction. RESULTS A single stage PCNL resulted in complete stone clearance in 5 children, while one required a second look procedure. Operative time ranged from 25 to 70 min with a mean of 43.3 ± 17.8 min. None of the patients required blood transfusion. Perforation of the renal pelvis occurred in one patient and was managed by prolonged insertion of nephrostomy tube. Hospital stay ranged from 1 to 6 days with a mean of 3 ± 2 days. Postoperative fever occurred in one child and persisted for 3 days. All children were followed for 3 months and were stone free. Patient with bilateral stones performed ESWL on the contra lateral side. CONCLUSION Children with stones in anomalous kidneys can be managed safely with PCNL when they are properly selected.

Corporeal Body Grafting Using Buccal Mucosa for Posterior Hypospadias With Severe Curvature

PURPOSE Severe penile curvature correction by corporeal body grafting has been successfully performed using various grafts and biomaterials. We present our initial experience with buccal mucosa as a free corporeal graft to correct severe penile curvature as part of a multistage approach to posterior hypospadias repair. MATERIALS AND METHODS A total of 12 children with a mean age of 6.2 years (range 4 to 8) with posterior hypospadias and severe ventral chordee (greater than 45 degrees) necessitating ventral grafting underwent correction using buccal mucosa. Preoperative androgen supplement was given when penile and glanular size was significantly small for age. Buccal mucosa was harvested from the inner side of the cheek or the lower lip. The harvested graft was defatted, fashioned and fixed to the ventral corporeal defect. The pre-grafting penile angle, immediate post-grafting angle and penile angle at 6 months were assessed. RESULTS All children had penoscrotal or perineal hypospadias, 4 had partial androgen insensitivity syndrome and 1 underwent multiple previous failed repairs. Androgen was given preoperatively in 3 children. After chordee release and urethral plate transection the penile angle was between 45 and 80 degrees. Mean graft length and width was 2.5 and 1.6 cm, respectively. All children had a straight penis at the end of the procedure and none required additive dorsal plication. At the last followup at 12 months all children had a straight penis except 2 with mild curvature (less than 10 degrees). No complications were noted with this technique. CONCLUSIONS Preliminary results of the novel use of buccal mucosa as a corporeal graft for severe chordee appear satisfactory. Longer term followup is needed to further document these data.

Partial Penile Disassembly for Isolated Epispadias Repair

OBJECTIVES Isolated male epispadias defect is present in 10% of cases of epispadias-exstrophy complex. Surgical repair of epispadias malformation remains debatable as evident by the different techniques adopted. The current study presents our experience in partial penile disassembly for isolated epispadias repair. METHODS Epispadias repair was performed on 11 male patients aged 4 to 13 years. Two were penopubic, 6 penile, and 3 glanular. All cases were fresh. Extensive disassembly of penile components was performed to the corporal attachments down to the horizontal branches of pubic bones. The corporal bodies were separated with the urethral plate left attached to 1 corpus to preserve its blood supply. Urethral plate was tubularized and then transported from dorsal to ventral position by using corporal rotation technique. Glanuloplasty was then performed. Patients were followed up for 6 to 12 months. RESULTS The penis had a satisfactory cosmetic appearance with no significant dorsal chordee. Two cases were transformed to subcoronal hypospadias, as it was difficult to bring the urethral plate to the tip of the glans because of its shortening. One child had a minute penopubic fistula that was repaired at a later stage. CONCLUSION Partial penile disassembly technique restores the anatomic relationship of the penile components. Our repair of partial penile disassembly is a simple modification of the Mitchell technique for isolated epispadias repair.