Islam Junaid

The Management of Bladder Lithiasis in the Modern Era of Endourology

The recent evolution in the management of vesical lithiasis is a result of the major advancements of modern endourology. The ideal method for achieving stone clearance, however, remains an issue of debate and evidence-based recommendations are lacking. Contemporary literature focuses on management options, such as extracorporeal shockwave lithotripsy, transurethral, percutaneous and minimally-invasive surgery, as well as state-of-the-art energy sources. Issues of particular interest include the results of comparative studies, the management of lithiasis in the paediatric population and the recent challenge of the traditional dogma that dictated BPH surgery for the management of vesical lithiasis secondary to bladder outlet obstruction.

Human papillomavirus is detected in transitional cell carcinoma arising in renal transplant recipients

Aims: We investigated the role of human papillomavirus (HPV) in the development of transitional cell carcinoma (TCC) arising in renal transplant recipients. Methods: Genomic DNA was extracted from 10 µm paraffin embedded sections of five TCCs arising in five renal transplant recipients using the QIAamp DNA mini kit according to the manufacturers instructions. β‐globin PCR was performed to test DNA adequacy. Samples were tested for the presence of HPV DNA by broad spectrum HPV PCR method using non‐biotinylated SPF10 primers (SPF1A, SPF1B, SPF1C, SPF1D, SPF2B, SPF2D) which amplify a short 65 bp fragment. Positive bands were identified on a 3% gel. Positive samples underwent a second HPV PCR and were amplified using biotinylated SPF10 primer set, which amplifies the same 65 bp region of the L1 open reading frame. INNO‐LiPA line probe assay was then performed to genotype the samples which uses a reverse hybridisation principle. Results: Four of five TCCs examined were positive for HPV. The high risk HPV16 was detected in three cases whereas in the fourth case an unclassifiable HPV genotype was present. In all DNA samples, β‐globin amplification was successful. Conclusions: Our results indicate that HPV and in particular HPV16 may play an aetiological role in the development of TCC in renal transplant patients.

A Training Model for Suprapubic Catheter Insertion: The UroEmerge™ Suprapubic Catheter Model

Suprapubic catheter insertion is a fundamental practical skill that all clinicians should be familiar with, yet there are great practical difficulties in training in this area. A training model was designed to facilitate teaching, and then this model was subsequently tested in an emergency urology practical skills course.

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.

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.

The Development of the Modern Prostate Biopsy

In the 1950s prostate cancer was known to occur in about 20% of men over the age of 55 and was the cause of death in about 5% of white men over the age of 50 (Huggins and Johnson, 1947). It accounted for 90% of all male genital cancers and 63% of male genitourinary cancers and it was believed that 5-10% of prostatic cancers were diagnosed early enough to permit operation with a reasonable chance of cure (Kaufman et al., 1954). Clearly diagnosis was paramount in order to initiate treatment and improve prognosis. The current accepted practice of diagnosing prostate cancer relies on histopathological examination of prostatic tissue obtained through transrectal ultrasound (TRUS) guided biopsy of the gland (Heidenreich et al, 2010). The TRUS-guided transrectal method of obtaining prostatic tissue has been described since the mid-1980s but before then, other methods of sampling the prostate gland were used. This chapter describes the development of the modern prostate biopsy from the techniques of the early 1900s of transperineal open biopsy to the current method of using ultrasound guidance to allow transrectal prostate biopsies.

Characterising Stent Symptoms Associated with a Segmental Thermo-Expandable Metallic Stent Using a Validated Stent Symptoms Questionnaire

Background: We use the Memokath 051TM, a segmental nickel-titanium alloy ureteric stent in patients with strictures and aim to characterize symptoms following stent insertion and evaluate its tolerability using a validated questionnaire. Methods: We mailed the validated ureteral stent symptom questionnaire to all patients who had undergone insertion of a ureteric Memokath 051TM stent over a one-year period. Responses were analyzed to evaluate the frequency and severity of symptoms in all 6 domains tested by the questionnaire. Results: Eighteen out of 23 patients completed the ureteral stent symptom questionnaire. In patients with unilateral stents; dysuria, severe frequency, nocturia, severe urgency and urge incontinence were seen in 28.6, 43, 72, 43 and 43% respectively. Severe frequency, urgency and dysuria in patients with bilateral stents were reported by 66, 25, and 50% respectively. Frank hematuria was reported by 29% of patients with unilateral stents. Lethargy was experienced by 23 and 25% of patients with unilateral and bilateral stents respectively with 75% of patients enjoying their social life. Conclusion: Although the study population is small, our results indicate that Memokath 051TM stents are well tolerated by patients in terms of quality of life. This study provides important information about stent related symptoms in patients undergoing this procedure.

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.

Use of a long-term metal stent in complex uretero-ileal anastomotic stricture.

Abstract Uretero-ileal anastomotic stricture is a potentially serious late complication after ileal conduit formation, with a reported incidence of 3–9%. The standard management technique is open surgical revision of the anastomosis with reimplantation of the affected ureter. This is technically challenging and has potential significant morbidity for the patient. Advances in endourological techniques now offer a variety of less-invasive treatment options, like balloon dilatation or laser ureterotomy followed by stent insertion. What happens when such open and minimally invasive techniques fail? Recently, using a combined antegrade and retrograde approach, we inserted a novel, semi-permanent, dual-expansion thermo-expandable metallic alloy stent across a recurrent ileal-ureteric stricture. We describe the technique and potential advantages of this minimally invasive method. This minimally invasive treatment option is of interest, as in contrast to other stents, it does not require routine change, and is resistant to corrosion and urothelial ingrowth, hence ensuring ease of exchange or removal if required.