Khaled Madbouly

Determination of the chemical composition of urinary calculi by noncontrast spiral computerized tomography

Various techniques for noncontrast spiral computerized tomography (NCCT) were utilized for the determination of the Hounsefield unit (HU) values of various types of urinary calculi with the aim of determining the best technique for distinguishing various stones compositions. A total of 130 urinary stones, obtained from patients who underwent open surgery, were scanned with a multidetector row scanner using 1.25xa0mm collimation at two energy levels of 100 and 120xa0kV at 240xa0mA. Two post-scanning protocols were used for the HU value assignment, tissue and bone windows, for both kV values. In both protocols, three transverse planes were defined in each stone, one near the top, one in the middle, and one near the bottom. Three regions of interest (ROI) were obtained in each plane. The absolute HU value was determined by three methods: the mean of the nine ROI, the mean of the central three ROI, and the central ROI in the middle plane. Determination of the stones’ composition was performed using the absolute HU value measured at 120xa0kV, the dual CT values (HU values at 100xa0kV−HU values at 120xa0kV), and HU values/stone volume ratio (HU density). All stones were analyzed by x-ray diffraction to determine their chemical composition. After the exclusion of groups with few calculi, 47 pure stones [25 uric acid (UA), 15 calcium oxalate monohydrate (COM), seven struvite], and 60 mixed stones [15 COM 60–90%+hydroxyl apatite (HA), 14 COM 40–90%+UA, 21 UA+COM <40%, ten mixed struvite+COM+hydroxyl apatite] were included in the statistical analysis. From the least to the most dense, the pure stone types were UA, struvite, COM. Mixed UA+COM<40% calculi were less dense but insignificantly different from pure UA, while when the COM ratio was ≥40% their density became higher than and significantly different from pure UA, and less than but not significantly differentiated from pure COM. Mixed COM+HA were the most dense stones. Using the absolute HU values at 120xa0kV and HU density, we could distinguish, with statistical significance, all pure types from each other, pure UA from all mixed calculi except UA+COM <40%, pure COM from mixed UA+COM <40%, and pure struvite from all mixed stones except mixed struvite stones. Dual CT values were not as good as absolute HU values and HU density in the determination of stone composition. These results demonstrate that absolute HU values and HU density derived from CT scanning using a small collimation size could uncover statistically significant differences among all pure and most of the mixed urinary stones. This permits more accuracy in the prediction of stone composition. Moreover, this technique permits diagnostic conclusions on the basis of single CT evaluation.

IMPACT OF LOWER POLE RENAL ANATOMY ON STONE CLEARANCE AFTER SHOCK WAVE LITHOTRIPSY: FACT OR FICTION?

PURPOSEnWe determined whether there is a significant relationship between the spatial anatomy of the lower pole on preoperative excretory urography and stone fragment clearance after shock wave lithotripsy.nnnMATERIALS AND METHODSnThe anatomical factors affecting lower pole stone clearance after shock wave lithotripsy were evaluated retrospectively in 108 patients. Stone-free status was assessed by renal computerized tomography with or without renal ultrasound. The stone-free rate at 3 months was correlated with lower pole infundibular length and width in mm. as well as with the lower pole infundibulopelvic angle in degrees. The statistical significance of each lower pole anatomical factor as well as other stone, renal and treatment factors were correlated with the stone-free rate using the Mann-Whitney and chi-square tests.nnnRESULTSnThree months after shock wave lithotripsy 79 patients (73.1%) were free of stones. Mean lower infundibular length plus or minus standard deviation was 20.9 +/- 6.56 mm., mean infundibular width was 5.65 +/- 2.34 mm. and the mean lower pole infundibulopelvic angle was 48.33 +/- 14.84 degrees. In 49 (45.4%) and 59 (54.6%) patients infundibular length was greater than 3 cm. and 3 cm. or less, respectively. Infundibular width was greater than 5 mm. and 5 mm. or less in 45 (41.7%) and 63 (58.3%) patients, respectively. No obtuse infundibulopelvic angles were noted. None of the 3 lower pole anatomical factors had any significant impact on the stone-free rate at 3 months. Renal morphology was the only factor significantly affecting the stone-free rate since stone clearance was significantly less in pyelonephritic kidneys (p = 0.0009).nnnCONCLUSIONSnDifferences in the intrarenal anatomy of the lower pole have no significant impact on stone clearance after shock wave lithotripsy. Further examination of the lower pole renal anatomy with a search for other contributing factors is still warranted.

Risk factors for the formation of a steinstrasse after extracorporeal shock wave lithotripsy: A statistical model

PURPOSEnWe studied the various stone, renal and therapy factors that could affect steinstrasse formation after extracorporeal shock wave lithotripsy (ESWL), Dornier Medical Systems Inc., Marietta, Georgia to define the predictive factors for its formation. Thus, steinstrasse could be anticipated and prophylactically avoided.nnnMATERIALS AND METHODSnBetween February 1989 and May 1999, 4,634 patients were treated with a Dornier MFL 5000 lithotriptor (Dornier Med Tech, GmbH, Germany). Renal stones were encountered in 3,403 patients and ureteral stones in 1,231. Steinstrasse were recorded in 184 patients, of whom 74 required intervention and formed the complicated group. All patient data, stone and renal characteristics, and data of ESWL were reviewed. Univariate and multivariate statistical analyses of patients, stones and therapy characteristics in correlation with the incidence of steinstrasse formation were performed to assign the factors that had a significant impact on steinstrasse formation.nnnRESULTSnThe overall incidence of steinstrasse was 3.97%. The steinstrasse was in the pelvic ureter in 74% of the cases, lumbar ureter in 21.7% and iliac ureter in 4.3%. Steinstrasse incidence significantly correlated with stone size and site, the power level (kV.) used during therapy and radiological renal features. Steinstrasse was more common with renal stones more than 2 cm. in diameter in a dilated system, especially with the use of high power (greater than 22 kV.) for disintegration. A statistical model was constructed to estimate the risk of steinstrasse formation accurately.nnnCONCLUSIONSnStone size and site, renal morphology and shock wave energy are the significant predictive factors controlling steinstrasse formation. If a patient has a high probability of steinstrasse formation, close followup with early intervention or prophylactic pre-ESWL ureteral stenting is indicated.

Extracorporeal shock wave lithotripsy in children: experience using two second‐generation lithotripters

Objectives To assess the value of extracorporeal shock wave lithotripsy (ESWL) in treating paediatric urolithiasis, and to determine factors that may affect the results.

Extracorporeal shock wave lithotripsy in anomalous kidneys: 11-year experience with two second-generation lithotripters

OBJECTIVESnTo present our experience with extracorporeal shock wave lithotripsy (ESWL) in patients with anomalous kidneys and to determine the factors that may influence the stone-free rate in such patients.nnnMETHODSnFrom February 1989 to February 2000, 198 patients were treated for urolithiasis in anomalous kidneys using ESWL. The mean patient age (SD) was 40.48 (11.53) years. The kidneys were horseshoe in 49 (24.7%), malrotated in 120 (60.6%), and duplex in 29 (14.7%). All patients were treated on an outpatient basis using two second-generation lithotripters (Dornier MFL 5000 and Toshiba Echolith). Pretreatment auxiliary measures were required in 6 patients (3%). Follow-up data were recorded at 3 months. The statistical analysis was performed using the chi-square and Mann-Whitney U tests, with differences considered statistically significant if P <0.05.nnnRESULTSnThe mean stone length (SD) was 13.54 (5.49) mm. The stones were single in 148 (74.7%), of new onset in 155 (78.3%), and on the right side in 82 (41.4%). All stones, but 5 (2.5%), were radiopaque. The overall stone-free rate was 72.2%. Neither the type of renal anomaly nor the type of lithotripter had any impact on the stone-free rate (P >0.05). Stone burden (length and number) had a significant influence on the stone-free rate (P <0.05). No extraordinary complications were recorded. Steinstrasse developed in 7 patients (3.5%). No deterioration of renal function or configuration was detected.nnnCONCLUSIONSnESWL is safe and reliable for treatment of urolithiasis in anomalous kidneys. It should be the primary therapy when the stones are less than 20 mm. The ESWL outcome is comparable for normal and anomalous kidneys when the calculus size is considered.

The urethral Kock pouch: long-term functional and oncological results in men

The Department of Urology in Mansoura has a well‐known experience in, among many things, urinary tract reconstruction in patients with bladder cancer. They review their results in 338 male patients who had a radical cystectomy and Kock pouch. They found good functional and oncological outcomes in properly selected patients. However, they also drew attention to several valve‐related complications.

Extracorporeal shock-wave lithotripsy monotherapy of partial staghorn calculi : Prognostic factors and long-term clinical results

Objective. To define factors affecting the success and long-term outcome of extracorporeal shock-wave lithotripsy (ESWL) monotherapy of partial staghorn calculi. Material and methods. We retrospectively reviewed 92 patients with partial staghorn calculi who were treated with ESWL monotherapy. The outcome of the treatment was evaluated after 3 months. Long-term follow-up data (>24 months) were available for 49 patients. These data were further analyzed to determine long-term outcome. Results. At 3 months, the overall stone-free rate was 59.8%. Multiple ESWL sessions were required in 85.8% of patients. Stone surface area >500u2009mm2 was the only factor that significantly decreased the stone-free rate. Post-ESWL complications occurred in 12 patients (13%), among whom renal obstruction was observed in 10.8%. Secondary procedures were needed in 17 cases (18.4%). After a mean follow-up period of 7.5 years, the stone-free rate was 59.2% (29/49) and one-third of patients developed recurrence. In the long term, clinically insignificant residual fragments (CIRFs) passed spontaneously in 23% of patients, remained stable in 38.5% and became bigger in 38.5%. Regrowth of CIRFs was related to a history of stone recurrence. No patients showed deterioration of kidney function on the treated side and an improvement in pre-ESWL hydronephrosis was observed in 73.3% of patients. Conclusions. ESWL is suitable for staghorn stones ≤500u2009mm2. In the long term, CIRFs became bigger and required secondary intervention in one-third of patients. A history of stone recurrence is a significant predictor of regrowth of CIRFs. ESWL provides long-term preservation of function of the treated kidneys; however, one-third of patients develop recurrence.

Efficacy of Local Subcutaneous Anesthesia Versus Intramuscular Opioid Sedation in Extracorporeal Shockwave Lithotripsy: A Randomized Study

PURPOSEnTo evaluate the analgesic efficacy of local subcutaneous (SC) anesthesia compared with intramuscular (IM) opioid sedation during extracorporeal shockwave lithotripsy (SWL) in a randomized study.nnnPATIENTS AND METHODSnAfter informed consent was obtained, 125 patients with urolithiasis who were scheduled for SWL were included in the study. The patients in each treatment session were randomized to receive either IM meperidine (group A) or SC infiltration of 10u2009mL 2% lidocaine and 10u2009mL 0.5% bupivacaine at the area of shockwave entry (group B). Degree of pain was rated by the patient using a five-point visual analogue scale (VAS).nnnRESULTSnThe study included 88 (70.4%) men and 37 (29.6%) women with a mean age of 47.6u2009±u200912.5 years and a mean body mass index (BMI) of 28.16u2009±u20094.67u2009kg/m2. Of the patients, 89, 26, and 10 received a single, two, or more than two treatment sessions, respectively (176 sessions). Maximum stone length was 10.68u2009±u20095.12u2009mm. Pretreatment stent placement was performed in 17 (13.6%) patients (28 sessions). Group A comprised 89 treatment sessions while 87 were involved in group B. Both groups were similar. Supplemental intrvenous sedation was needed in two (2.5%) and four (4.6%) sessions in groups A and B, respectively. VAS was not different between both groups (Pu2009=u20090.063). Patients with pretreatment stent placement had significantly lower VAS score compared with patients without stents (Pu2009=u20090.012). Sex and BMI had no impact on the VAS score.nnnCONCLUSIONSnLocal SC anesthesia alone is effective for analgesic purposes during extracorporeal SWL. Sex, age, and BMI have no relation to analgesia requirement.

Association of the modified frailty index with adverse outcomes after penile prosthesis implantation

Abstract Objectives: To investigate frailty as a predictor of surgical outcome in elderly patients undergoing penile prosthesis implantation. Material and methods: A total of 54 elderly patients, above 60 years of age, underwent penile prosthesis implantation between 2012 and 2014. Their data were collected and retrospectively analyzed. A modified frailty index (mFI) was calculated for each patient based on 11 risk factors from the Canadian Study of Health and Aging Frailty Index. The 1-year adverse outcomes were correlated with mFI, patients’ and procedure’s risk factors. Results: Mean age was 64.9u2009±u20095.2 years. No mortality was reported in our patients, however, one-year adverse outcomes were encountered in 43 (79.6%) patients. Among all studied variables, the 1-year adverse outcomes was not significantly association with mFI, but with preoperative glycosylated hemoglobin A1c (HbA1c) (pu2009=u20090.031) and associated Peyronie’s disease (PD) (pu2009=u20090.000). HbA1c, dyslipidemia, hypertension, PD and duration of the procedure were predictive of infection complications (pu2009<u20090.05). Only PD and HbA1c sustained an independent significant impact. Conclusions: mFI is not a predictive of post-penile prosthesis implantation adverse outcomes in elderly patients with impotence. Degree of diabetic control and association with PD was associated with the 1-year adverse outcomes and infection complications.

A Prospective Randomized Study of Pfannenstiel Versus Expanded Port Site Incision for Intact Specimen Extraction in Laparoscopic Radical Nephrectomy

PURPOSEnTo compare intra- and postoperative outcome of patients undergoing laparoscopic radical nephrectomy with intact specimen extraction through a Pfannenstiel (PFN) transverse suprapubic or expanded port site (EPS) incision in a prospective randomized fashion.nnnPATIENTS AND METHODSnPatients undergoing laparoscopic transperitoneal radical nephrectomies for suspected renal tumors were randomized for intact renal specimen extraction via a PFN or EPS incision. Operative, perioperative, 1 week, 6 weeks, and 6 months postoperative parameters were prospectively recorded and analyzed including specimen weight, size in maximum diameter, incision length, total operative time, extraction time, estimated blood loss, length of hospital stay, pain score in the postoperative holding area and on the first post operative day, narcotic consumption, time to fluid intake/full diet intake, unassisted ambulation, cosmesis, and wound-related complications. A postoperative quality-of-life questionnaire was also filled out by all the patients.nnnRESULTSnOur series included 51 patients: 26 in the PFN group and 25 in the EPS group. The two groups were similar in demographic characteristics and intraoperative and postoperative parameters apart from a longer PFN incision (P<0.00). First postoperative day pain score was significantly less in the PFN group than in the EPS group (P=0.023). Complication rate was less in the PFN group, although not statistically significant. Hospital stay was significantly shorter in the PFN than in the EPS group (P=0.01). Mean cosmesis and operative satisfaction scores at week 1, week 6, and 6 month visits were not significantly different between both groups. Compared with the EPS group, PFN group patients significantly will choose the same operation if they would do it again (P=0.004).nnnCONCLUSIONSnPFN incision has less morbidity, pain score, and hospital stay compared with EPS incision for intact specimen extraction after transperitoneal laparoscopic radical nephrectomy. Both incisions are associated with high operative satisfaction, good cosmesis, and a low rate of wound complications.