Khalid Fouda Neel

Total endoscopic management (TEM approach) of children with non-compliant neuropathic bladder: A preliminary report

PURPOSEnWe prospectively evaluated the efficacy and durability of a combination of intradetrusor botulinum-A toxin (BTX-A) and endoscopic treatment of vesicoureteric reflux (VUR) to manage children with myelomeningocele (MMC) and non-compliant refluxing bladders who were not responding to standard conservative therapy. We also evaluated whether this combined therapy can lower intravesical pressure, increase bladder capacity, gain social continence and protect the upper tract from recurrent urinary tract infection.nnnMATERIAL AND METHODSnA total of 10 patients with a mean age of 5.9+/-3.6 years (range 2-12 years) with MMC (eight females and two males) were prospectively involved in the study. All patients were fully compliant to clean intermittent catheterization, and all were non-responders (failed to gain continence and/or poor compliance) to the maximum tolerable dose of anticholinergics and catheterization. All patients were subjected to cystoscopic intradetrusor injection of 12 U/kg (maximum 300 U) of BTX-A in an infection-free bladder. They all had VUR (16 refluxing ureters, six patients with bilateral VUR) and did not show resolution in the pretreatment voiding cystourethrogram; accordingly, submucosal injection of Deflux was performed either with the second BTX-A treatment (initial four patients) or with the first BTX-A treatment (the other six patients). The grade of reflux was G III, IV and V in three, seven and six ureters, respectively.nnnRESULTSnThe maximum bladder capacity increased significantly from 79+/-49 to 155+/-57 ml (p<0.022), and the maximum detrusor pressure decreased significantly from 55+/-16 to 37+/-11 cm H(2)O (p<0.001). Fifteen out of 16 (93.75%) refluxing ureters were completely resolved (one of them on second attempt), and one (6.25%) (GV reflux) remained unchanged despite of two attempts. Of six incontinent patients, five reached complete dryness between catheterizations and one showed partial improvement.nnnCONCLUSIONSnA combination of BTX-A and endoscopic correction of VUR is a simple and effective way to overcome the increased risk of high intravesical pressure and recurrent UTI. This treatment decreases the incidence of renal damage in children on whom conservative management fails to help, in a minimally invasive way.

Total Endoscopic and Anal Irrigation Management Approach to Noncompliant Neuropathic Bladder in Children: A Good Alternative

PURPOSEnWe prospectively evaluated the efficacy and durability of combined intradetrusor botulinum-A toxin and endoscopic treatment for vesicoureteral reflux with anal irrigation as a total endoscopic and anal irrigation management approach. This minimally invasive protocol is used to manage myelomeningocele and noncompliant bladder in children who do not respond to standard conservative therapy and have urine and stool incontinence.nnnMATERIALS AND METHODSnTen females and 3 males with a mean +/- SD age of 5.3 +/- 2.5 years with myelomeningocele and vesicoureteral reflux who did not respond to standard conservative treatment were prospectively included in this study. All had at least 1 year of followup. All patients received a cystoscopic intradetrusor injection of 12 U/kg (maximum 300 U) botulinum-A toxin into an infection-free bladder. Vesicoureteral reflux in a total of 20 refluxing ureters, including bilateral vesicoureteral reflux in 7 patients, showed no resolution on pretreatment voiding cystourethrogram. Thus, we administered a submucosal Deflux injection. Since most patients were still diaper dependent due to stool incontinence, we extended management to include complete bowel rehabilitation with the new Peristeen anal irrigation system to manage stool incontinence.nnnRESULTSnMean maximum bladder capacity increased significantly from 75 +/- 35 to 150 +/- 45 ml after 1 month (p <0.02), to 151 +/- 48 after 6 months (p <0.002) and to 136 +/- 32 after 1 year (p <000). Maximum detrusor pressure decreased significantly from 58 +/- 14 to 36 +/- 9 cm H(2)O after 1 month (p <0.001), to 39 +/- 9 after 6 months (p <0.001) and to 38 +/- 6 after 1 year (p = 000). Of 20 refluxing ureters (95%) completely resolved, including 1 after attempt 2, and 1 with grade V vesicoureteral reflux remained unchanged despite 2 attempts. Seven of 8 urinary incontinent patients (87.5%) attained complete dryness between catheterizations and 1 partially improved. Ten of 13 patients achieved stool dryness with anal irrigation 1 to 2 times weekly. Three patients who were stool continent on standard enemas did not require this irrigation system.nnnCONCLUSIONSnThis new total endoscopic and anal irrigation management approach is a comprehensive, minimally invasive, safe, simple, effective way to achieve most goals when treating these patients by protecting the upper tract, maintaining the bladder at safe pressure and providing a satisfactory social life with satisfactory urine and stool continence.

Peristeen anal irrigation as a substitute for the MACE procedure in children who are in need of reconstructive bladder surgery

INTRODUCTIONnWe evaluate the efficacy of the Peristeen (Coloplast A/S, Kokkedal, Denmark) transanal irrigation (TAI) system, as a stool cleansing mechanism, to gain stool continence in children who need reconstructive bladder surgery and have fecal incontinence.nnnMETHODSnWe prospectively evaluated children with neuropathic bladder and bowel dysfunction who were intended for reconstructive bladder surgery and the Malone antegrade continence enema (MACE) procedure. All patients were started on the Peristeen TAI system at least 3 months before surgery to assess their response. Each patients bowel function, frequency of using the system, satisfaction (and that of their parents) and diaper independency were evaluated before and after reconstructive surgery.nnnRESULTSnWe included 18 patients (11 female, 7 male) who were evaluated from April 2006 to the present. The mean age of the group was 7.6 years (range: 4-15). Fifteen patients (83.3%) showed complete dryness from stools. Of the 15 patients, 8 (53.3%) were able to be diaper-free, while 6 continued wearing diapers due to fear of soiling and 1 due to urinary incontinence. The patients underwent reconstructive bladder surgery and continued to use the Peristeen TAI system with the same results postoperatively. The main limitation of this study is the small number of patients included, although this is a very specific patient group.nnnCONCLUSIONnOur initial results suggest that the Peristeen TAI system is a successful conservative substitute for the MACE procedure in children who require reconstructive bladder surgery.

Percutaneous nephrolithotomy in children: A preliminary report.

Objectives: The recurrence of pediatric nephrolithiasis, the morbidity of repeated open surgical treatment as well as our experience in percutaneous nephrolithotomy (PNL) in adult patients, all derived us to shift to PNL for managing renal stones >1.5 cm in pediatric patients. Our aim of this study is to evaluate the safety and efficacy of PNL in pediatric patients. Materials and Methods: During the period of the month between May 2011 and April 2013, 38 children (47 renal units) underwent PNL for renal stones 1.5-5 cm in length. Patient demographics, stone characteristics, and clinical outcome were prospectively studied. Data of those who underwent conventional and tubeless PNL were compared. Median follow-up period was 12 months (range: 6-24). Results: The median age at presentation was 8-year (range: 3-12). The operative time ranged from 30 to 120 min (median 90). Overall stone clearance rate was 91.5% after single PNL. The median hospital stay was 3 days. Auxiliary procedures were successful for the remaining 4 patients (nephroscopic clearance in one and shockwave lithotripsy in 3). Tubeless PNL was performed in 17 renal units with a comparable outcome to conventional ones. The perioperative complications were noted in 5/47 (10.6%) of all procedures (Clavien Grade II in 4 and Clavien Grade IIIa in 1) and were managed conservatively. Conclusions: Percutaneous nephrolithotomy for renal stones in pediatric patients is safe and feasible if performed by a well-experienced endourologist. Tubeless PNL is a better choice for children.

Laparoscopic versus open orchiopexy in the management of peeping testis: A multi-institutional prospective randomized study

OBJECTIVEnPeeping testis is an inconsistently palpable/seen undescended testis that migrates back and forth at the internal inguinal ring. Both open and laparoscopic orchiopexy are effective forms of management. The present study aimed to evaluate the efficacy and safety of both approaches.nnnPATIENTS AND METHODSnBetween September 2007 and January 2012, 46 peeping inguinal testes were randomly treated with either open (25 cases) or laparoscopic (21 cases) orchiopexy procedures. Spermatic vessels were preserved for all cases. Operative details, postoperative morbidity and final testicular site and size were recorded.nnnRESULTSnThe median age of the children was 2.5 years (range 0.5-12.0). The follow-up period ranged from 1.0 to 5.5 years. Of these testes, 20 in the open surgery group and 19 in the laparoscopic group maintained correct intrascrotal position (P = 0.428). Re-do orchiopexy was indicated for two cases in the surgical group (P = 0.493). No cases of testicular atrophy or hernia were encountered.nnnCONCLUSIONnOpen and laparoscopic orchiopexy procedures for peeping testes are fairly comparable. However, laparoscopy is relatively more effective, as two re-do orchiopexies were required in the open surgical group.

Extracorporeal Shockwave Lithotripsy for Ureterolithiasis in Patients with Urinary Bilharziasis: Efficacy and Variables That Influence Treatment Outcome

Objectives: Schistosomiasis affecting the ureter is commonly accompanied by ureteric dilatation with or without ureteric stricture and altered ureteric wall motility that can influence extracorporeal shockwave lithotripsy (ESWL) results. This study attempts to identify variables that may influence the outcome of ESWL in the treatment of ureterolithiasis in patients with urinary bilharziasis.Patients and Methods: Forty–three patients with urinary schistosomiasis and ureterolithiasis treated with ESWL were reviewed. The study data include characteristics of patients, stones, urinary tract treated and details of ESWL treatment.Results: Thirty–five patients (81.3%) were stone–free at 3 months. Multivariate analysis with logistic regression identified two significant variables that influenced treatment outcome, namely the presence of ureteric stricture (p = 0.004) and the ESWL voltage (p = 0.003). Ten ureteric strictures were encountered in 9 patients (21%), the majority of these were diagnosed post–ESWL when patients failed to pass well–fragmented stones in spite of pre–ESWL evaluation.Conclusions: In situ ESWL is a safe and effective first line of treatment for urinary stones in bilharzial ureters. The presence of concomitant bilharzial stricture is a significant variable which affects the treatment outcome. Every effort should be made to rule out and deal with possible complicating factors such as ureteric strictures in the pretreatment period.

Endoscopic correction of vesicoureteral reflux in children with a solitary kidney: the risk of obstruction.

PURPOSEnWe aimed to review patients with a solitary kidney and ipsilateral vesicoureteral reflux (VUR) who underwent endoscopic correction of VUR (ECVUR) and to evaluate the prevalence of obstruction in this group of patients.nnnMATERIALS AND METHODSnWe retrospectively reviewed the files of all patients who underwent ECVUR at our center between January 2000 and June 2011. Only patients with a solitary kidney and ipsilateral VUR were included.nnnRESULTSnThirteen patients met our criteria. Two patients (15.38%) developed obstruction post-ECVUR. Both patients developed anuria in the first 24xa0h after surgery and required intervention. Two patients (15.38%) had increasing hydroureteronephrosis that was discovered on follow-up ultrasound, with no symptoms or signs of obstruction. Both were managed conservatively.nnnCONCLUSIONnOur results showed a higher percentage of obstruction post-ECVUR in patients with a solitary kidney (15.38%), who required immediate intervention. Thus, we recommend giving clear instructions to parents of patients with VUR and a solitary kidney post-ECVUR before discharge from the hospital regarding decreased urine output and loin pain. We recommend a follow-up ultrasound to rule out obstruction and detect new-onset hydronephrosis.

Biofeedback as single first-line treatment for non-neuropathic dysfunctional voiding children with diurnal enuresis

INTRODUCTIONnNon-neurogenic dysfunctional voiding (NDV) accounts for a significant portion of pediatric urology outpatient clinic visits. Biofeedback (BF) is a promising, non-invasive modality for treating children with DV and daytime wetting. Our objective was to investigate BFs efficacy as a single first-line treatment for children with NDV and diurnal enuresis.nnnMETHODSnA retrospective cohort study was conducted with a total of 61 consecutive patient records from January 2009 to March 2016. All children with NDV who had BF as first-line treatment were included. Full urological histories, physical examinations, dysfunctional voiding symptom score (DVSS), urine analysis, ultrasound (US), and uroflowmetry (UFM), and electromyogram (EMG) were performed and recorded for all patients before and after finishing the last BF cycle. The patients satisfaction scale was also obtained.nnnRESULTSnThe mean age was 10±2.6 years. Most patients (80.3%) were females. The presenting symptoms were diurnal enuresis, urinary tract infections, and voiding discomfort in 52 (85.2%), 16 (26.2%), and 38 (62.3%) patients, respectively. Six months after the last BF cycle, there was a statistically significant objective improvement in US and UFM+EMG findings with the disappearance of EMG signals in 40 of 61 (65.5%) patients. There was also a significant subjective symptomatic improvement, as the mean DVSS had decreased from 14 to 7.9 (p=0.003). Forty-seven patients (77%) were satisfied, while only eight (13.1%) were not.nnnCONCLUSIONSnBF is considered a potentially effective, single first-line treatment modality for children with DV and diurnal enuresis. Long-term outcome assessments are needed to assess the childrens compliance and symptom recurrence.

The Reading Habits of Medical Students at Medical College King Saud University

Abstract Background Understanding the reading habits of medical students provide insights and opportunities for medical educators to evaluate the learning needs of the students and improve the teaching methods. The purpose of the present study was to describe the reading habits of King Saud medical students in a fifth year clinical rotation, which previously have not been described. Methods A questionnaire was administered to 96 medical students rotating through their fifth year at the King Saud University College of Medicine during 2008-2009 academic years. The questionnaire focused on issues related to the reading habits. Results Seventy three of 96 (76%) medical students in a fifth year clinical rotation completed the questionnaire. Students reported reading for an average of 4.3(SD 5) (median three hours per week, range zero to 35 hours per week). The most commonly used and useful reading resource were pocket books and medical text books. Approximately 90% of students reported problems in reading about their patients. Conclusions Students spend sufficient amount of time reading medical pocket books and lecture handouts with less time spend on online sources. The majority of students reported problems in reading that medical educators need to address.

Long-term results using a transanal irrigation system (Peristeen®) for treatment of stool incontinence in children with myelomeningocele

INTRODUCTIONnFaecal incontinence due to constipation associated with myelomeningocele (MMC) is a frustrating problem. It could have a bad impact on patients and their families quality of life. Conservative measures could be a starting point. In case of failure, Malone antegrade continence enema (MACE) is commonly considered. However, it is associated with higher complications. Peristeen transanal irrigation (TAI) depends on the injection of water into the colon through a rectal catheter with an inflatable balloon to promote a controlled evacuation of large quantities of faecal contents. Transanal irrigation could be an alternative in these patients to avoid surgery.nnnOBJECTIVEnThe objective of this study was to evaluate the long-term effectiveness and satisfaction of TAI management (Peristeen®, Coloplast, Denmark) in children with MMCxa0whoxa0failed to respond to conservative measures for stool incontinence.nnnSTUDY DESIGNnAll patients with MMC who did not respond to conservative measures for stool incontinence and were using TAI with the last follow-up 6 months before the end date were included. Data were collected retrospectively from January 2008 till January 2016. The data collected includedxa0the age of starting Peristeen, duration of using the Peristeen, acceptance and compliance of the patients family with the TAI. Success was defined as stool continence.nnnRESULTSnA total of 109 patients (55 males and 54 females) diagnosed as having MMC were started on TAI Peristeen. With a mean follow-up of 48 months (24-108), 101 patients (90.4%) achieved complete stool continence and 8 patients were considered failures.nnnDISCUSSIONnThe study results are comparable with those of previously reported publications. The main limitation of Peristeen TAI is that it cannot be performed by the patient himself/herself. This may present a problem with later independence.nnnCONCLUSIONnTransanal irrigation with Peristeen® system is a safe and good alternative option for stool incontinence when other conservative measures fail.