Mahmoud Eladl

Bladder preservation multimodality therapy as an alternative to radical cystectomy for treatment of muscle invasive bladder cancer

Study Type – Therapy (case series) 
Level of Evidence 4

Protective effect of trapidil and l-arginine against renal and hepatic toxicity induced by cyclosporine in rats.

Rationale: Cyclosporine A (CsA) leads to renal and liver injury, production of free radicals and nitric oxide (NO) deficiency. This study investigates the possible protective effects of trapidil and l-arginine against CsA-induced tissue injury. Objectives: Forty adult male Wistar rats (180 ± 20 g) were divided into five groups, eight animals in each. The first group served as control, second group served as CsA group, third group served as CsA + trapidil group, fourth group served as CsA + l-arginine group, and fifth group served as CsA + trapidil + l-arginine group. Kidney and liver functions, inflammatory mediators, cytokines, oxidant and antioxidant parameters as well as histopathological studies of renal and liver tissue were assessed in all groups. Main findings: CsA induced renal and hepatic dysfunction, which was confirmed by laboratory and histopathological examination. Administration of trapidil diminished the renal and liver injury and significantly attenuated the levels of serum creatinine, urea, aspartate aminotransferase (AST), alanine aminotransferase (ALT), interleukin-1β (IL-1β), tumor necrosis factor alpha (TNF-α), monocyte chemoattractant protein-1 (MCP-1), and oxidative stress, while it significantly elevated the level of serum nitric oxide and the activity of antioxidative stress. l-Arginine gave the same trend as trapidil, but trapidil effect was more pronounced. Coadministration of trapidil + l-arginine significantly ameliorated the toxic effect of CsA, but did not differ significantly from the effect of trapidil alone. Conclusions: Treatment with trapidil or l-arginine diminished the renal and hepatic CsA-induced toxicity. However, the effect of trapidil was more pronounced. Therefore, treatment with trapidil alone may be the most economic and effective as a potential therapeutic agent in CsA injury.

Predictors of improvement in semen parameters after varicocelectomy for male subfertility: A prospective study

INTRODUCTION We aim to predict results of varicocelectomy on sperm density and progressive motility using preoperative clinical, laboratory and radiological data and to propose cut-off values for significant parameters. METHODS This prospective study was carried out between July 2011 and June 2014. We included 123 patients in our study. They were diagnosed with primary infertility with varicocele, were scheduled for varicocelectomy, and completed their follow-up. We excluded patients with azoospermia, total necrospermia, recurrent varicocele, and pituitary hormonal abnormalities. Varicocele was diagnosed and graded by physical examination and colour Doppler ultrasound. Semen analyses were completed preoperatively and 6 months postoperatively. Microscopic subinguinal varicocelectomy was done in all cases. Patient demographics, pre- and postoperative clinical data (varicocele grade and semen parameters) were statistically analyzed. RESULTS The mean ± standard deviation of age, body mass index, and subfertility duration was 28.3 ± 7.4 years, 29.1 ± 2.7 kg/m(2), and 21.9 ± 7.1 months, respectively. About 53% of our patients (n = 66) had bilateral varicocele, and unilateral disease was found in the other 57 (46.3%) cases. Varicocele grade I was diagnosed in 42 (34.1%) patients, while the other 81 (65.9%) patients had grade II or III. Higher grades of varicocele, preoperative total testosterone level, sperm density, and progressive motility had a statistically significant impact on the outcome of varicocelectomy in univariate testing. Multivariate logistic analysis revealed that grade of preoperative varicocele (95% confidence interval [CI] 5.6-6.3, p = 0.007) and sperm density (95% CI 2.7-1.6, p = 0.0035), and progressive motility (95% CI 1.1-2.3, p = 0.0123) are independent predictors of semen parameters improvement after varicocelectomy. CONCLUSION The grade of the varicocele, sperm density, and progressive motility are major predictors of outcome in varicocelectomy. Cut-off values of >8 million/mL and >18% for sperm density and progressive motility, respectively, in men with varicocele grade II or III, indicate a successful outcome.

Outcome of α-blockers, with or without methylprednisolone combination, in medical expulsive therapy for lower ureteric stones: A prospective randomised study.

Abstract Objectives: To compare the safety and efficacy of tamsulosin, alfuzosin, and their combinations with methylprednisolone, in the medical management of lower ureteric stones. Patients and methods: Between September 2012 and June 2014, patients diagnosed with a single lower ureteric stone of ⩽10 mm (longest dimension) were enrolled. Patients with urinary tract infection, severe hydronephrosis, pregnancy, hypertension, diabetes, ulcer disease, or renal insufficiency were excluded. According to the medication added to the analgesic anti-inflammatory, patients were stratified into four groups, with 53 patients in each. Group I patients received tamsulosin 0.4 mg and those in Group II received tamsulosin 0.4 mg and methylprednisolone 8 mg. Group III patients received alfuzosin 10 mg and those in Group IV received alfuzosin 10 mg and methylprednisolone 8 mg. Treatment was continued until stone expulsion or to a maximum of 2 weeks. The patients’ demographics, stone criteria, and stone-free rates were calculated and analysed. Results: The mean (SD) maximum stone dimension was 7.8 (1.5), 8.1 (1.3), 7.9 (1.6) and 8.0 (1.4) mm in Groups I, II, III and IV, respectively. Groups II and IV had significantly higher stone-free rates than Groups I and III (P < 0.05), whilst there were no statistically significant differences between Groups I and III or between Groups II and IV. There was no statistical difference among the four groups for the time to stone expulsion. Three patients in Group II and two patients in Group IV developed transient hyperglycaemia, which resolved after cessation of methylprednisolone. Conclusions: The combination of alfuzosin or tamsulosin with methylprednisolone seems to be effective and safe for managing lower ureteric stones of <1 cm.

Predictors of severity and treatment response in children with monosymptomatic nocturnal enuresis receiving behavioral therapy.

OBJECTIVE To evaluate the role of bladder volume and bladder wall thickness measurement by ultrasound in assessing severity and predicting response to behavioral therapy in children with monosymptomatic nocturnal enuresis. METHODS 122 children (68 boys and 54 girls) aged 5-9 years underwent ultrasound evaluation of bladder volume and bladder wall thickness, followed by calculation of the bladder volume wall thickness index (BVWI). They were treated using first-line management (behavioral therapy) for 4 months. Correlation of severity and treatment response to ultrasound bladder measurements was investigated. RESULTS Only 74 children completed the study: 16 showed complete response to treatment, 25 good response, 18 partial response, and 15 children showed no response. Age, gender and location of residence did not correlate to severity or to treatment response. Ultrasound measured bladder volume also did not correlate to either severity or response. Bladder wall thickness showed a strong correlation to both severity and response to treatment, as did BVWI. CONCLUSION Ultrasound measured bladder wall thickness and BVWI are strongly associated with the severity of nocturnal enuresis and are highly predictive of treatment response to behavioral therapy. It is recommended that any child with monosymptomatic nocturnal enuresis should undergo an abdominal ultrasound examination before starting treatment.

Diuresis and inversion therapy to improve clearance of lower caliceal stones after shock wave lithotripsy: A prospective, randomized, controlled, clinical study

Objective: To improve the clearance of lower caliceal stones (LCSs) after shock wave lithotripsy (SWL) using a combination of intra-operative forced diuresis and inversion therapy. Materials and Methods: One hundred and fifty-seven consecutive patients with symptomatic, single LCSs of 5-20 mm size were prospectively randomized into two groups. The first (study group, SG) underwent SWL at the time of the maximum diuresis with the patient in the Trendelenburg position with an angle of 30 degree, while the second group (control group, CG) underwent standard SWL. After the last SWL session, patients were followed-up regularly using plain abdominal X-ray and renal ultrasound. The primary endpoint of the study was the stone-free rate (SFR) at 12 weeks. Results: A total of 141 patients completed the study treatment protocol and follow-up: 69 patients in SG and 72 patients in CG. Both groups were comparable in baseline data. SG showed significantly higher SFR at all follow-up time points. At week 12, 78.3% of SG were rendered stone free, whereas only 61.1% were stone free in CG (P = 0.030). Also, there was a significantly higher SFR for larger stones (>10 mm) and stones with higher attenuation value (>500 Hounsfield units) in SG than CG. Mild non-significant complications were reported in both groups. Conclusion: SWL with intraoperative forced diuresis and inversion seems to be an effective measure with minimal extra cost to improve LCS clearance post-SWL.

MP13-05 VENTRALLY PLACED BUCCAL MUCOSAL GRAFT URETHROPLASTY FOR LONG ANTERIOR URETHRAL STRICTURE

INTRODUCTION AND OBJECTIVES: To evaluate the use of penile circular skin graft versus flap as a ventral onlay for bulbo-penile stricture urethra. METHODS: Between 2003 and 2009, 37 patients with bulbopenile stricture were randomized to penile methods circular skin graft (PCG 18) or flap (PCF 19). Inclusion criteria included postinstrumentation or idiopathic stricture. Exclusion criteria were unhealthy skin and previous urethrotomy/urethroplasty. Patients had urethrogram at three weeks, three months, one year, and urethroscopy when needed. Any subsequent urethrotomy/urethroplasty was considered a failure. Chi-square and Student’s t test were used for analysis. RESULTS: Patients’ ages were 45.3 (range: 30 e 65) and 45.5 (35-60) yr in PCGP P .000). Early postoperative complications were similar in both groups. Superficial skin necrosis occurred only in the PCF group (3 cases). Late complications of mild postvoid dribbling occurred similarly in both groups. One patient in PCF had a urethro-cutaneaous fistula at the level of fossa navicularis that was repaired later. Stricture recurred in 5 (27.7%) and 4(21%) patients in PCG and PCF, respectively (P .249). Four patients had visual internal urethrotomy (2, 2), four needed anastmotic urethroplasty (2, 2) in PCG and PCF, respectively, and one needed buccal mucosal graft in the PCG group. CONCLUSIONS: At intermediate follow-up, both penile circular graft and flap had similar and high success as a ventral onlay for repair of long bulbo-penile stricture with a low rate of complications.

The validity of testicular aspirate cytology and DNA image-analysis of the aspirate in the assessment of infertile men.

Abstract Objective: To assess the possibility of using cytological examination and DNA image-analysis of testicular fine-needle aspirates instead of open surgical biopsy in the investigation of infertile men, as testicular biopsy has long been used for investigating infertility but the interpretation of histological slides is usually subjective. Patients and methods: Thirty-three men (aged 22–36 years) were evaluated for infertility and underwent both open biopsy and fine-needle aspiration of their testes. Subsequently, the needle aspirates were assessed histopathologically and cytologically, and by DNA image cytometry. The percentages of haploid, diploid and tetraploid cells were determined for each patient. Results: The cases were divided into four categories: (1) Complete spermatogenesis, with a DNA pattern of 1n > 2n > 4n; (2) Maturation arrest, with a DNA pattern of 2n > 4n with no haploid cells; (3) Sertoli cell-only syndrome, with a DNA pattern of only 2n, with no haploid or tetraploid cells; (4) Hypospermatogenesis, with a variable DNA pattern, i.e. mild with 1n > 2n, moderate with 2n > 1n > 4n, and marked where the DNA pattern was 2n > 4n > 1n. From the cytological and DNA image-analysis of the aspirate a diagnosis was possible that had a strong correlation with the histological diagnosis of the same case. From image analysis we could exclude interstitial cells, Sertoli cells and sperms on the static image, and differentiate between spermatozoa and spermatids based on morphological characteristics in the cytological smear. This technique can therefore be used to quantitatively determine the percentages of various cell types within the seminiferous tubules. By coupling image ploidy analysis and cytological examination of a cytological smear, spermatogenesis can be assessed accurately. Conclusion: Image cytometry could be used to exclude interstitial cells, Sertoli cells and sperms on the static image and so produce an accurate assessment of spermatogenesis. A combination of ploidy and cell morphology characteristics in cytological smears provides an accurate, reproducible and easily used alternative to open testicular biopsy.