Mahmoud M. Shalaby

The Impact of Training Residents on the Outcome of Robotic-Assisted Sacrocolpopexy

Objective. To evaluate the surgical outcomes of robotic-assisted sacrocolpopexy (RASCP) before and after the incorporation of hands-on training for urology and gynecology residents. Study Design. Forty-one patients underwent RASCP between December 2008 and March 2010 with one surgeon. RASCP was performed in the context of surgical repair of complex pelvic organ prolapse and/or stress urinary incontinence. The first 20 cases (group I) were performed exclusively by the attending surgeon. In the last 21 cases (group II), the urology resident performed a 50% or more of the RASCP while the gynecology resident performed the supracervical hysterectomy. The primary outcome measure was vaginal vault support at 24 weeks postoperatively based on pelvic organ prolapse quantification (POP-Q). Results. Mean ± SD operative time for the entire surgery including RASCP was 282.3 ± 51.3 min and median EBL was 83.1 ± 50.4 mL. Patient demographics and stage of disease did not differ between groups. Procedure time, PACU time, blood loss, and intraoperative complications were similar between groups. Follow-up POP-Q evaluations demonstrated significant correction of all points on vaginal examination for both groups (P < 0.001). Conclusions. Incorporation of resident training during RASCP allows teaching of robotic surgery techniques in an effective manner without prolonging operative time or affecting the overall surgical outcome.

Single puncture percutaneous nephrolithomy for management of complex renal stones

BackgroundThe purpose of this report is to assess the safety and efficacy of single lower pole access for multiple and branched renal calculi. A prospective non randomized clinical study included 26 patients with complex renal stones (9 patients had branched renal stones and the other 17 had multiple renal stones) in the period from May 2003 to May 2004. Mean patient age was 42 years ± 13.2 (range 18 to 67 years). All patients underwent percutaneous nephrolithotomy (PCNL) via a single lower calyceal puncture. Small stones were intactly extracted by a range of stone graspers while large stones (smallest diameter more than 1 cm) were disintegrated using either the pneumatic EMS Swiss lithoclast or Holmium YAG laser. Flexible nephroscope was used for stones inaccessible by the rigid instruments.FindingsOverall stone-free rate was 74.8%. Patients with residual stones were managed by one session of shock wave lithotripsy (SWL). Mean operative time was (80 minutes ± 27.4) for branched stones and (49.1 minutes ± 15.9) for multiple stones. No significant blood loss reported. Perforation of pelvicalyceal system occurred in 2 patients (11.5%) with no serious sequelae. Only 1 patient developed secondary hemorrhage which necessitated blood transfusion and selective angio-embolization.ConclusionIn our hands, the efficacy and safety of single lower calyceal puncture PCNL in management of complex renal stones are comparable to those of the general procedure stated in literature.

The management of the persistent Müllerian duct syndrome.

Abstract Objectives: To report the findings and management of patients with persistent Müllerian duct syndrome (PMDS). Patients and methods: Nineteen phenotypically male patients (aged 8 months to 27 years) presented with testicular maldescent. All of them had normal male external genitalia. Two of them had had a previous diagnosis of persistent Müllerian structures. All patients were karyotyped, and had a hormonal profile, diagnostic laparoscopy, retrograde urethrocystogram, gonadal biopsies, and surgical management according to the findings. The follow-up was based on a clinical examination, abdominal ultrasonography (US) and scrotal colour-Doppler US at 3 and 6 months after surgery, and every 6 months thereafter. Results: Diagnostic laparoscopy showed the presence of persistent Müllerian structures in all 19 patients. All patients had a normal male karyotype (46XY). Ten patients had a laparoscopic excision of their Müllerian structures while the remaining nine patients had their Müllerian structures left in place. No malignant changes were found in the excised Müllerian tissues. Of the 37 gonadal biopsies taken, 31 (84%) indicated normal testes. Conclusions The incidence and prevalence of PMDS are not well estimated. Müllerian structures should be removed whenever possible to avoid the risk of malignant transformation. The early diagnosis of PMDS makes possible the excision of Müllerian structures and a primary orchidopexy. A long-term follow-up is needed for patients with intact Müllerian structures and magnetic resonance imaging might be a better method than US for that purpose. Most of the patients had normal testicular histology, which might allow fertility.

Combined Mathieu and Snodgrass urethroplasty for hypospadias repair: A prospective randomized study

Objectives:  To evaluate the outcomes of combined Mathieu and Snodgrass urethroplasty for distal hypospadias repair and to compare them with the two techniques separately.

Quantitative Evaluation of Heavy Metals and Trace Elements in the Urinary Bladder: Comparison Between Cancerous, Adjacent Non-cancerous and Normal Cadaveric Tissue

The role of heavy metals and trace elements (HMTE) in the development of some cancers has been previously reported. Bladder carcinoma is a frequent malignancy of the urinary tract. The most common risk factors for bladder cancer are exposure to industrial carcinogens, cigarette smoking, gender, and possibly diet. The aim of this study was to evaluate HTME concentrations in the cancerous and adjacent non-cancerous tissues and compare them with those of normal cadaveric bladder. This prospective study included 102 paired samples of full-thickness cancer and adjacent non-cancerous bladder tissues of radical cystectomy (RC) specimens that were histologically proven as invasive bladder cancer (MIBC). We used 17 matched controls of non-malignant bladder tissue samples from cadavers. All samples were processed and evaluated for the concentration of 22 HMTE by using Inductively Coupled Plasma Optical Emission Spectrometry (ICP-OES). Outcome analysis was made by the Mann-Whitney U, chi-square, Kruskal-Wallis, and Wilcoxon signed ranks tests. When compared with cadaveric control or cancerous, the adjacent non-cancerous tissue had higher levels of six elements (arsenic, lead, selenium, strontium, zinc, and aluminum), and when compared with the control alone, it had a higher concentration of calcium, cadmium, chromium, potassium, magnesium, and nickel. The cancerous tissue had a higher concentration of cadmium, lead, chromium, calcium, potassium, phosphorous, magnesium, nickel, selenium, strontium, and zinc than cadaveric control. Boron level was higher in cadaveric control than cancerous and adjacent non-cancerous tissue. Cadmium level was higher in cancerous tissue with node-positive than node-negative cases. The high concentrations of cadmium, lead, chromium, nickel, and zinc, in the cancerous together with arsenic in the adjacent non-cancerous tissues of RC specimens suggest a pathogenic role of these elements in BC. However, further work-up is needed to support this conclusion by the application of these HMTE on BC cell lines.

The laparoscopic management of symptomatic renal cysts: A single-centre experience

Abstract Objectives: To present our experience of treating symptomatic renal cysts by different techniques of laparoscopic decortication, as there are many treatment options for such cysts, each of them with advantages and drawbacks. Patients and methods: Between January 2002 and December 2012, 51 patients underwent laparoscopic renal-cyst decortication; 15 of them had recurrent cysts after percutaneous aspiration. A retroperitoneal approach was adopted in 44 cases, transperitoneal in four and laparo-endoscopic single-site surgery (LESS) cyst decortication in three (two of them had bilateral renal cyst decortications in the same session). All patients were diagnosed by ultrasonography and computed tomography to determine the Bosniak classification of the cyst. Pain and cyst recurrence were assessed during the follow-up. Results: All procedures were completed successfully, with no major intraoperative complications. The mean (range) operative duration was 56 (35–125) min, affected by the site and number of cysts unroofed. All patients were symptom-free except one, who had a recurrent large cyst, anteriorly located, and who underwent open cyst decortication. Conclusions: Laparoscopic decortication of symptomatic renal cysts should be the standard of care, especially after failed percutaneous aspiration or decortication. LESS cyst decortication is a promising technique, especially with bilateral pathology. It is feasible with conventional laparoscopic instruments and gives a better cosmetic outcome.

Management of the Looping Vas Deferens During Laparoscopic Orchiopexy

PURPOSE A number of variables should be assessed during laparoscopic orchiopexy, including vas anatomy. A looping vas deferens enters the inguinal canal and loops back to the abdominal cavity. This anatomical variant is not uncommonly encountered. Some groups considered this condition in their laparoscopic classification of nonpalpable testis. We present our experience with managing the looping vas during laparoscopic orchiopexy. MATERIALS AND METHODS We identified this condition in 18 procedures. In 14 cases it was possible to bring the vas back to the abdominal cavity. In 3 cases the loop could not be brought back laparoscopically and an inguinal incision was used. After the vas was dissected free and dropped into the abdominal cavity pneumoperitoneum was resumed and the procedure was completed laparoscopically. A Web based survey was done to test the value of this method. RESULTS A total of 17 procedures were completed successfully with preservation of the vas deferens while in 1 the vas was inadvertently cut. A looping vas did not significantly affect operative time. All 18 testes were viable and retained the scrotal position on followup scrotal Doppler ultrasound. CONCLUSIONS Verification of vasal anatomy is a crucial step that should be completed before any dissection. Bringing a looping vas back to the abdominal cavity is usually feasible laparoscopically but in a few cases this may require a small incision to dissect the vasal loop from its inguinal attachments.

Which is better for pain reduction during transrectal ultrasound-guided biopsy of the prostate: Intravenous diazepam, local periprostatic nerve block, or combination? controlled randomized study

Background: Transrectal ultrasound-guided prostate biopsy (TRUSPB) is considered the procedure of choice for the diagnosis of prostate cancer. Men undergoing this biopsy experience high psychological stress. Different studies recommend techniques as sedation, lidocaine gel intrarectally, periprostatic nerve block alone, or nitrous oxide inhalation as effective methods of analgesia during procedural-related pain or discomfort. We evaluated three techniques for pain relief during TRUSPB and evaluated if there was any increase in the incidence of complications when employing either technique. Setting: Assiut University Hospital, Assiut, Egypt. Methods: Three hundred patients of age 43–92-year-old underwent TRUSPBs. Patients were allocated randomly into three equal groups to receive intravenous (IV) diazepam 5 mg slowly (Group I), bilateral periprostatic nerve block by 10 ml of 1% lidocaine solution injected under ultrasound guidance (Group II), or combined IV diazepam and the periprostatic nerve block (Group III). Results: The mean pain score was 4.95 for patients in Group I, 4.15 for patients in Group II, and 2.18 for patients in Group III with statistically significant findings (F = 120.27, P < 0.001). TRUSPB under combined IV sedation and local anesthesia had no significant increase in the incidence of complications. Conclusions: Patients should have analgesia during TRUSPB to decrease the procedure pain and to improve tolerance permitting proper aiming for biopsy cores without increasing the patient distress. The combined IV sedation and local periprostatic nerve block are efficient in controlling and limiting pain better than employing each technique alone with no significant increase in complications incidence.

Treatment of premature ejaculation: a new combined approach

Background Selective serotonin reuptake inhibitors (SSRIs) are utilized to treat premature ejaculation (PE). However, their effect is moderate, with no universally adopted schedule. A possible role for pelvic floor dysfunction in the pathogenesis of PE was reported previously. Objective The aim of this study was to compare the efficacy of combined sertraline and pelvic floor rehabilitation with either line in patients with an unsatisfactory response to SSRIs. Design, setting, and participants From June 2009 to December 2012, 74 PE patients with an unsatisfactory response to sertraline 50 mg were enrolled and subjected to pelvic floor rehabilitation as an alternative therapy, and then a combination of both was tested on the same group. Outcome measurements and statistical analysis Relationships with outcome were analyzed using the Student t-test, Pearson′s correlation, and linear regression. Results and limitations The baseline intravaginal ejaculatory latency time (IELT) was 20-110 s (mean ± SD = 56.35 ± 21.67). With sertraline 50 mg therapy alone, IELT reached 90-180 s (mean ± SD = 121.69 ± 21.76, P = 0.0001). Of them, 44 (59.46%) patients failed to exceed an IELT of 120 s. With pelvic floor rehabilitation alone, IELT reached 90-270 s (mean ± SD = 174.73 ± 45.79, P = 0.0001). Of them, 13 (17.56%) patients failed to exceed an IELT of 120 s. Using a combination therapy of both, IELT reached 180-420 s (mean ± SD = 297.57 ± 59.19, P = 0.0001). This response was significantly higher than the baseline IELT and that of either lines alone (P = 0.0001, for all tests). Conclusion Pelvic floor rehabilitation is an important addition when treating PE, particularly in patients with pelvic floor dysfunction. We recommend this combination in patients with an unsatisfactory response to SSRIs. Patient summary Causes of PE differ considerably. In this paper, we compared the outcomes of two single treatment lines together with a combination of both. The combination therapy was more effective than either line alone.